COVID-19 Vaccination Perspectives and Illnesses Among Law Enforcement Officers, Firefighters, and Other First Responders in the US, January to September 2021

Law enforcement officers, firefighters, and other first responders are at increased risk of SARS-CoV-2 infection compared with health care personnel¹ but have relatively low COVID-19 vaccine uptake.² COVID-19 was the leading cause of line-of-duty deaths among US law enforcement officers in 2021 (323 of 482 deaths [67%]).³ Using data from the Arizona HEROES (Healthcare, Emergency Response, and Other Essential Workers Study) and RECOVER (Research on the Epidemiology of SARS-CoV-2 in Essential Response Personnel) cohorts, we assessed attitudes toward COVID-19 vaccination and illness burden among vaccinated and unvaccinated first responders.

The HEROES and RECOVER studies are cohorts of first responders and other essential workers with a shared data collection protocol^4,5 (eMethods in the Supplement). Eligible participants were enrolled in Florida, Minnesota, Oregon, Texas, Utah, and Arizona; were 18 to 85 years of age; and worked at least 20 hours per week in occupations involving direct contact (<3 feet) with others. Information on participant race and ethnicity was self-reported on the enrollment survey to understand how attitudes and vaccination practices differ in the US first responder workforce that is traditionally non-Hispanic White.

From January 1 to September 30, 2021, participants contributed weekly nasal specimens using home-based kits and reported COVID-19–like symptoms via text message. Respiratory specimens were tested using reverse transcriptase–polymerase chain reaction assay for SARS-CoV-2. Participant characteristics were collected at enrollment; COVID-19–related duration of illness and missed work were assessed at the beginning and end of each illness. Vaccine knowledge, attitudes, and practices were assessed in quarterly follow-up surveys. Participants were considered fully vaccinated 14 days after receipt of all recommended primary vaccine doses. All participants provided written informed consent. Study protocols were approved by the institutional review boards at participating sites. This study followed the STROBE reporting guideline.

Sociodemographic characteristics and attitudes toward COVID-19 vaccines were compared for unvaccinated vs fully vaccinated participants with standardized mean difference and χ² and 2-sample t tests. Incidence rates of COVID-19 were calculated from January through September 2021 using repeated-measures Poisson regression (eMethods in the Supplement) and compared by first responder type. Statistical significance was defined as a 2-tailed P < .05. All analysis were conducted with SAS software, version 9.4 (SAS Institute, Inc)

Among 1415 participants, 1113 (79%) were men; 302 (21%), women; 416 (29%), Hispanic; and 1338 (95%), White. In terms of occupation, 964 were firefighters (68%); 238, law enforcement officers (17%); and 213, other first responders (15%) (Table). Mean (SD) age was 41.3 (9.7) years. Of these, 1163 participants (82%) completed an attitude survey (363 of 586 [62%] unvaccinated vs 800 of 829 [97%] vaccinated). Among the fully vaccinated, 406 (35%) said they trusted the government regarding COVID-19 vaccines; among the unvaccinated, 45 (12%) trusted the government. Unvaccinated first responders were less likely than their vaccinated counterparts to believe that COVID-19 vaccines are effective (61 [17%] vs 430 [54%], respectively) or safe (54 [15%] vs 435 [54%], respectively).

A total of 184 COVID-19 illnesses with assay-confirmed SARS-CoV-2 infection were identified among first responders. From January through September 2021, among law enforcement officers, COVID-19 incidence per 1000 person-weeks was 11.9 (95% CI, 7.0-20.1) in unvaccinated and 0.6 (95% CI, 0.2-2.5) in vaccinated individuals. Incidence was also higher among unvaccinated (9.0 [95% CI, 6.4-12.7]) vs vaccinated (1.8 [95% CI, 1.1-2.8]) firefighters. Among participants with laboratory-confirmed COVID-19, mean (SD) duration of illness (15.3 [11.7] vs 19.7 [16.9] days) and missed work (67.6 [25.8] vs 85.2 [49.3] hours) were lower among vaccinated than unvaccinated individuals, but differences were not statistically significant.

This cohort study found that unvaccinated first responders were more likely to develop COVID-19 and less likely to believe in the effectiveness and safety of vaccines than their vaccinated counterparts. Study limitations include a small number of COVID-19 illnesses among vaccinated individuals (n = 24), limiting precision of estimates and precluding adjustment for potential confounders. Most participants were White and from Florida and Arizona, limiting generalizability of the results. Our findings suggest that state and local governments with large numbers of unvaccinated first responders may face major workforce disruptions due to COVID-19 illness. Given the effectiveness of the COVID-19 vaccines during the public health emergency, governments should consider vaccine mandates with regular testing and alternative work assignments for unvaccinated workers. Furthermore, the low trust in government among first responders suggests a need to leverage trusted nongovernmental sources to increase vaccination rates.

Accepted for Publication: May 28, 2022.

Published: July 19, 2022. doi:10.1001/jamanetworkopen.2022.22640

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Caban-Martinez AJ et al. JAMA Network Open.

Corresponding Author: Alberto J. Caban-Martinez, DO, PhD, MPH, Department of Public Health Sciences, Leonard M. Miller School of Medicine, University of Miami, 1120 NW 14th St, Rm 1035, Miami, FL 33136 (acaban@med.miami.edu).

Author Contributions: Ms Grant and Dr Thompson had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Caban-Martinez, Schaefer-Solle, Thompson, Burgess.

Acquisition, analysis, or interpretation of data: Caban-Martinez, Gaglani, Olsho, Grant, Thompson, Burgess.

Drafting of the manuscript: Caban-Martinez, Thompson, Burgess.

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

Statistical analysis: Grant, Thompson.

Obtained funding: Caban-Martinez, Olsho, Thompson, Burgess.

Administrative, technical, or material support: Caban-Martinez, Olsho, Schaefer-Solle, Thompson.

Supervision: Caban-Martinez, Gaglani, Olsho, Thompson.

Conflict of Interest Disclosures: Dr Caban-Martinez reported receiving grants from the National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention (CDC) and grants from Federal Emergency Management Agency (FEMA) to investigate cancer risk in US firefighters during the conduct of the study. Dr Gaglani reported receiving institutional grants from the CDC-Abt Associates during the conduct of the study and grants from the CDC, CDC–Abt Associates, CDC–Vanderbilt University Medical Center, CDC-Westat, and Janssen Pharmaceuticals outside the submitted work. Dr Olsho reported receiving grants from the National Center for Immunization and Respiratory Diseases at the CDC during the conduct of the study. Dr Schaefer-Solle reported receiving grants from the CDC during the conduct of the study. Dr Burgess reported receiving grants from the CDC and FEMA during the conduct of the study. No other disclosures were reported.

Funding/Support: This study was supported by contracts 75D30120R68013 (Marshfield Clinic Research Institute), 75D30120C08379 (University of Arizona), and 75D30120C08150 (Abt Associates) from the National Center for Immunization and Respiratory Diseases and the CDC.

Role of the Funder/Sponsor: Investigators from CDC were involved in all aspects of the study, including design and conduct of the study, analysis and interpretation of the data, and preparation, review, and approval of the manuscript. The CDC had the right to control decisions about publication via the CDC publication clearance process.

Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the collaborating institutions.

Additional Information: Data will be made available by the CDC when objectives of the research are complete.