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April 27, 2021

COVID-19 Vaccinations in Nursing Home Residents and Staff Give Robust Protection, Though Breakthrough Infections Still Possible

Author Affiliations
  • 1Consulting Editor, JAMA Health Forum and JAMA
JAMA Health Forum. 2021;2(4):e211195. doi:10.1001/jamahealthforum.2021.1195

Nursing home residents and staff members who have been vaccinated against SARS-CoV-2 are much less likely to become infected, have symptomatic illness, and require hospitalization compared with their unvaccinated counterparts, according to reports from the Centers for Disease Control and Prevention (CDC) of cases in Kentucky and Chicago nursing facilities.

Even so, a small percentage of fully vaccinated residents experienced breakthrough infections, and 2 nursing home residents died, pointing to the importance of a continued focus on infection prevention and control practices.

Both reports, published in the CDC’s Morbidity and Mortality Weekly Report, note that although vaccines to prevent COVID-19 have been found to be highly effective in clinical trials, the data on COVID-19 vaccine effectiveness in skilled nursing facilities and against emerging variants of SARS-CoV-2 are limited.

In the Kentucky report, researchers detailed an outbreak involving a newly introduced SARS-CoV-2 variant in a single nursing facility that was touched off by an unvaccinated health care worker. All residents and health care personnel had been offered vaccination with the 2-dose Pfizer-BioNTech vaccine. Seventy-five of 83 residents (90.4%) and 61 of 116 health care workers (52.6%) had received 2 vaccine doses; most of them received the second dose more than 14 days before the outbreak began and were thus considered fully protected.

A total of 26 residents and 20 health care workers tested positive for SARS-CoV-2, including 18 residents and 4 workers who had received their second vaccine dose more than 2 weeks before the start of the outbreak. Unvaccinated residents and health care personnel had 3.0 and 4.1 times the risk of infection compared with their vaccinated counterparts.

Vaccination also was protective against developing symptomatic COVID-19, with both vaccinated residents and health care workers 87% less likely than their unvaccinated counterparts to have symptomatic illness. In addition, vaccine effectiveness against hospitalization was more than 94% among residents. Neither vaccinated nor unvaccinated health care workers were hospitalized.

Three residents died, 2 of whom were unvaccinated.

Although the R.1 variant involved in the outbreak is not among variants identified “as a CDC variant of concern or interest,” the authors noted that it has several important mutations. One mutation, D614G, shows evidence of increasing SARS-CoV-2 transmissibility, and other mutations might reduce the effectiveness of neutralizing antibodies.

“Although vaccination was associated with decreased likelihood of infection and symptomatic illness, 25.4% of vaccinated residents and 7.1% of vaccinated [health care personnel] were infected, supporting concerns about potential reduced protective immunity to R.1,” the researchers noted. The study also identified 4 possible reinfections, suggesting that natural immunity to this variant was limited or waning.

“Low acceptance of vaccination among [skilled nursing facility health care personnel] might increase the likelihood of SARS-CoV-2 introduction and transmission within a facility,” they added.

The second CDC report, detailing coronavirus infections in skilled nursing facilities in Chicago, also highlights the importance and effectiveness of vaccination in preventing COVID-19 in high-risk group settings such as nursing homes, as well as the occurrence of breakthrough infections among fully vaccinated individuals. Routine screening of residents and staff members turned up 627 coronavirus cases in 75 of 78 skilled nursing facilities.

Of the 627 cases of coronavirus infection, just 22 (4%) occurred in fully vaccinated people, including 12 residents and 10 staff members. Unvaccinated individuals accounted for 71% of infections, and partially vaccinated persons accounted for 23% of cases.

“Although rare, postvaccination breakthrough infection can occur because COVID-19 vaccines do not offer 100% protection,” the authors said.

Most of the cases of breakthrough infections—14 of 22 (64%)—were asymptomatic; 5 individuals experienced mild nonspecific symptoms or mild symptoms specific to COVID-19. Two residents were hospitalized for COVID-19, 1 of whom died.

“Maintaining high vaccination coverage among residents and staff members is also important to reduce opportunities for transmission within facilities and exposure among persons who might not have achieved protective immunity after vaccination,” the authors of the Chicago study said.

The authors of both reports also said their findings demonstrate the importance for nursing homes to follow recommended COVID-19 prevention and control practices. These practices include work restrictions, isolation and quarantine, routine testing of residents and staff members, and use of personal protective equipment, regardless of vaccination status.

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Article Information

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Stephenson J. JAMA Health Forum.

Corresponding Author: Joan Stephenson, PhD, Consulting Editor, JAMA Health Forum (Joan.Stephenson@jamanetwork.org).

Conflict of Interest Disclosures: None reported.

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