Association of State COVID-19 Vaccine Mandates With Staff Vaccination Coverage and Staffing Shortages in US Nursing Homes
Original Investigation
Question Are state COVID-19 vaccine mandates for US nursing home employees associated with staff vaccination coverage and reported staff shortages?
Findings This cohort study of nursing homes in 38 states found that states with a vaccine mandate experienced an increase in staff vaccination coverage compared with facilities in states with no mandate and no worsening of reported staffing shortages following the mandates.
Meaning These findings suggest that given the waning vaccine-induced immunity and low booster dose coverage among nursing home staff in many parts of the US, state mandates for booster doses may be warranted to improve and sustain vaccination coverage in nursing homes.
Importance Several states implemented COVID-19 vaccine mandates for nursing home employees, which may have improved vaccine coverage but may have had the unintended consequence of staff departures.
Objective To assess whether state vaccine mandates for US nursing home employees are associated with staff vaccination rates and reported staff shortages.
Design, Setting, and Participants This cohort study performed event study analyses using National Healthcare Safety Network data from June 6, 2021, through November 14, 2021. Changes in weekly staff vaccination rates and reported staffing shortages were evaluated for nursing homes in states with mandates after the mandate announcement compared with changes in facilities in nonmandate states. An interaction between the mandates and county political leaning was considered. Data analysis was performed from February to March 2022.
Exposures Weeks after announcement of a state’s COVID-19 vaccine mandate.
Main Outcomes and Measures Weekly percentage of all health care staff at a nursing home who received at least 1 COVID-19 vaccine dose, and a weekly indicator of whether a nursing home reported a staffing shortage.
Results Among 38 study-eligible states, 26 had no COVID-19 vaccine mandate for nursing home employees, 4 had a mandate with a test-out option, and 8 had a mandate with no test-out option. Ten weeks or more after mandate announcement, nursing homes in states with a mandate and no test-out option experienced a 6.9 percentage point (pp) increase in staff vaccination coverage (95% CI, −0.1 to 13.9); nursing homes in mandate states with a test-out option experienced a 3.1 pp increase (95% CI, 0.5 to 5.7) compared with facilities in nonmandate states. No significant increases were detected in the frequency of reported staffing shortages after a mandate announcement in mandate states with or without test-out options. Increases in vaccination rates in states with mandates were larger in Republican-leaning counties (14.3 pp if no test-out option; 4.3 pp with option), and there was no evidence of increased staffing shortages.
Conclusions and Relevance The findings of this cohort study suggest that state-level vaccine mandates were associated with increased staff vaccination coverage without increases in reported staffing shortages. Vaccination increases were largest when mandates had no test-out option and were also larger in Republican-leaning counties, which had lower mean baseline vaccination rates. These findings support the use of state mandates for booster doses for nursing home employees because they may improve vaccine coverage, even in areas with greater vaccine hesitancy.
High COVID-19 vaccination coverage among direct care staff is critical to avoid and manage nursing home COVID-19 outbreaks and deaths,1,2 yet many staff remained unvaccinated months after vaccines became available.3 COVID-19 vaccination for nursing home staff serves 3 purposes: (1) to protect residents who are particularly vulnerable to severe infection and may not mount sufficient vaccine-induced immunity,4 (2) to protect staff who themselves have experienced a high toll of infection and morbidity,5,6 and (3) to control viral transmission to mitigate nursing home outbreaks.1,7 New COVID-19 variants along with low staff vaccination rates in many US nursing homes despite extensive coordinated vaccination campaigns have led several states to implement mandates requiring nursing home employees to be vaccinated against COVID-19.8,9 These state policies were mostly introduced ahead of the federal mandate that was announced as a final rule by the Centers for Medicare & Medicaid Services (CMS) on November 4, 2021.10
How state COVID-19 vaccine mandates affected nursing home workers is largely unknown. Specifically, it is not clear whether mandates necessarily increased staff vaccination rates, and there are several reasons for this lack of clarity. First, state mandates may include a number of potential exemptions that might allow many workers to remain unvaccinated. A number of states adopted mandates that had a test-out option for employees who wanted to remain unvaccinated for any reason, meaning that staff could choose to submit to additional COVID-19 testing in lieu of receiving the vaccine. Likewise, state policies may allow for medical or religious exemptions from the mandate. Finally, mandates may not have been strictly enforced, thereby allowing out-of-compliance staff to continue working.
How state COVID-19 vaccine mandates affected the supply of nursing home workers is also unclear. Many nursing home leaders have expressed substantial concerns that requiring vaccination as a prerequisite for working in a nursing home may lead many direct care staff to leave the industry, potentially worsening the already severe worker shortages experienced by nursing homes throughout the pandemic.11,12
Lastly, how the success of state COVID-19 vaccine mandates may be affected by the predominant political preferences of a given geographic location is also unknown. This factor can strongly influence perceptions of vaccines,13 and has been shown to correlate strongly with vaccine acceptance and uptake.3,14,15 Consequently, mandates may have varying success in terms of achieving their intended policy goal (eg, increasing staff vaccination coverage without worsening staff shortages) in areas with differing political leanings.
A study in Mississippi evaluated how the nation’s first state-level COVID-19 vaccine mandate affected nursing home employees and staff vaccine coverage.16 The findings indicated that in the weeks after the June 15, 2021, enactment , the nursing home staff vaccination rates increased compared with comparator states without a mandate; however, the gains were modest and failed to raise levels to industry benchmarks. Notably, Mississippi’s policy provided a test-out option for employees.
The purpose of this cohort study was to examine the association of state COVID-19 vaccine mandates with staff vaccination coverage and staffing shortages at nursing homes. We examined these relationships among states with and without test-out options in their mandates and across counties with different political leanings.
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