High staff vaccination rates help nursing homes beat COVID

ST. LOUIS — Nursing homes in Missouri with the vast majority of staff vaccinated tend to have strikingly lower rates of COVID-19 cases among residents, according to federal records, a trend that may offer broader lessons about the virus and how it can be slowed.

Many nursing homes in the state had six, seven or even eight in 10 employees vaccinated, but still recorded relatively high virus caseloads among residents this year. But all the homes with 90% or more of their staff vaccinated saw caseloads — and deaths — dip to near zero.

"Back in November and December, when you had a person turn positive, you knew you were going to find other people in the home that were positive. Because there was no protection at all, pre-vaccine," said Dr. Charles Crecelius, medical director for two St. Louis-area nursing homes and an elder care specialist for BJC Medical Group. "Now ... I can't say it's not happening. But the average outbreak, there's a couple people, and you get it clamped down."

"We've showed, in nursing homes: Vaccines work," Crecelius continued. "They really dramatically lower the case rate and the death rate."

Nursing homes are at a crossroads. In the coming weeks, the federal government will release a rule requiring all employees to get vaccinated at facilities certified to receive Medicare and Medicaid dollars, but nursing home leaders worry some staff will quit when faced with such a mandate. At the same time, the more contagious delta variant of the coronavirus is spreading rapidly throughout the U.S., and — while case rates are well below the devastating levels of last year — nursing homes are still reporting some outbreaks.

Missouri nursing homes with very high staff vaccination rates have generally had low case rates over the course of 2021, according to a Post-Dispatch analysis of U.S. Centers for Medicare and Medicaid Services COVID-19 infection, death and vaccination data.

Local researchers analyzed the data and found similar patterns. Looking at records from more than 500 Missouri nursing homes between May 24 and Aug. 29, "as the percent of vaccinated staff increased, the risk of COVID-19 infections among residents significantly decreased," wrote researchers, including senior author and Saint Louis University professor Enbal Shacham, in a paper submitted for publication last week.

The data didn't always provide a clear trend, suggesting other factors played a role. For instance, some nursing homes with very low vaccination rates also reported very low resident case rates. And Shacham's study found nursing homes with more residents had higher odds of infections, and also increasing case rates in the surrounding county boosted the odds of infection among the nursing home's residents.

But the U.S., too, indicated staff vaccination played a large role in resident infection rates: In a news release earlier this month, the Centers for Medicare and Medicaid Services, known as CMS, said U.S. nursing homes with 75% or lower staff vaccination rates have higher rates of preventable COVID-19 infections.

Chipping away

Vaccinations began for Missouri nursing home residents and staff Dec. 28. By that point, nursing homes statewide had reported nearly 19,000 COVID-19 cases, and almost 3,000 deaths, according to federal data, or about 44% of the state's total reported virus deaths.

Through the rest of winter, and into spring, weekly case and death counts in Missouri nursing homes declined.

Momentum has been building toward vaccine mandates for nursing home workers, with a sweeping federal requirement expected in coming weeks. More than 84% of nursing home residents are now immunized in Missouri.

But seniors still represent 15% of the state's cases and 81% of the deaths. And despite months of effort, only about half of the state's nursing home employees have been vaccinated, making Missouri the third-worst in the nation, trailed only by Florida and Louisiana.

Maries Manor, a 98-bed nursing home about 25 miles northwest of Rolla, has a 100% vaccination rate among residents. Most were immunized during the facility's first COVID-19 vaccine clinic, Administrator Josh Cross said recently. But getting employees vaccinated has been more difficult.

Cross said over the past eight months, he has been constantly trying to educate, alleviate fears and provide incentives. At one point, he offered unvaccinated employees $25 to get a first dose. Cross talked to employees again and again, before each monthly vaccine clinic.

"Slowly but surely, it worked," Cross said. "I chipped away at so many people who were not going to get it."

As of Aug. 22, the facility had 82% of staff fully vaccinated, and Cross said 91% had a first dose.

Since the beginning of the pandemic, Maries Manor has reported 18 COVID-19 cases among its residents, and three deaths, according to CMS data. All of the cases and deaths were reported before Jan. 24.

Cross said he'd prefer all visitors be vaccinated, too, "but we know in rural Missouri that's very, very unlikely." In Maries County, 35% of the population has received a first dose of vaccine, and 32% has been fully vaccinated, according to state data.

Vaccine mandates

On Aug. 18, President Joe Biden announced the nursing home staff vaccine mandate. On Aug. 26, Illinois Gov. J.B. Pritzker announced vaccine requirements for workers in high-risk settings, including nursing homes and schools.

And on Sept. 9, Biden announced the requirement would be expanded to hospitals, home health agencies, dialysis clinics and other federally funded health care settings.

Some area nursing homes are already mandating vaccines for staff. BJC HealthCare's Memorial Care Center, in St. Clair County, requires employees to get vaccinated as part of the BJC health system's requirement. St. Luke's Surrey Place also requires the vaccines for its employees, as part of St. Luke Hospital's employee mandate. Bethesda Health Group, a St. Louis County-based chain with 14 communities, announced Aug. 23 all of its employees, volunteers and vendors needed to get vaccinated by Nov. 1.

But Nikki Strong, executive director of the Missouri Health Care Association, a trade group for long-term care facilities, said at a hearing at the Missouri Capitol on Tuesday she believes the vaccine mandate will exacerbate existing staffing shortages in nursing homes.

"We don't believe that a straightforward mandate is the appropriate way to achieve full vaccination in our facilities," Strong said.

Strong said 83 of 275 Missouri nursing homes in a recent survey said they'd expect to lose 25% to 49% of their staff if there was a mandate, and 91 said they'd expect to lose 50% or more.

"The staffing crisis is not getting better. We don't have the resources to pay and compete with the fast food restaurants, the convenience stores, the Walmarts, whomever," Strong said.

Strong said she is not expecting the federal rule to be finalized until mid-to-late October, so the details of the mandate are still unknown. It is unclear how it will be enforced, and whether there will be an option for employees to get tested regularly if they do not want to get vaccinated.

State Rep. Peter Merideth, D-St. Louis, said during the hearing he believed a vaccine mandate may be one factor in the staffing shortages, but the larger focus should be on improving wages for nursing home workers, and raising reimbursement rates.

"Yeah, we're adding another requirement on them," Merideth said. "That might be the straw that broke the camel's back, but the tough job they've had for the last two years for the little pay, undoubtedly is a bigger factor in the staffing crisis, is it not?"

Vaccine misinformation

Lavetta Richardson, a certified medical technician who has worked for 13 years at Mary, Queen and Mother Center in Shrewsbury, said she supports a mandate because without one, people will not get vaccinated.

Richardson caught COVID-19 in the summer of 2020, and was sick for about six weeks with body aches, headaches and loss of appetite. Her husband also caught the virus and was hospitalized.

"It was just miserable," Richardson said.

She got her first shot in January, and now she talks to her co-workers about the vaccines as a union-appointed "safety steward" for the nursing home. She said she recently gathered with her co-workers and told them about her experience with COVID-19.

"A lot of people, they get the misinformation, and they carry it with them," Richardson said. "It's hard to change their minds."

Nursing home administrators and physicians told the Post-Dispatch vaccine incentives have helped some, but the real progress increasing staff vaccination rates has been made through one-on-one conversations about employees' concerns.

Elsberry Missouri Health Care Center in Lincoln County has a 100% vaccination rate among residents and 93% among staff, and has reported just one case — a false positive, staff said. Administrator Linda Haake said many things helped keep case rates down. The facility paid employees when they were staying home awaiting a test result. It encouraged outdoor visitation. And only vaccinated visitors were allowed to visit residents in their rooms.

But she also worked hard to get staff vaccinated: She said she would pull employees aside who weren't getting vaccinated or were on the fence, ask them about their questions and concerns, and try to find experts who could answer them. The facility also offered $100 gift cards.

Dr. David Carr, a geriatrician and professor of medicine and neurology at Washington University, said the efficacy of the vaccine is clear.

"I don't doubt, if it hadn't been for the vaccination, that we would have had a tremendous number of outbreaks that just would've kept going on," said Carr, who is also the medical director of Parc Provence, a dementia care facility in Creve Coeur.

Carr believes nursing homes have survived the worst of COVID-19. They now benefit from having at least a portion of their employees vaccinated, and most of their residents. But he does worry that, with other mutations of the virus, there will be more waves of cases.

"Hopefully nothing like we had before," he said. "But I think we're going to continue to be at risk here, over the winter and spring."