Disclaimer: Early release articles are not considered as final versions. Any changes will be reflected in the online version in the month the article is officially released.
Volume 28, Number 8—August 2022
Estimating COVID-19 Vaccine Effectiveness for Skilled Nursing Facility Healthcare Personnel, California, USA
We estimated real-world vaccine effectiveness among skilled nursing facility healthcare personnel who were regularly tested for SARS-CoV-2 infection in California, USA, during January‒March 2021. Vaccine effectiveness for fully vaccinated healthcare personnel was 73.3% (95% CI 57.5%–83.3%). We observed high real-world vaccine effectiveness in this population.
The COVID-19 pandemic has severely affected skilled nursing facility (SNF) residents and healthcare personnel (HCP) (1,2). HCP are at high risk for SARS-CoV-2 exposure during patient care (3,4), and were among the earliest groups prioritized for COVID-19 vaccination starting in mid-December 2020 (5). Through June 2021, all SNF HCP in California, regardless of vaccination status or symptoms, were required to undergo at least weekly screening testing for SARS-CoV-2 infection (6). This system provided us with ideal conditions to assess vaccination effectiveness.
We estimated real-world effectiveness of COVID-19 vaccination against PCR-confirmed SARS-CoV-2 infections in SNF HCP in California by using a matched case‒control study. We identified SNF HCP COVID-19 case-patients and controls from the statewide communicable disease reporting system (Appendix). We selected persons 18–54 years of age (Appendix) with specimen collection dates during January‒March 2021. We obtained COVID-19 vaccination status from the California Immunization Registry (Appendix).
We defined partial vaccination as >1 vaccine dose received before specimen collection with a second dose (if received, for a 2-dose series vaccine) <14 days before collection, and full vaccination as the second dose (or 1 dose in a single-dose series) received >14 days before specimen collection. We matched case-patients to controls on specimen collection date and SNF county by using simple random sampling (without replacement) and a 1:1 ratio. We applied conditional logistic regression to estimate vaccine effectiveness for partial and full vaccination (compared with no vaccination).
Because of the density-based selection of the control series, in which controls are time-matched to case-patients, drawing from a risk set of persons who are at risk for becoming case-patients at the time the case is detected, the odds ratio approximates the incidence rate ratio without reliance on the rare disease assumption (7). We examined age, sex, and California Healthy Places Index (HPI) composite health score (8) by using HCP residential address and race and ethnicity (Appendix) as potential confounders.
We performed the analysis before and after excluding case-patients and controls who had previously confirmed positive test results 90- day and 180-day windows (Table). We performed analyses by using SAS version 9.4 (https://www.sas.com). This study received an exempt determination from the California Committee for the Protection of Human Subjects.
Of the 4,238 study participants, 28.9% (1,224) were partially or fully vaccinated; 71.1% (3,014) were classified unvaccinated, including 47.8% (2,025) who did not have a California Immunization Registry COVID-19 vaccination record and 23.3% (989) who were vaccinated on or after specimen collection date. A higher proportion of controls than case-patients were partially or fully vaccinated (Table). Among the fully vaccinated, 91.5% received Pfizer-BioNTech vaccine (https://www.pfizer.com) and 8.5% received Moderna vaccine (https://www.modernatx.com). Among the partially vaccinated, 54% received Pfizer-BioNTech vaccine, 45% received Moderna vaccine, and <1% received a combination of 2 different vaccines (e.g., Pfizer-BioNTech and Moderna). All Johnson & Johnson/Janssen vaccine (https://www.janssencovid19vaccine.com) recipients, representing 1.7% of participants matched to a vaccination record, were classified as unvaccinated because the vaccination date was after the specimen collection date.
Vaccine effectiveness was 73.3% (95% CI 57.5%–83.3%) for full vaccination (Table). We observed no substantial change (<10%) in vaccine effectiveness estimates produced by the models with or without removal of previous positive test results (Table). We assumed the model excluding previous positive test results within 90 days was the most appropriate because this model excludes persons with potential residual viral shedding and agrees with the national COVID-19 disease (new) case definition (9) that excludes persons who had previous positive test results within 90 days. Adjustment for age, sex, and HPI score did not change vaccine effectiveness estimates by >10%, and inclusion of race/ethnicity did not alter the full vaccination estimate by >10% (Appendix Tables 2–5).
A major strength of our study is that SNF HCP were tested regularly irrespective of symptoms or known exposure, enabling us to capture their infection status and estimate vaccine effectiveness for prevention of COVID-19, including asymptomatic infection. The unchanged vaccine effectiveness estimate after adjustment for HPI score reflects that COVID-19 vaccination efforts for SNF HCP engaged persons regardless of their residential community. One limitation is that the study period was before the Delta or Omicron virus variants became dominant. Because serial testing of vaccinated SNF HCP in California stopped during July 2021, the study period could not be expanded to examine effectiveness against later variants or changes in vaccine effectiveness over time since vaccination. In addition, a higher proportion of case-patients and controls were classified as partially vaccinated, rather than fully vaccinated, during the study period, and we did not have sufficient follow-up time to assess waning of vaccine effectiveness. Some residents could have been misclassified as HCP, but the age selection criteria limiting age group helped minimize this factor. Finally, misclassification of vaccination status is possible, but most likely is nondifferential, which we would expect to bias the odds ratio toward the null.
Inconclusion, we observed high real-world effectiveness of COVID-19 vaccination in SNF HCP in California. Our methods can guide future studies evaluating vaccine effectiveness.
Dr. Magro is a research scientist in the Healthcare-Associated Infections Program, Center for Health Care Quality, California Department of Public Health, Richmond, CA. Her primary research interests are healthcare-associated infections and antimicrobial drug resistance.
The California Department of Public Health thanks all California healthcare personnel, laboratorians, and local health departments throughout the COVID-19 pandemic for their diligent work. We thank the California Department of Public Health COVID-19 Science Branch and Data teams and the Center for Health Care Quality Skilled Nursing Facilities Analytics team for their support and data resources provided to successfully complete this study.
- AARP Public Policy Institute. Issues. Long-term services and supports and family caregiving. AARP Nursing Home Dashboard [cited 2022 Jan 11]. https://www.aarp.org/ppi/issues/caregiving/info-2020/nursing-home-covid-dashboard.html
- Kaiser Family Foundation. Coronavirus (COVID-19). Nursing homes experienced steeper increase in COVID-19 cases and deaths in August 2021 than the rest of the country [cited 2022 Jan 11]. https://www.kff.org/coronavirus-covid-19/issue-brief/nursing-homes-experienced-steeper-increase-in-covid-19-cases-and-deaths-in-august-2021-than-the-rest-of-the-country
- Roth A, Feller S, Ruhnau A, Plamp L, Viereck U, Weber K, et al. Characterization of COVID-19 outbreaks in three nursing homes during the first wave in Berlin, Germany. Sci Rep. 2021;11:24441.
- Taylor J, Carter RJ, Lehnertz N, Kazazian L, Sullivan M, Wang X, et al.; Minnesota Long-Term Care COVID-19 Response Group. Serial testing for SARS-CoV-2 and virus whole genome sequencing inform infection risk at two skilled nursing facilities with COVID-19 outbreaks—Minnesota, April–June 2020. MMWR Morb Mortal Wkly Rep. 2020;69:1288–95.
- Dooling K, Marin M, Wallace M, McClung N, Chamberland M, Lee GM, et al. The Advisory Committee on Immunization Practices’ updated interim recommendation for allocation of COVID-19 vaccine—United States, December 2020. MMWR Morb Mortal Wkly Rep. 2021;69:1657–60.
- California Department of Public Health. All facilities letter 20–53 [cited 2022 Jan 6]. https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/AFL-20-53.aspx
- Rothman KJ, Greenland S, Lash T. Case‒control studies. In: Rothman KJ, Greenland S, Lash T. Modern epidemiology, 3rd ed. Philadelphia: Lippincott Williams and Wilkins; 2008. p. 124–5.
- Public Health Alliance of Southern California. The California healthy places index (HPI) [cited 2022 Jan 11]. https://healthyplacesindex.org
- Council of State and Territorial Epidemiologists (CSTE). Update to the standardized surveillance case definition and national notification for 2019 novel coronavirus disease (COVID-19). CSTE position statement 21-ID-01. 2021 Aug [cited 2022 Jan 20]. https://cdn.ymaws.com/www.cste.org/resource/resmgr/21-ID-01_COVID-19_updated_Au.pdf
Suggested citation for this article: Magro M, Parriott A, Mitsunaga T, Epson E. Estimating COVID-19 vaccine effectiveness for skilled nursing facility healthcare personnel, California, USA. Emerg Infect Dis. 2022 Aug [date cited]. https://doi.org/10.3201/eid2808.220650