Nursing Home Residents Lagging On Latest COVID-19 Vaccine Dose, CDC Report Shows

As of February 11, 2024, only 40.5% of nursing home residents—individuals who are among the highest risk for severe cases of COVID-19—had received an updated dose of the 2023/2024 vaccine, which was initially recommended in September 2023, according to the CDC’s latest morbidity and mortality report.¹ Getting this population the updated vaccine dose is critical, as nursing home residents continue to be disproportionately affected by SARS-CoV-2 infection and its related severe outcomes, even amid lower peak rates of infections in the 2023-2024 respiratory virus season compared with the prior 3 years.

Among this population in the weeks covered by this report (October 16, 2023–February 11, 2024), a range of 14.9% to 26.1% of nursing homes reported 1 or more SARS-CoV-2 infections, with weekly rates of associated hospitalization ranging from 3.8 to 7.1 per 10,000 residents. The report was compiled by David Franklin, MPH, a public health analyst with CACI International, and a member of the Division of Healthcare Quality Promotion within the National Center for Emerging and Zoonotic Infectious Diseases at the CDC, among several other colleagues.

“COVID-19 continues to cause substantial morbidity among nursing home residents. Nursing homes should continue to implement recommended infection prevention and control practices, including encouraging residents, caregivers, and nursing home staff members to remain up to date with all recommended COVID-19 vaccine doses to limit the introduction and spread of SARS-CoV-2 infection within nursing homes,” Franklin and colleagues wrote,¹ adding that the continued ongoing observation of SARS-CoV-2 infections and COVID-19–associated hospitalizations in this patient population will remain essential for developing and assessing the current evidence-based interventions.

During the aforementioned 2023-2024 respiratory virus season, the peak rate of infection for COVID-19 was 133.8 per 100,000 residents, occurring in the week ending December 3, 2023. This is a decrease from the prior 3 seasons of 2020-2021 (306 per 100,000), 2021-2022 (435 per 100,000), and 2022-2023 (176 per 100,000). Despite this decrease, though, the morbidity among nursing home residents was still significantly higher—greater than 8 times—the peak weekly rate of 0.87 per 10,000 among all US adults aged 70 years or older in that season. “Although data reported to NHSN [National Healthcare Safety Network] by nursing homes cannot be directly compared with those submitted by hospitals because of differences in methodology and populations, this stark difference underscores the high risk for COVID-19–associated hospitalization among nursing home residents,” Franklin et al wrote.

The CDC’s Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, most recently updated March 18, 2024, can be found here:

Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic

In terms of facility percentages, outside of the previously noted range for 1 or more cases, a range of 8.6% (during the week ending February 11, 2024) to 16.6% (the week ending January 7, 2024) for nursing homes reporting 2 or more cases. Cumulatively, the weekly SARS-CoV-2 infection rate was 109.3 per 10,000 residents. The highest rates reported in the Midwest region at 130.1, which includes nursing homes in Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin; and the lowest rates were reported in the South region at 93.1, which includes homes in Alabama, Arkansas, Delaware, the District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia.

Franklin and colleagues did note that there are at least 4 limitations to this report, the first being that as the nursing homes themselves report these data, the possibility of misclassified information about SARS-CoV-2 infection, COVID-19–associated hospitalization, and COVID-19 vaccination status is present. Additionally, the analysis was conducted with aggregated facility-level data, which could present some issues with accounting for confounding factors such as time since vaccination, previous infection, age, or comorbidities.

Otherwise, the only limiting aspects were that the analysis did not account for testing differences on a facility or regional level, and the NHSN definition of COVID-19–associated hospitalization (which is noted as a hospital admission within 10 days after a laboratory-confirmed SARS-CoV-2 infection) may not have aligned with the classification of some hospital level data provided. “However, NHSN’s method for defining COVID–19–associated hospitalizations is consistent with that of other surveillance systems,” the authors noted.

This report covers a time period of just a few months after a 2023 study, published in the Journal of Post-Acute and Long-Term Care Medicine (JAMDA) by Ana Montoya, MD, MPH, and colleagues, examined the incidence of and resident characteristics associated with breakthrough infections and severe illness among nursing home residents who had received 2 mRNA COVID-19 vaccines (1 complete primary vaccine series).² The study confirmed much of what this recent CDC report suggests, namely that COVID-19 has disproportionately impacted nursing homes. Early on, one-third of the US COVID-19 infections occurred in these facilities, and to date, 1.2 million nursing home residents have died of COVID-19.

Altogether, Montoya et al’s analysis included 23,172 nursing home residents, of which 5% (n = 1173) developed an incident breakthrough infections. Among residents who contracted a breakthrough COVID-19 infection, 8.6% were hospitalized or died within 30 days of their diagnosis. The average time of breakthrough infection was 250 days after vaccination. Those with breakthrough infection were typically older and non-Hispanic White, and were more likely to have chronic obstructive pulmonary disease, dementia, or osteoarthritis, but less likely to have functional impairment. The factors most associated with severe or fatal breakthrough infection included being 85 years or older, bowel incontinence, coronary artery disease, chronic kidney disease, and schizophrenia.

REFERENCES
1. Franklin D, Barbre K, Rowe TA, et al. COVID-19 Vaccination Coverage, and Rates of SARS-CoV-2 Infection and COVID-19–Associated Hospitalization Among Residents in Nursing Homes — National Healthcare Safety Network, United States, October 2023–February 2024. CDC Weekly. April 18, 2024. 73(15);339-344. https://www.cdc.gov/mmwr/volumes/73/wr/mm7315a3.htm
2. Resident Factors Associated With Breakthrough SARS-CoV-2 Infections. Montoya A, Wen K, Travers JL, et al. JAMDA. 2023;24(6):901-905. doi:10.1016/j.jamda.2023.02.102