By Gary Evans, Medical Writer

Healthcare workers — some of whom were initially hesitant to take one of the rapidly developed COVID-19 vaccines — are receiving immunization in an uneven national rollout marked by delays, chaos, and disruptions. Although there are reports of some healthcare workers declining vaccination, there is a growing perception that most healthcare workers will welcome immunization at a time when the pandemic is worsening.

“For me, at the end of the day, it came down to, ‘Somebody’s got to get it,’” says Courtney Paschal, ADN, RN, an emergency nurse at a VA hospital in Augusta, GA. “That’s how we beat polio and measles — somebody had to get [immunized]. Is there a risk? Absolutely. But this is me standing up and getting this vaccine so we can somehow tackle this virus and save people I care about in the future. That is a small price to pay.”

The vaccination program at her facility was just starting when Hospital Employee Health talked to Paschal, and she was on the waiting list.

“Our facility was only able to lock in [a limited number of] vaccines,” she says. “Ideally, you want to offer it to all healthcare workers, but the priority was to set it aside for any clinical worker in the emergency room or the ICU because we primarily handle the COVID patients.”

The Food and Drug Administration (FDA) has granted emergency use authorizations (EUA) to two messenger RNA vaccines for COVID-19. Both show an efficacy of about 95%. At a meeting on Dec. 10, 2020, the FDA granted emergency use authorization for the vaccine developed by Pfizer and BioNTech in the United States for those age 16 years and older. The FDA followed at a Dec. 17, 2020, meeting with approving an EUA of a vaccine by Moderna for those age 18 years and older. The Centers for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices (ACIP) has voted in favor of distributing both vaccines, with healthcare workers and long-term care residents the first priority.

However, there has been considerably lower uptake of the vaccine than originally projected, in large part due to erratic logistics in various states trying to immunize these first recommended groups. The lack of federal funding and planning to help states conduct the vaccinations has been “appalling,” said ACIP member Beth Bell, MD, MPH, of the University of Washington.

“[Public health] jurisdictions are under immense stress now and have been for quite some time,” Nancy Messonnier, MD, director of CDC’s national center for immunization and respiratory diseases, said at a Dec. 30, 2020, press conference. “As the threat of COVID-19 disease and death remains a problem here in the U.S., jurisdictions are supporting the largest vaccine rollout in the country’s history and trying to maintain standard public health services.” (The transcript is available at: https://www.cdc.gov/media/releases/2020/t1230-cdc-update-covid-19.html.)

Predicting the numbers of vaccinated workers will steadily increase, Messonnier noted the virus was first detected only a year ago. “So far, more than 2.6 million people, including healthcare professionals and nursing home and assisted living facility residents have received the first dose.”

The Pfizer and Moderna vaccines were developed at a record pace, which raised some safety concerns due to perceptions the process had been politicized in an election year.

“I’ll be honest with you — at the very beginning, I was one of those who was absolutely not going to do it,” Paschal says.

After researching the vaccines and talking to experts, Paschal became convinced it was the best option when she saw two of her colleagues contract coronavirus.

“I’m 32, and I work with two other nurses my age with no comorbidities,” she says. “They have both gone to the ICU. It doesn’t discriminate. There is no rhyme or reason to who gets [COVID-19] and why some get so sick. It’s very unpredictable.”

Although there has been some logistical chaos and delays as the vaccine rolls out, the sense of added security with immunization is appealing to some healthcare workers.

“I have two young children and grandparents I take care of, so I am constantly worried about what I’m going to bring home,” Paschal says. “I think I’m going to find a little comfort in having some added protection for myself and others around me.”

On the other hand, there were reports of vaccine reluctance and refusal in the Los Angeles area, with reports of from 20% to 40% frontline nurses and doctors declining an initial offer of vaccine in Los Angeles County.1

In a bizarre incident still under investigation as this report was filed, a hospital pharmacist at Aurora Medical Center in Grafton, WI, admitted to intentionally removing vials of Moderna vaccine from a refrigerator to render them useless. The hospital reported 57 vials — enough for more than 500 doses — had to be discarded after 12 hours at room temperature.

“We immediately launched an internal review and were led to believe this was caused by inadvertent human error,” Aurora Medical said in a statement on Dec. 30, 2020. “The individual in question today acknowledged that they intentionally removed the vaccine from refrigeration. We have notified appropriate authorities for further investigation. We continue to believe that vaccination is our way out of the pandemic. We are more than disappointed that this individual’s actions will result in a delay of more than 500 people receiving their vaccine. This was a violation of our core values, and the individual is no longer employed by us.” (The statement is available at: https://www.advocateaurorahealth.org/news/coronavirus-disease-covid-19-updates-from-advocate-aurora-health.)

The pharmacist was subsequently arrested, but close to 60 healthcare workers had been immunized with the first dose of the non-refrigerated vaccine. The employees should be at no risk, but they cannot be assumed to be adequately protected and may be reimmunized.2 There is no evidence that any other vaccines were tampered with, and the hospital is continuing to immunize employees despite the actions of one “bad actor,” Jeff Bahr, MD, president of Aurora Health Care Medical Group, said at a press conference.

“It’s important to note that despite the actions of one individual, the vaccine program here and [others] across the country remain safe and critical to get us out of the pandemic,” he said. (The statement is available at: https://www.advocateaurorahealth.org/news/coronavirus-disease-covid-19-updates-from-advocate-aurora-health.)

In another unusual incident, 60 ED staff members at Kaiser Permanente San Jose (CA) Medical Center tested positive for COVID-19 between Dec. 27 and Jan. 5, according to multiple news reports. One staff member died. Investigators are looking into whether the outbreak was caused by a staff member’s attempt to boost morale by visiting the ED in an air-powered costume on Christmas Day. The staff had received one dose of vaccine 10 days earlier, but both currently approved vaccines require a second dose several weeks after the first.3

There is broad consensus that healthcare workers and long-term care residents were the appropriate pick as top priority for the vaccine, but state health jurisdictions have some flexibility to administer immunizations in accordance with their local situations. Texas public health officials recently advised healthcare workers without access to vaccine in their facilities to seek immunization at larger systems and community pharmacies.

“Some healthcare workers who work in smaller settings and are not affiliated with a large institution are reporting difficulty in accessing the vaccine,” the health department noted. “Hospitals and other large providers may be in a unique position to assist in this unprecedented situation by serving as community vaccinators for healthcare workers in Phase 1a.”4

Some healthcare systems reported communication breakdowns and confusion about which staff members should receive the vaccine. An estimated 1,300 resident/fellow physicians in training were left out of first-round vaccination at Stanford University because of a reported problem with an algorithm to guide the process. Stanford officials apologized for the error and moved to correct the situation after the residents protested and sent a blistering letter to administration.

“It is important for us to articulate to you that at this time, residents are hurt, disappointed, frustrated, angry, and feel a deep sense of distrust toward the hospital administration, given the sacrifices we have been making and the promises that were made to us,” according to the letter. “Many of us know senior faculty who have worked from home since the pandemic began in March 2020, with no in-person patient responsibilities, who were selected for vaccination. In the meantime, we residents and fellows strap on N95 masks for the tenth month of this pandemic without a transparent and clear plan for our protection in place.”5

An element of PPE fatigue, particularly concerning the tight-fitting N95 respirators, has some healthcare workers hoping they can scale down a bit after receiving two doses of vaccine. Hamad Husainy, DO, FACEP, an emergency physician at Helen Keller Hospital in Sheffield, AL, says at times during the pandemic, he has worn an N95 respirator at all times for all patients. He may revert to a surgical mask after becoming fully immunized.

“Some of my colleagues might debate or question that, but at some point we have to figure out how to revert, and of course the vaccine will help with that,” he says. “The temptation is going to be ‘I don’t need to be as protected [with PPE] because I have had the vaccination.’”

In vaccinating healthcare personnel (HCP), employee health departments should know the systemic signs and symptoms that may follow the first few days after immunization, the CDC advised.

“Systemic signs and symptoms, such as fever, fatigue, headache, chills, myalgia, and arthralgia, can occur following COVID-19 vaccination,” the CDC stated.6 “Inform HCP about the potential for short-term systemic signs and symptoms post-vaccination and potential options for mitigating them if symptoms arise (e.g., nonsteroidal anti-inflammatory medications or acetaminophen).”

These symptoms can appear the same day and the following two days, with most presenting on the day after immunization. The reactions are more frequent and severe following the second dose of vaccine, which is given 21 days later for the Pfizer vaccine and 28 days for Moderna.

In contrast to vaccine reactions, cough, shortness of breath, rhinorrhea, sore throat, or loss of taste or smell are more consistent with SARS-CoV-2 infection. “Strategies are needed for healthcare facilities to appropriately evaluate and manage post-vaccination signs and symptoms among HCP,” the CDC said.6 The idea is to avoid unnecessarily excluding HCP with only post-vaccination signs and symptoms from work while detecting those that may have SARS-CoV-2 or other infections. (See Table 1.)

Ideally, workers could be immunized before days off using a system of staggered delivery so not everyone in a single department or unit is vaccinated at the same time, the CDC advised.

Husainy says his hospital uses this approach. He also has scheduled days off after his vaccination — which, at one point, he questioned taking.

“I was very skeptical for a while,” he acknowledges. “I knew the science was going to have to come out about it [eventually]. I was able to do a little research and understand the [vaccine] mechanism. It would be prudent to have a little more data and proof, so to speak, that it will not cause adverse events. But being on the frontlines, I recognize the need to make sure that we all stay safe. The other thing is I’m just sort of tired of [COVID-19]. I’m ready for it to be over. I think a lot people are. There is a subset of people who want to take [the vaccine] just to get this thing over with. Let’s move on.”

Concurring with this sentiment is Mike Hastings, MSN, RN, CEN, immediate past president of the Emergency Nurses Association (ENA), which recommends vaccination for its members.

“We looked at the evidence and felt this is our best option,” he says. “The vaccines look safe — definitely the benefit gained outweighs any potential risk. It definitely outweighs the risk of prolonging this pandemic and waiting for further information. I’m scheduled to get my vaccine in just a couple of hours, and I look forward to being able to get it.”

The logistical delays and confusion at some facilities is due in part to the CDC designating all healthcare workers in the 1a category to receive immunization. There may be insufficient vaccine supplies in many areas, so a lot of the healthcare workforce will be immunized in stages.

If this is the case, the CDC recommends considerations for sub-prioritization of equal importance:

  • HCP with direct patient contact who are unable to telework;
  • HCP working in residential care or long-term care facilities;
  • HCP with documented acute COVID-19 infection in the preceding 90 days may choose to delay vaccination until near the end of the 90-day period to facilitate vaccination of HCP susceptible to infection, as evidence suggests reinfection is uncommon during this period after initial infection.

“Every healthcare organization is essentially having to figure out how they are administering them and getting them out to the frontline staff,” Hastings says. “Hospitals are having to decide who do we do first. Out of all of our employees, who are the most at risk? What we are seeing is that emergency departments, the ICU, and the units where COVID-19 patients are being housed are kind of the priority right now. The goal is to vaccinate all staff, and it’s just going to be a matter of time before we vaccinate everyone.”

Having looked at the risks and benefits of immunization, Hastings says the shortened timeline for vaccine development essentially cut out a lot of “red tape.”

“The research studies — with a [large] number of people who got the vaccine — met the standards,” he says. “They were completely blinded studies that met the level of evidence that one would want. It’s reassuring to know that.”

Having seen people ill with COVID-19 come into the ED, Hastings saw the risk of remaining unvaccinated.

“It will put me more at ease to know that I have helped my own body’s self-defense,” he says. “I’m not going to lighten up on wearing my mask [or stop] social distancing. I will still adhere to those things until we get the community immunity we need.”

Editor’s note: The ENA has posted “COVID Bytes,” audio and video clips that include an explanation of how the vaccines work and advice modeling model science-driven behavior, at: https://www.ena.org/practice-resources/COVID-19.

REFERENCES

  1. Shalby C, Baumgaertner E, Branson-Potts H, et al. Some healthcare workers refuse to take COVID-19 vaccine, even with priority access. Los Angeles Times. Dec. 31, 2020. https://www.latimes.com/california/story/2020-12-31/healthcare-workers-refuse-covid-19-vaccine-access
  2. Romo V. Pharmacist arrested, accused of destroying more than 500 Moderna vaccine doses. NPR. Dec. 31, 2020. https://www.npr.org/2020/12/31/952536531/pharmacist-arrested-accused-of-destroying-more-than-500-moderna-vaccine-doses
  3. Hollyfield A, Nguyen C, Gee L. 1 dead, 60 infected in COVID-19 outbreak at San Jose Kaiser hospital. ABC 7 News. Jan. 5, 2021. https://abc7news.com/kaiser-outbreak-permanente-san-jose-medical-center-coronavirus-bay-area-covid-19/9386112/
  4. Texas Department of State Health Services. Guidance on vaccinating Phase 1A and 1B populations. Dec. 24, 2020. https://www.dshs.texas.gov/immunize/covid19/12242020-Guidance-on-Vaccinating-Phase-1A-and-1B-Populations.pdf
  5. Chief Residents, Emergency Medicine Department, Department of Surgery, Department of Anesthesiology, et al. Stanford University. Letter to Stanford University, Stanford School of Medicine, Stanford Health Care, and Stanford Children’s Health Leadership. Dec. 17, 2020. https://assets.documentcloud.org/documents/20432343/stanford-letter.pdf
  6. Centers for Disease Control and Prevention. Post vaccine considerations for healthcare personnel. Updated Dec. 13, 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/post-vaccine-considerations-healthcare-personnel.html

 

 

        
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
                            

Table 1. Suggested Approaches to Evaluating and Managing New-Onset Systemic
Post-Vaccination Signs and Symptoms in HCP

                        
                            

HCP Signs and
Symptoms

                        
                            

Suggested Approach

                        
                            

Additional Notes

                        
                            

Signs and symptoms unlikely to be from
COVID-19 vaccination:

                            

Presence of ANY systemic signs and symptoms consistent with SARS-CoV-2 infection (e.g., cough, shortness of breath, rhinorrhea, sore throat, loss of taste or smell) or another infectious etiology (e.g., influenza) that are not typical for post-vaccination signs and symptoms.

                        
                            

Exclude from work pending evaluation for possible etiologies, including SARS-CoV-2 infection, as appropriate.

                            

Criteria for return to work depends on the suspected or confirmed diagnosis. Information on return to work for HCP with SARS-CoV-2 infection is available at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/return-to-work.html.

                        
                            

If performed, a negative SARS-CoV-2 antigen test in HCP with signs and symptoms that are not typical for post-vaccination signs and symptoms should be confirmed by SARS-CoV-2 nucleic acid amplification test (NAAT). Further information on testing is available here:

                            

https://www.cdc.gov/coronavirus/2019-nCoV/lab/index.html

                        
                            

Signs and symptoms that may be from either COVID-19 vaccination, SARS-CoV-2 infection, or another infection:

                            

Presence of ANY systemic signs and symptoms (e.g., fever, fatigue, headache, chills, myalgia, arthralgia) that are consistent with post-vaccination signs and symptoms, SARS-CoV-2 infection or another infectious etiology (e.g., influenza).

                            

Fever in healthcare settings is defined as a measured temperature of 100.0°F (37.8°C) or higher.

                        
                            

Evaluate the HCP. HCP who meet the following criteria may be considered for return to work without viral testing for SARS-CoV-2:

                            

• Feel well enough and are willing to work and

                            

• Are afebrile* and

                            

• Systemic signs and symptoms are limited only to those observed following COVID-19 vaccination (i.e., do not have other signs and symptoms of COVID-19 including cough, shortness of breath, sore throat, or change in smell or taste).

                            

If symptomatic HCP return to work, they should be advised to contact occupational health services (or another designated individual) if symptoms are not improving or persist for more than two days. Pending further evaluation, they should be excluded from work and viral testing should be considered. If feasible, viral testing could be considered for symptomatic HCP earlier to increase confidence in the cause of their symptoms.

                            

*HCP with fever should, ideally, be excluded from work pending further evaluation, including consideration for SARS-CoV-2 testing. If an infectious etiology is not suspected or confirmed as the source of their fever, they may return to work when they feel well enough.

                            

In facilities where critical staffing shortages are anticipated or occurring, HCP with fever and systemic signs and symptoms limited only to those observed following vaccination could be considered for work if they feel well enough and are willing. These HCP should be re-evaluated, and viral testing for SARS-CoV-2 considered, if fever does not resolve within two days.

                        
                            

If performed, a negative SARS-CoV-2 antigen test in HCP who have symptoms that are limited only to those observed following COVID-19 vaccination (i.e., do not have cough, shortness of breath, sore throat, or change in smell or taste) may not require confirmatory SARS-CoV-2 NAAT testing. Additional information is available here: https://www.cdc.gov/coronavirus/2019-ncov/lab/resources/antigen-tests-guidelines.html

                        
                            

SOURCE: Centers for Disease Control and Prevention, https://www.cdc.gov/coronavirus/2019-ncov/hcp/post-vaccine-
considerations-healthcare-personnel.html