SciLine interviewed: Dr. Stefan Gravenstein, a geriatrician, professor of medicine, and the director of the division of geriatrics and palliative care at Brown University, as well as associate director of the Providence Veterans Administration Medical Center. His research explores immunity and infection in older adults, including influenza and vaccine responses. In the pandemic, he has been studying COVID-19 epidemiology, transmission, and immunity in nursing homes, and the worrisomely high levels of vaccine hesitancy among nursing home health aides.
What is the thinking behind prioritizing older adults in long-term care facilities for COVID-19 vaccination?
STEFAN GRAVENSTEIN:So a majority of mortality is happening in older adults. And the oldest old fare the worst, and the ones living in nursing homes, the worst of the worst. Assisted living is the step down from that, and other older adults, the step down from that. So those risks are higher than risks from coexisting conditions.
What kind of informed consent is needed for a COVID-19 vaccination? And how is that obtained for older adults with cognitive challenges such as dementia?
STEFAN GRAVENSTEIN: There’s two types of issues here. One of them is, how much consent do they need to be able to give for a public health emergency? And a second type of question is, who is the person who can actually give permission in that individual? So the short and correct answer for this is, you want the person who’s getting the vaccine to at least assent, meaning that they give permission even if they don’t understand it. But there really isn’t quite high enough of a bar. If you’re not confident they can understand what they’re saying yes to, then you’d like to have their durable power of attorney or legally authorized representative weigh in and make sure they agree also. That can be a verbal consent. It doesn’t have to be in writing.
How are long-term care facilities working to prevent vaccine side effects from overwhelming daily activities?
STEFAN GRAVENSTEIN: When we think about vaccine reactogenicity, you should know that younger people have more reactogenicity than older people, so they typically will have a little bit more arm soreness and other kinds of side effects from the vaccine. Having said that, when we look at our health care workers, we have a sample that – in a study that Dr. Barbara Bardenheier is leading, looking for specifically vaccine side effects. So this is a sample of some 24,000 nursing home staff, and in that group, about 60% have been getting the vaccine. And with that, after the first dose in the majority and all of that group of 60% and a second dose in about 10% of them, we’ve only had 24 callouts – 24 people not feeling well enough to go to work the next day. And no serious adverse events where they weren’t able to be back to work within two or three days. No anaphylaxis. In our residents, we had no serious adverse events that were different from people who were not getting the shot.
What measures can help limit COVID-19 exposure during the vaccination process in long-term care facilities?
STEFAN GRAVENSTEIN: I’m not sure if everybody will agree with me on what the approach should be, but the first thing I would do is make sure that the people who are giving the vaccine themselves are vaccinated so they don’t become vectors of disease as they’re handing out vaccine. The second thing is, because of the nature of the cold chain, the difficulty of keeping the vaccine cold until moments before it’s given, I think they have to have sort of procedures set up that allows people to be ready to get vaccinated so that they can go through the supply and not waste any of the vaccine in the process. That means that they need to do sign-up sheets, get the list ready, have a time planned, figure out how long it’s going to take, making sure that everybody can wait the 15-to-30 minutes after the shot to be watched and also have enough room that they can socially distance while all this is happening. So not executed well is, you know, if you can’t keep your 6 feet apart between people when they’re in their line, if the people in the line aren’t also wearing their masks – so if they don’t have masks, they should have masks available that they can put on those residents when they’re coming through – that there’s hand-washing and other kinds of things that they use to augment the personal protective equipment and, ideally, when they’re putting these people in the line, that they have face shields or some other facial coverings to protect inoculation of the eyes in addition to the work with the mask. After the vaccine is done, the people who are getting vaccinated should make sure they do a hand-sanitizing or a hand-washing when they get back, and the face shields or whatever else they’re wearing should get washed, too, if they’re taking that back with them.
How widespread is vaccine hesitancy among health care workers in long-term care facilities?
STEFAN GRAVENSTEIN: The health care workers in nursing homes typically have much lower vaccine uptake than health care workers in other settings. For influenza, for example, when we see health care workers in hospitals getting influenza vaccine, usually the uptake in those settings is between 60% and 95%. In nursing homes, that’s between 50% and 70% for that vaccine, which has been around for a long time. For the SARS-COV-2, the COVID vaccine, nationally, the uptake with the first round of vaccination has been much lower, below 40%. There was a paper published in ARNWR (ph) just on Monday that said it was 38% of staff and the – vaccinated by January 17 in a program where already 78% of residents have been vaccinated in 90% of facilities where vaccine had been offered.
What fuels the anti-vaccine sentiment among staff in long-term care facilities?
STEFAN GRAVENSTEIN: So the reasons why people decline vaccine is the same, I think, whether or not they’re health care workers, and it begins with who your trusted source is. If your trusted source is your best buddy, they may or may not be an expert in vaccines, and then it’s subject to whatever their belief system is. So there is no doubt that minority groups, such as Blacks, have in general lower vaccine uptake for the SARS-COV-2 vaccine and also influenza vaccine, among other vaccines. So the reason that their uptake is low is multifold. One is, who’s their trusted source? And if their trusted source is influenced, for example, from a life or previous life experience from a relative, like the Tuskegee experiments or something like this, then their suspicion about health care workers and whether a program that’s intended to help them is, in fact, maybe something surreptitiously different, then they may have hesitancy that exceeds that of other people.
What can journalists do to address vaccine hesitancy?
STEFAN GRAVENSTEIN: You know, so I think one of the things that people have trouble with is figuring out where to get trusted information. And how do they know that the source they’re getting – that they go to is trusted information? Because clearly, the reason they get it from that source is because they trust them. So I think one of the things that could be done is to say, in addition to your news source, wherever you get your news, here’s a place you can also fact-check. And then give them a place where they can either log in or call or review.