Covid-19 Vaccine Rollout for Elder Care Facilities: A Global Perspective

Abstract:

This article examines how elder care providers across the world handled the COVID-19 vaccine rollout. Its focus is on residential settings—nursing homes, group homes, and assisted living residences—though it also has information from providers on the experience of community-dwelling elders who receive home- and community-based care. The article shares challenges and opportunities faced by providers in 12 countries when rolling out COVID-19 vaccines, focused on acceptance, type, and uptake percentage among providers. It also shares lessons learned and suggested action items to achieve high levels of vaccine uptake.

Key Words:

vaccine rollout, COVID-19, nursing homes, group homes, assisted living residences, vaccine acceptance

During the COVID-19 pandemic, elder care providers experienced unprecedented challenges in attempting to protect residents, who were disproportionately affected by the virus. To protect residents and staff members from this highly infectious and potentially lethal virus, most countries surveyed prioritized vaccination for all residents of long-term care facilities. This would appear to be a straightforward and effective way to reduce the spread and severity of COVID-19. However, if such an approach was rolled out without careful consideration of promoting global equity, it might intensify already existing health disparities.

This article examines how elder care providers in various parts of the world handled the COVID-19 vaccine rollout for elders and staff members. Its focus is on residential settings such as nursing homes, group homes, and assisted living residences, though it has also integrated information from providers on the experience of community-dwelling elders who receive home- and community-based care. The article shares challenges and opportunities faced by providers in 12 countries involving the rollout of the COVID-19 vaccination process with the focus on three areas: vaccine acceptance, type of vaccines, and vaccine uptake percentage among providers. It also shares lessons learned and suggested action items to achieve high levels of vaccine uptake.

The mass COVID-19 vaccination rollout was swiftly coordinated in countries such as Israel and the United Kingdom, while others struggled to acquire enough vaccines and/or to coordinate logistics. Since the vaccine rollout started in December 2020, each country has been dealing with unique challenges in instituting mass vaccination. However, despite these challenges, enough people have been vaccinated to significantly slow the spread and lethality of the disease.

Despite the outbreak of a deadlier new variant that first emerged in December 2020, far fewer new cases resulted in hospitalizations and deaths than before the vaccine was available as of this writing in Fall, 2021. This underlines the continued importance of vaccinating those most at risk of hospitalization or death from COVID-19, including older people—especially those in long-term care facilities, where infections can spread easily. In addition to the threat of severe illness or death, there is the effect on quality of life to consider. Most providers have limited visits from family and friends and access to in-person social events and activities for residents for a long period of time because vaccine uptake rates in their areas are still too low for comfort.

As the COVID-19 vaccine rollout progresses, providers and policy makers face critical questions about how to ensure a high rate of vaccinations and follow-up vaccinations (i.e., booster shots) among elders and staff members. Due to the serious worker shortage, policies and logistics for the vaccinations should be as accessible as possible, to avoid creating hurdles to employment. For example, providers might offer pay for time off taken to receive or recover from the vaccine, and they should clearly spell out any local policies that mandate vaccines for elder care workers.

Because COVID-19 is the deadliest pandemic in recent history, the vaccine rollout has highlighted healthcare challenges and inequities on a global level. The most critical issue is a lack of equitable distribution of the vaccine, a challenge that urgently calls for an international solution. The pandemic also revealed the importance of broader public health-related discourse about how to resolve the conflict between individual interests in making private healthcare decisions and public health interests.

While knowledge and data about COVID-19 in healthcare settings has been widely disseminated, there has been limited collaboration between elder care providers or sharing of the knowledge they gained on the front lines of the pandemic and the vaccination effort. For example, which ways of preparing residents and staff for the vaccine were helpful? Which were not? What education and outreach strategies were most effective? Which logistical and communication strategies could be helpful for countries where vaccination uptake is still low? Providers’ answers to these questions could help improve strategies used in the current vaccination effort and in future health crises.

Study Design

The information included in this article comes from two sources. One is desktop research based on published articles, reports, and public data available through reputable websites. The sources of this data are mainly governments, think tanks, and academic and research institutions. The other type of information was gleaned through interviews with academics, policy makers, executive directors of elder care associations, and chief executive officers and directors of elder care organizations in 12 countries.

Data Collection

Due to geographical distances and language limitations, interviews were conducted remotely via video conference and email communication. A semi-structured interview was employed to allow participants to provide details about their experiences and insights. Its purpose was to shed light on how providers acquired and administered COVID-19 vaccines to their residents and staff members, how they prepared residents and staff for the vaccine, and how they perceived the effectiveness of guidelines and policy support for the COVID-19 vaccine rollout.

The information collected through interviews is current as of the date the interviews were conducted (March–July 2021). Interviewees also were contacted in mid-October 2021 to share updated information on vaccination rates in their organizations and more. The organizations’ situations and programs, as well as the policies of their governments, may have changed since then.

Participants

Twenty participants completed semi-structured interviews. They were identified through connections with the Global Ageing Network and the Atlantic Fellows Program in Oxford, England. Senior managers in selected organizations were contacted by members of the Global Ageing Network and asked whether they would like to participate in a video conference interview with a researcher.

Table 1: Participants' Information

Findings

Findings from desktop research, interviews, and content analysis are organized by three areas. This section introduces the emerged global trends and patterns of the vaccine rollout in relation to elder care settings: vaccine acceptance, type of vaccines, and vaccine uptake percentage among providers.

Vaccine Acceptance

Vaccine acceptance among residents was high in most of the countries. Refusals came from family members who were worried about side effects, frailty, and rumors and misinformation that had been spread through social media. South Africa had a lower acceptance rate among residents than the other countries, due to religious reasons and/or the fear of side effects.

The vaccination acceptance rate was initially lower among staff members, due mainly to fears spurred by misinformation, religious objections, and existing medical conditions. One common concern, based on unfounded rumors, was that the vaccine would interfere with fertility. Some staff members wanted to wait and see what happened to others who were vaccinated before receiving a vaccine. Many eventually decided to be vaccinated. In some countries, providers were not able to know staff members’ vaccination status due to privacy law.

In middle- to lower-income countries, acceptance rates were higher among staff members from the beginning. According to a few providers, staff appreciated having access to vaccines. To encourage staff members to be vaccinated, providers in Canada, Australia, and the Netherlands arranged to give them two days’ paid leave. Almost one year after the vaccine rollout started, Australia, Canada, and the U.K. made vaccination mandatory for healthcare and elder care workers. Due to the staff shortage, most providers found it challenging to care for residents while staff members were receiving or recovering from vaccinations.

Chart 1 shows the timing and progress of the vaccine rollout process in the 12 countries. This chart clearly shows the inequity of vaccine distribution on a global level. It also shows the level of national governmental leadership and capacity for implementing an effective mass vaccination process. Starting dates and speed of vaccination varied, but a few distinct patterns emerged. High-income countries were able to start vaccinating people more quickly than middle- to low-income countries, except for a few, such as Australia and Japan. They also more quickly secured enough vaccine for the needed number of doses.

Providers in Argentina and South Africa mentioned that they waited a long time between the first and second doses due to a vaccine shortage. According to the World Health Organization (WHO), more than 80% of the world’s COVID-19 vaccines were supplied to high-income countries, with just 0.3% to people in low-income countries receiving them by April 2021 (WHO, 2021). It shows the total number of people who received all the doses prescribed for the vaccine they received, divided by the total population of the country.

What is striking about this result is the clear divide between high- and middle- to low-income countries. This may be due to vaccine availability, logistical challenges involving mass vaccine rollout, hesitancy to take the vaccines (especially among younger people), and limited access to vaccination sites.

Chart 1: Share of the Population Fully Vaccinated Against COVID-19

Type of Vaccines

As Table 2 shows, different types of vaccines are available in the participating countries. Among the eight types of vaccines, all administered Pfizer/BioNTech. Moderna was used in all but the Dominican Republic. The third most popular type was AstraZeneca, which was used by 9 countries except for Singapore, South Africa, and Israel. Johnson & Johnson was used by Mexico, South Africa, and European countries. Chinese and Russian vaccines were not as popular as others. It appears that higher-income countries administered Pfizer, AztraZeneca, Moderna, and Johnson & Johnson. Middle- to lower-income countries also use these vaccines, but added Chinese and Russian vaccines as well.

Table 2: Type of Vaccines in 12 Countries

Source: Our World in Data, Coronavirus (COVID-19) Vaccination 

Vaccine Uptake Percentage Among Providers

Table 3 shows the percentage of vaccine uptake among residents and staff members for interview participants. This table also lists the countries that enforced mandatory vaccination for elder care workers. Vaccine uptake is much higher in all countries for residents and staff members than for the total population. The highest vaccination rates among staff members were reached due to government mandates. At the same time, even countries that did not mandate the vaccine had relatively high vaccination rates over time. This could be thanks to the leadership of elder care providers, peer support within the industry, and a government willing to prioritize vaccination for elders in long-term care settings.

Table 3: Vaccine Uptake Percentage Among Providers in 12 Countries

Key Lessons Learned

Learning from past crises and developing a deep and multicultural understanding of the ongoing challenges they posed may help elder care providers to better prepare for future emergency planning. Six key lessons and action items emerged from interviews with providers and other stakeholders around the world:

Lesson 1:

National governmental leadership was key to an effective COVID-19 vaccine rollout.

Action items:

• Establish a national level of leadership and secure funding to acquire vaccines quickly.

• Develop educational campaigns to encourage elder care workers to get vaccinated.

• Combat misinformation spread by social networking systems.

• Make vaccination sites available near where elders live, ideally within walking distance.

• Develop a vaccination system that allows elders and their loved ones to make appointments and access vaccination sites easily and without long waits.

Lesson 2:

Elders living in long-term care facilities were able to access vaccinations more easily than community-dwelling elders, due to organizational support.

Action items:

• Develop a more holistic vaccine rollout system that includes elders and staff members in facilities and elders receiving home- and community-based services.
• Develop a person-centered vaccine rollout system to ensure that elders with dementia are able to obtain vaccinations.
• Design an effective appointment system with multiple ways for community-dwelling elders to easily make vaccination appointments.
• Develop a system of training to allow in-house nurses to administer vaccinations to elder care facility residents and staff.
• Use long-term care facilities as resource hubs for community-dwelling elders.

Lesson 3:

Staff members had lower vaccine acceptance rates than elders.

Action items:

• Clearly define the priority group for vaccinations, making sure elder care and home- and community-based care workers are included in “healthcare workers.”
• Make vaccination schedules and access as convenient as possible (e.g., on-site vaccination for staff members).
• Pay staff members for their time spent getting to and receiving vaccines and transportation costs.

Lesson 4:

COVID-19 revealed a lack of equitable distribution and choices of vaccines.

Action items:

• Have further conversations on the equitable distribution of vaccines during a global pandemic, with the aim of ensuring that:
  • Higher-income countries will not be able to acquire vaccines earlier than middle- and lower-income countries in the future.
  • Most or all of the major brands of vaccines will not go to higher-income countries, forcing middle- and lower-income countries to acquire less popular and presumably less effective vaccines.
  • Distribution will be equitable for urban and rural areas and for residents of all income levels and ethnicity within every country.

Lesson 5:

The COVID-19 vaccine rollout shed light on ethical considerations in relation to public health.

Action items:

• Develop robust strategies to encourage staff members to vaccinate, while respecting their privacy and right to choose.
• Start a conversation on the balance between public health benefits and personal rights in a pandemic.
• Develop guidelines and strategies on how to avoid discrimination against unvaccinated people.
• Develop a vaccination procedure that does not create a technology divide that disadvantages people due to age, income, or education.

Lesson 6:

Streamlined communication with a designated contact point was key to an effective vaccine rollout.

Action items:

• Establish streamlined communications with key government sectors to avoid creating confusion when sharing information about the vaccine process among providers, family members, and staff members.
• Establish a designated contact division or individual to provide information to and answer questions from providers via phone, video call, and email.

Concluding Thought

Almost two years since our world began living with COVID-19, we are still facing challenges. To protect the lives of frail older adults in elder care facilities, it is crucial that we advance our discussions on ethical responsibilities among elder care providers, learning from their experiences. We hope the insights shared by providers in this article will reach other providers around the world, contributing to a sharing of knowledge that will allow us collectively to better prepare for future pandemics.

This study revealed global equity and ethical issues. It was clear that there is lack of equity in access to and choice of vaccines, with higher-income countries doing far better than their less affluent counterparts. Close to a year into the vaccination process, some countries have surplus vaccines, thanks to citizens who refuse to get vaccinated, while others struggle with not having enough. These inequities occur not only between countries but within countries, as urban areas rack up high rates of vaccination while rural areas lag behind. (Kaiser Family Foundation, 2021)

There is a growing need for international collaboration to tackle this global pandemic. Considering that elders and staff in elder care settings were disproportionally affected by COVID-19, long-term care sectors will need even stronger collaboration and information exchange systems. It is our hope that this report will generate interest not only among elder care providers but among policy makers and international organizations, strengthening networks to help avoid duplication of efforts and share best practices and lessons learned.

Emi Kiyota, PhD, is an associate professor in the Yong Loo Lin School of Medicine at the National University of Singapore, and Director, Health District at Queenstown.

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