Assessment of Provision of COVID-19 Vaccination in Dialysis Clinics and Patient Vaccination Coverage

For patients who undergo maintenance dialysis, COVID-19 is associated with increased risk for severe illness and death.^1-3 However, this population was not specifically recommended to be prioritized for COVID-19 vaccination.⁴ On March 25, 2021, a federal effort was announced to offer COVID-19 vaccinations in dialysis clinics as part of the COVID-19 Health Equity Plan.⁵ Two national dialysis care organizations—DaVita Inc and Fresenius Medical Care—partnered with the Centers for Disease Control and Prevention (CDC) to provide COVID-19 vaccination in their clinics and coordinate vaccine distribution to other dialysis organizations. We evaluated COVID-19 vaccination in dialysis clinics, vaccination coverage, and disparities from December 1, 2020, to June 13, 2021.

In this public health program evaluation, eligible patients had an active DaVita or Fresenius clinic admission and 1 or more in-center or home dialysis treatments between December 1, 2020, and June 13, 2021. Beginning December 2020, patients undergoing dialysis could receive COVID-19 vaccination at dialysis clinics or other locations subject to availability and local eligibility. Beginning March 29, 2021, dialysis clinics could receive federally supplied COVID-19 vaccines for in-clinic administration. Participating DaVita and Fresenius clinics (N = 5192) tracked patients’ race and ethnicity, vaccination status, and location of vaccination.

We calculated vaccination status based on 1 or more vaccine doses and examined coverage on the date preceding initiation of federal allocation (March 28, 2021) and on June 13, 2021. Proportions were compared using χ² tests. This activity was reviewed by the CDC and conducted per applicable federal law and CDC policy.

In all, 483 602 patients were included: 17.3% Hispanic, 4.1% non-Hispanic Asian, 32.1% non-Hispanic Black, 40.6% non-Hispanic White, 2.9% other, and 3.1% unknown. By June 13, 2021, 64.5% of patients had received at least 1 COVID-19 vaccine dose (Table). Before federal vaccine allocation, vaccination coverage among non-Hispanic White patients was 52.0%, exceeding that among non-Hispanic Black patients (45.2%) and similar to Hispanic patients (51.3%); non-Hispanic Asian patients had higher coverage (60.0%). By June 13, 2021, vaccination coverage among non-Hispanic Black patients approached that for non-Hispanic White patients (63.0% vs 65.5%) and was higher among non-Hispanic Asian (74.1%) and Hispanic (69.5%) patients than non-Hispanic White patients.

Overall, 50.7% of patients were vaccinated in a dialysis clinic (Figure). Among non-Hispanic White vaccinees, 42.5% received vaccination in a dialysis clinic; in comparison, Hispanic (62.2%), non-Hispanic Black (55.4%), and non-Hispanic Asian (49.5%) patients were more likely to receive vaccination in a dialysis clinic (P < .001 for each comparison).

Of all vaccinated patients, 50.7% were vaccinated in a dialysis clinic, and Hispanic patients had greater vaccination coverage than non-Hispanic White patients after the federal vaccine allocation increased clinic access to vaccine. Offering vaccination at the regular point of care may facilitate vaccinations in minority groups disproportionately affected by COVID-19 and may have improved vaccine access for Hispanic and Black patients.

Higher proportions of racial and ethnic minority patients than non-Hispanic White patients received vaccination in a dialysis clinic, suggesting that offering vaccines in a convenient location by a trusted source was particularly beneficial to these groups. Few other strategies have demonstrated reductions in vaccination disparities.⁶

This evaluation had limitations. Although we focused on partial vaccination, 90.0% of patients who received at least 1 dose were fully vaccinated by July 11, 2021. Incomplete tracking of vaccinations administered outside of dialysis clinics may have occurred. In addition, some patients had limited duration of care and opportunity for in-clinic vaccination.

The findings suggest that offering COVID-19 vaccines within dialysis clinics could reduce vaccination disparities. The federal vaccine allocation improved the ability to vaccinate high-risk patients when many states still had a limited vaccine supply. For ongoing and future vaccination efforts, public health agencies and policy makers should consider ensuring vaccine is available to dialysis clinics for onsite administration.

Accepted for Publication: February 8, 2022.

Published Online: April 4, 2022. doi:10.1001/jamainternmed.2022.0627

Corresponding Author: Priti R. Patel, MD, MPH, Centers for Disease Control and Prevention, 1600 Clifton Rd, MS US 12-3, Atlanta, GA 30329 (ppatel@cdc.gov).

Author Contributions: Drs Patel and Tanz had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: Patel, Tanz, Hamilton, Giullian, Novosad.

Drafting of the manuscript: Patel, Novosad.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Patel, Tanz, Hamilton.

Obtained funding: Giullian.

Administrative, technical, or material support: Patel, Tanz, Swanzy, Giullian.

Supervision: Patel, Hymes, Giullian, Novosad.

Conflict of Interest Disclosures: Dr Patel reported having stock ownership in Pfizer and Johnson & Johnson. Dr Hamilton reported being an employee, with stock options, of Fresenius Medical Care outside the submitted work. Ms Swanzy reported being employed by and having stock ownership in DaVita Inc. Dr Hymes reported being employed by Fresenius Medical Care during the conduct of the study and outside the submitted work. Dr Giullian reported being employed by and having stock ownership in DaVita Inc during the conduct of the study, receiving income from and having stock ownership in DaVita Inc outside the submitted work, and being a member of the Nephrosant Board of Directors. No other disclosures were reported.

Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Additional Contributions: The authors thank the following individuals for their contributions to the Federal Dialysis Provider COVID-19 Vaccine Partnership: Sarah Mahlstedt, PhD, Gauri Adettiwar, MPH, Chris Duggar, MPH, Anita Patel, PharmD, MS, Carolyn T.A. Herzig, PhD, MS, Heather Ewing Ogle, MPH, MA, Matt Henn, MPH, MBA, Michael J. Asselta, MBA, Jarrod Pearson, JD, Ginine Brentar, MPA, Stephanie Hendrickson, MBA, Bill Crawford, Nathan Muzos, BS, Mary New, DNP, MSN/INS, RN, Nkenge H. Jones-Jack, PhD, MPH, Roua El Kalach, PharmD, BCPS, Robert Truelove, Suzanne O’Neill, BA, Kathleen Belmonte, MS, RN-CS, MBA, Chance Mysayphonh, PharmD, Julie Hawkins, JD, Lucy Cosgrove, MPH, Milton Martinez, DrPH, MPH, Alan S. Kliger, MD, Jeffrey Silberzweig, MD, Lori B. Moore, PharmD, Ruth Link-Gelles, PhD, Angela Guo, MPH, Melisa Thombley, JD, Robert J. Kossmann, MD, Mark Gray, BS, Ashley Wadley, MPH, Israel Cross, PhD, Joanna Willetts, MS, Parker Calbert, MBA, Adrienne Adkins-Provost, DBA, MSL, RN, William J. Valle, Javier J. Rodriguez, MBA, and Susan Stark.