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COVID-19 Vaccine Uptake Among Residents and Staff Members of Assisted Living and Residential Care Communities—Pharmacy Partnership for Long-Term Care Program, December 2020–April 2021

Open AccessPublished:August 24, 2021DOI:https://doi.org/10.1016/j.jamda.2021.08.015

      Abstract

      Objectives

      In December 2020, CDC launched the Pharmacy Partnership for Long-Term Care Program to facilitate COVID-19 vaccination of residents and staff in long-term care facilities (LTCFs), including assisted living (AL) and other residential care (RC) communities. We aimed to assess vaccine uptake in these communities and identify characteristics that might impact uptake.

      Design

      Cross-sectional study.

      Setting and Participants

      AL/RC communities in the Pharmacy Partnership for Long-Term Care Program that had ≥1 on-site vaccination clinic during December 18, 2020–April 21, 2021.

      Methods

      We estimated uptake using the cumulative number of doses of COVID-19 vaccine administered and normalizing by the number of AL/RC community beds. We estimated the percentage of residents vaccinated in 3 states using AL census counts. We linked community vaccine administration data with county-level social vulnerability index (SVI) measures to calculate median vaccine uptake by SVI tertile.

      Results

      In AL communities, a median of 67 residents [interquartile range (IQR): 48-90] and 32 staff members (IQR: 15-60) per 100 beds received a first dose of COVID-19 vaccine at the first on-site clinic; in RC, a median of 8 residents (IQR: 5-10) and 5 staff members (IQR: 2-12) per 10 beds received a first dose. Among 3 states with available AL resident census data, median resident first-dose uptake at the first clinic was 93% (IQR: 85-108) in Connecticut, 85% in Georgia (IQR: 70-102), and 78% (IQR: 56-91) in Tennessee. Among both residents and staff, cumulative first-dose vaccine uptake increased with increasing social vulnerability related to housing type and transportation.

      Conclusions and Implications

      COVID-19 vaccination of residents and staff in LTCFs is a public health priority. On-site clinics may help to increase vaccine uptake, particularly when transportation may be a barrier. Ensuring steady access to COVID-19 vaccine in LTCFs following the conclusion of the Pharmacy Partnership is critical to maintaining high vaccination coverage among residents and staff.

      Keywords

      Following the US Food and Drug Administration's Emergency Use Authorizations of the first vaccines for prevention of coronavirus disease 2019 (COVID-19), the Advisory Committee on Immunization Practices recommended that residents and staff members of long-term care facilities (LTCFs) be prioritized in the first phase of COVID-19 vaccine allocation.
      • Dooling K.
      • McClung N.
      • Chamberland M.
      • et al.
      The Advisory Committee on Immunization Practices' interim recommendation for allocating initial supplies of COVID-19 vaccine - United States, 2020.
      As congregate settings, LTCFs pose increased risk for transmission of SARS-CoV-2, the virus that causes COVID-19,
      Centers for Medicare & Medicaid Services
      COVID-19 nursing home data.
      and residents are also at increased risk for severe COVID-19 illness due to older age or underlying health conditions.
      CDC COVID-19 Response Team
      Severe outcomes among patients with coronavirus disease 2019 (COVID-19) - United States, February 12-March 16, 2020.
      LTCFs include skilled nursing facilities (SNFs) and other nursing homes, assisted living (AL) and other residential care (RC) communities, and residential facilities for persons with intellectual and developmental disabilities. AL/RC communities provide assistance with activities of daily living (eg, bathing and toileting) and may also provide some health care services (eg, management and administration of medications) in a residential setting; these communities represent approximately 44% of US LTCFs.
      • Harris-Kojetin L.
      • Sengupta M.
      • Lendon J.
      • et al.
      Long-term care providers and services users in the United States: Data from the National Study of Long-Term Care Providers, 2015-2016.
      Data from October 2020 indicated that 22% of AL/RC communities with available data reported at least 1 case of COVID-19 among residents or staff members, and that COVID-19–associated mortality among the resident population was significantly higher than that among the general population (21% vs 3%).
      • Yi S.H.
      • See I.
      • Kent A.G.
      • et al.
      Characterization of COVID-19 in assisted living facilities - 39 states, October 2020.
      To facilitate COVID-19 vaccination of residents and staff members in LTCFs, CDC launched the Pharmacy Partnership for Long-Term Care Program in December 2020.
      Centers for Disease Control and Prevention
      Understanding the Pharmacy Partnership for Long-Term Care Program.
      This program, a public-private partnership with 3 pharmacies (CVS, Managed Health Care Associates, and Walgreens), conducted on-site visits to enrolled LTCFs to provide end-to-end management of the COVID-19 vaccination process, including appropriate storage, handling, and transport of vaccines, vaccine administration, and fulfillment of reporting requirements. More than 62,000 LTCFs across 49 states enrolled in the program and received on-site vaccinations for residents and staff members. Early estimates from the first month of the program indicated that a median of 78% of residents and 38% of staff members in SNFs received at least a first dose of COVID-19 vaccine.
      • Gharpure R.
      • Guo A.
      • Bishnoi C.K.
      • et al.
      Early COVID-19 first-dose vaccination coverage among residents and staff members of skilled nursing facilities participating in the Pharmacy Partnership for Long-Term Care Program - United States, December 2020-January 2021.
      Complementing these results, we aimed to assess vaccine uptake in AL/RC communities participating in the program and identify community and county characteristics that might impact uptake. Specifically, we assessed the association between uptake and county-level social vulnerability, which has been shown to impact COVID-19 vaccine uptake in LTCFs
      • Lee J.T.
      • Althomsons S.P.
      • Wu H.
      • et al.
      Disparities in COVID-19 vaccination coverage among health care personnel working in long-term care facilities, by job category, National Healthcare Safety Network - United States, March 2021.
      and broader population settings.
      • Hughes M.M.
      • Wang A.
      • Grossman M.K.
      • et al.
      County-level COVID-19 vaccination coverage and social vulnerability - United States, December 14, 2020-March 1, 2021.
      • Barry V.
      • Dasgupta S.
      • Weller D.L.
      • et al.
      Patterns in COVID-19 vaccination coverage, by social vulnerability and urbanicity - United States, December 14, 2020-May 1, 2021.
      • Whiteman A.
      • Wang A.
      • McCain K.
      • et al.
      Demographic and social factors associated with COVID-19 vaccination initiation among adults aged ≥65 years - United States, December 14, 2020-April 10, 2021.

      Methods

      Participating pharmacies reported LTCF-level aggregate COVID-19 vaccine administration data to CDC through a web-based data platform. This analysis included AL/RC communities that had at least 1 on-site vaccination clinic run by a participating pharmacy from December 18, 2020 (date of first on-site clinic), through April 21, 2021 (date of clinic completion for >99% enrolled communities; data as of April 28, 2021). Communities were classified as AL or RC based on self-identification during program signup. Pfizer-BioNTech COVID-19 vaccine and Moderna COVID-19 vaccine were administered through the program; both products required a 2-dose series for completion. Pharmacies generally conducted 3 on-site clinics at each community for administration of first and second vaccine doses; clinics were scheduled approximately 21-28 days apart depending on vaccine product. Smaller communities may have received only 2 clinics if all residents and staff members were vaccinated and a third clinic was not deemed necessary.
      To estimate uptake, we calculated the cumulative number of first and second doses of vaccine administered to residents and staff members at each clinic and normalized by the reported total bed capacity per community (presented as number vaccinated per 100 reported beds for AL communities and per 10 reported beds for RC communities to account for differences in average community size; Supplementary Tables 1-2). Additionally, we estimated the percentage of residents who received a first dose of COVID-19 vaccine in AL communities in 3 states (Connecticut,
      Connecticut COVID-19 Response
      Nursing homes and assisted living facilities data.
      Georgia,
      Georgia Department of Community Health
      Long-term care facility COVID-19 report.
      and Tennessee
      Tennessee Department of Health
      Long term care facility data.
      ) that reported resident census counts (number of occupied beds) in publicly available COVID-19 reports obtained via systematic website searches
      • Yi S.H.
      • See I.
      • Kent A.G.
      • et al.
      Characterization of COVID-19 in assisted living facilities - 39 states, October 2020.
      during February 2-4, 2021. AL census counts were not available for additional states; RC census counts were available only for a small number of communities and were not included because of insufficient sample size. We linked community-level vaccination data from these states to AL census data using standardized values of community name and address. We calculated the estimated first-dose uptake per 100 residents by dividing the number of first doses of COVID-19 vaccine administered by the reported census count. Estimated first-dose uptake exceeded 100% if reported doses administered were greater than resident census counts.
      We linked AL/RC communities with county-level social vulnerability index (SVI) measures.
      Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry/Geospatial Research, Analysis, and Services Program. CDC/ATSDR Social Vulnerability Index, 2018 Database, US.
      SVI is based on county rankings of 15 census measures associated with social determinants of health and is summarized in 4 themes: (1) socioeconomic status, (2) household composition and disability status, (3) racial or ethnic minority status and language, and (4) housing type and transportation. A higher SVI score indicates higher social vulnerability. For communities without a reported Federal Information Processing Standards (FIPS) code (used for identification of US counties), the address zip code was mapped to the corresponding county FIPS code in the US Department of Housing and Urban Development–US Postal Service zip Code Crosswalk.
      US Department of Housing and Urban Development
      HUD USPS ZIP code crosswalk files.
      When multiple counties mapped to a single zip code, we chose the county with the highest proportion of residential and business addresses. Counties were classified into tertiles for each of the 4 SVI themes. We calculated the median vaccine first-dose uptake among residents and staff members of AL/RC communities by SVI tertile.
      All analyses were performed using SAS statistical software (version 9.4; SAS Institute, Cary, NC) and R (version 4.0.2, R Core Team, Vienna, Austria). This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.
      See eg, 45 CFR part 46, 21 CFR part 56; 42 USC §241(d); 5 USC §552a; 44 USC §3501 et seq.

      Results

      As of April 21, 2021, 18,980 AL communities and 16,874 RC communities conducted COVID-19 vaccination clinics through the Pharmacy Partnership for Long Term Care Program. In total, 765,792 residents and 513,293 staff members in AL communities and 222,987 residents and 213,146 staff in RC communities received at least 1 COVID-19 vaccine dose. The median bed size was 35 [interquartile range (IQR): 10-77] among participating AL communities and 6 (IQR: 4-6) among RC communities.
      In AL communities, a median of 67 residents (IQR: 48-90) and 32 staff members (IQR: 15-60) per 100 beds received a first dose of vaccine at the first on-site clinic; in RC communities, a median of 8 residents (IQR: 5-10) and 5 staff members (IQR: 2-12) per 10 beds received a first dose (Table 1). Cumulatively as of April 21, 2021, a median of 75 residents (IQR: 54-100) and 47 staff members (IQR: 24-85) per 100 beds in AL communities received a first dose of vaccine, and 66 residents (IQR: 45-88) and 37 staff members (IQR: 17-70) per 100 beds received a second dose. In RC communities, a median of 9 residents (IQR: 7-13) and 8 staff members (IQR: 3-18) per 10 beds received a first dose of vaccine, and 8 residents (IQR: 5-10) and 7 staff members (IQR: 2-14) per 10 beds received a second dose.
      Table 1COVID-19 Vaccine Uptake in Assisted Living and Residential Care Communities
      Communities self-identified as assisted living (AL) or other residential care (RC) for this analysis. Classification and characteristics of AL and RC communities can differ by state; however, RC communities are generally smaller than AL communities. Additionally, AL communities might offer various levels of on-site nursing or medical care whereas RC communities might not; the care offered is less extensive than what is offered in a skilled nursing facility or nursing home.
      —Pharmacy Partnership for Long-Term Care Program, December 2020–April 2021
      Assisted Living: Cumulative Vaccine Uptake, Median (IQR) per 100 Beds
      Uptake is presented as number vaccinated per 100 reported beds for AL communities and per 10 reported beds for RC communities to account for differences in community size; median bed size was 35 (interquartile range [IQR]: 10-77) in AL and 6 (IQR: 4-6) in RC.


      (n = 18,980)
      Residential Care: Cumulative Vaccine Uptake, Median (IQR) per 10 Beds
      Uptake is presented as number vaccinated per 100 reported beds for AL communities and per 10 reported beds for RC communities to account for differences in community size; median bed size was 35 (interquartile range [IQR]: 10-77) in AL and 6 (IQR: 4-6) in RC.


      (n = 16,874)
      Residents
       First dose
      Clinic 167 (48-90)8 (5-10)
      Clinic 275 (54-100)9 (7-12)
      Clinic 3
      Smaller communities may not have conducted third clinics if all residents and staff members were vaccinated in the first 2 clinics. Third clinics were conducted in 15,025 (79%) AL communities and 9881 (59%) RC communities as of April 21, 2021.
      75 (54-100)9 (7-13)
       Second dose
      Clinic 10 (0-0)0 (0-0)
      Clinic 260 (40-82)7 (4-10)
      Clinic 3
      Smaller communities may not have conducted third clinics if all residents and staff members were vaccinated in the first 2 clinics. Third clinics were conducted in 15,025 (79%) AL communities and 9881 (59%) RC communities as of April 21, 2021.
      66 (45-88)8 (5-10)
      Staff members
       First dose
      Clinic 132 (15-60)5 (2-12)
      Clinic 244 (23-81)8 (3-17)
      Clinic 3
      Smaller communities may not have conducted third clinics if all residents and staff members were vaccinated in the first 2 clinics. Third clinics were conducted in 15,025 (79%) AL communities and 9881 (59%) RC communities as of April 21, 2021.
      47 (24-85)8 (3-18)
       Second dose
      Clinic 10 (0-0)0 (0-0)
      Clinic 228 (12-56)5 (1-10)
      Clinic 3
      Smaller communities may not have conducted third clinics if all residents and staff members were vaccinated in the first 2 clinics. Third clinics were conducted in 15,025 (79%) AL communities and 9881 (59%) RC communities as of April 21, 2021.
      37 (17-70)7 (2-14)
      Communities self-identified as assisted living (AL) or other residential care (RC) for this analysis. Classification and characteristics of AL and RC communities can differ by state; however, RC communities are generally smaller than AL communities. Additionally, AL communities might offer various levels of on-site nursing or medical care whereas RC communities might not; the care offered is less extensive than what is offered in a skilled nursing facility or nursing home.
      Uptake is presented as number vaccinated per 100 reported beds for AL communities and per 10 reported beds for RC communities to account for differences in community size; median bed size was 35 (interquartile range [IQR]: 10-77) in AL and 6 (IQR: 4-6) in RC.
      Smaller communities may not have conducted third clinics if all residents and staff members were vaccinated in the first 2 clinics. Third clinics were conducted in 15,025 (79%) AL communities and 9881 (59%) RC communities as of April 21, 2021.
      Resident census data were available for 89 of 118 (75%) participating AL communities in Connecticut, 192 of 330 (58%) in Georgia, and 232 of 289 (80%) in Tennessee (Table 2). The median percentage of beds occupied was 68% (IQR: 55-81) in Connecticut, 58% (IQR: 48-69) in Georgia, and 70% (IQR: 58-84) in Tennessee. This resulted in an estimated median resident first-dose uptake of 93% (IQR: 85-108) in Connecticut, 85% in Georgia (IQR: 70-102), and 78% (IQR: 56-91) in Tennessee at the first on-site clinic. Cumulatively as of April 21, 2021, first-dose uptake increased to 106% (IQR: 97-131) in Connecticut, 98% in Georgia (IQR: 84-120), and 88% (IQR: 66-100) in Tennessee.
      Table 2First-Dose COVID-19 Vaccine Uptake Among Residents, by Bed Capacity and Resident Occupancy, in Assisted Living Communities—Pharmacy Partnership for Long-Term Care Program, December 2020-April 2021
      VariableCTGATN
      Unlinked,
      “Unlinked” indicates communities not matched to publicly available resident census data; “linked” indicates communities matched to resident census data. Uptake per 100 residents was calculated only for linked communities. Census data were available for AL communities in 3 states; RC census data were available only for a small number of facilities and are not presented.


      Median (IQR)

      (n = 29)
      Linked,
      “Unlinked” indicates communities not matched to publicly available resident census data; “linked” indicates communities matched to resident census data. Uptake per 100 residents was calculated only for linked communities. Census data were available for AL communities in 3 states; RC census data were available only for a small number of facilities and are not presented.


      Median (IQR)

      (n = 89)
      Unlinked,

      Median (IQR)

      (n = 138)
      Linked,

      Median (IQR)

      (n = 192)
      Unlinked,

      Median (IQR)

      (n = 57)
      Linked,

      Median (IQR)

      (n = 232)
      Occupancy-to-capacity ratio
      Occupancy-to-capacity ratio was calculated as resident census (dated January 27–February 2, 2021) divided by total number of reported beds.
      68 (55-81)58 (48-69)70 (58-84)
      Clinic 1
       Uptake per 100 beds
      First-dose uptake per 100 beds was calculated as number of first doses of COVID-19 vaccine administered normalized per 100 reported beds (total bed capacity). First-dose uptake per 100 residents was calculated as number of first doses of COVID-19 vaccine administered normalized per 100 residents in census counts (occupied beds).
      55 (41-63)68 (55-83)51 (31-71)49 (36-63)54 (42-67)53 (40-71)
       Uptake per 100 residents (%)93 (85-108)85 (70-102)78 (56-91)
      Clinic 2
       Uptake
      Uptake for clinics 2 and 3 is cumulative vaccine uptake inclusive of previous clinics.
      per 100 beds
      65 (48-78)75 (60-92)60 (37-79)57 (43-75)57 (44-72)59 (45-75)
       Uptake
      Uptake for clinics 2 and 3 is cumulative vaccine uptake inclusive of previous clinics.
      per 100 residents (%)
      103 (95-119)97 (82-117)88 (64-100)
      Clinic 3
       Uptake
      Uptake for clinics 2 and 3 is cumulative vaccine uptake inclusive of previous clinics.
      per 100 beds
      65 (52-80)77 (61-96)61 (38-83)59 (44-76)57 (44-73)59 (46-76)
       Uptake
      Uptake for clinics 2 and 3 is cumulative vaccine uptake inclusive of previous clinics.
      per 100 residents (%)
      106 (97-131)98 (84-120)88 (66-100)
      “Unlinked” indicates communities not matched to publicly available resident census data; “linked” indicates communities matched to resident census data. Uptake per 100 residents was calculated only for linked communities. Census data were available for AL communities in 3 states; RC census data were available only for a small number of facilities and are not presented.
      Occupancy-to-capacity ratio was calculated as resident census (dated January 27–February 2, 2021) divided by total number of reported beds.
      First-dose uptake per 100 beds was calculated as number of first doses of COVID-19 vaccine administered normalized per 100 reported beds (total bed capacity). First-dose uptake per 100 residents was calculated as number of first doses of COVID-19 vaccine administered normalized per 100 residents in census counts (occupied beds).
      § Uptake for clinics 2 and 3 is cumulative vaccine uptake inclusive of previous clinics.
      Among the 35,854 participating AL/RC communities, 34,934 (97%) were linked to county-level SVI data. For both residents and staff members, cumulative first-dose vaccine uptake decreased with increasing social vulnerability related to socioeconomic status (SVI theme 1) and household composition and disability status (SVI theme 2) (Figure 1). However, uptake increased with increasing social vulnerability related to racial orethnic minority status and language (SVI theme 3) and housing type and transportation (SVI theme 4).
      Figure thumbnail gr1
      Fig. 1First-dose COVID-19 vaccine uptake,∗ by social vulnerability index (SVI) theme and tertile, among residents and staff members of assisted living (A and B) and other residential care (C and D) communities—Pharmacy Partnership for Long-Term Care Program, December 2020–April 2021. ∗Includes cumulative first-dose vaccine uptake as of April 21, 2021. SVI ranks counties according to 15 social factors (indicators): (1) percentage of persons with incomes below poverty threshold, (2) percentage of civilian population (aged ≥16 years) that is unemployed, (3) per capita income, (4) percentage of persons aged ≥25 years with no high school diploma, (5) percentage of persons aged ≥65 years, (6) percentage of persons aged ≤17 years, (7) percentage of civilian noninstitutionalized population with a disability, (8) percentage of single-parent households with children aged <18 years, (9) percentage of persons who are racial/ethnic minorities (all persons except non-Hispanic White), (10) percentage of persons aged ≥5 years who speak English “less than well,” (11) percentage of housing structures with ≥10 units (multiunit housing), (12) percentage of housing structures that are mobile homes, (13) percentage households with more persons than rooms (crowding), (14) percentage of households with no vehicle available, and (15) percentage of persons in group quarters. Estimates are created using 2014-2018 (5-year) data from the American Community Survey. The 15 indicators are categorized into 4 themes: (1) socioeconomic status (indicators 1-4), (2) household composition and disability (indicators 5-8), (3) racial/ethnic minority status and language English (indicators 9 and 10), and (4) housing type and transportation (indicators 11-15). Additional details are available at https://www.atsdr.cdc.gov/placeandhealth/svi/documentation/SVI_documentation_2018.html. Higher tertile indicates increased social vulnerability.

      Discussion

      Early data have indicated that COVID-19 vaccination is effective in reducing the risk for SARS-CoV-2 infection among LTCF residents
      • Britton A.
      • Jacobs Slifka K.M.
      • Edens C.
      • et al.
      Effectiveness of the Pfizer-BioNTech COVID-19 vaccine among residents of two skilled nursing facilities experiencing COVID-19 outbreaks - Connecticut, December 2020-February 2021.
      ; thus, targeted COVID-19 vaccination campaigns, as conducted through the Pharmacy Partnership for Long-Term Care Program, are critical to interrupting virus transmission and decreasing COVID-19–associated morbidity and mortality in LTCFs. Through the Pharmacy Partnership, more than 1.7 million residents and staff members in AL/RC communities received on-site COVID-19 vaccination. First-dose vaccine uptake among both residents and staff increased with subsequent on-site clinics, which could result from doses administered to individuals who were not present at the first clinic (eg, new resident admissions or staff not working during clinic dates) or decreasing vaccine hesitancy over time.
      Across 3 states with available resident census data, an estimated median of 78% to 93% of residents were vaccinated at the first on-site clinic in AL communities. These results are consistent with prior analyses indicating that a median of 78% of residents were vaccinated in SNFs during the first month of the program.
      • Gharpure R.
      • Guo A.
      • Bishnoi C.K.
      • et al.
      Early COVID-19 first-dose vaccination coverage among residents and staff members of skilled nursing facilities participating in the Pharmacy Partnership for Long-Term Care Program - United States, December 2020-January 2021.
      With subsequent clinics, median first-dose uptake among residents in AL communities in these states increased to 88% to 106%. Uptake above 100% likely resulted from new admissions and discharges of residents in these communities; because Pharmacy Partnership data were reported in aggregate at the community level and resident census data were obtained at a single point in time, we could not account or adjust for resident turnover. Other systems to monitor weekly COVID-19 vaccination coverage in long-term care settings, such as the National Healthcare Safety Network (NHSN) LTCF component, can fill this gap following the conclusion of the Pharmacy Partnership program.
      • Geller A.I.
      • Budnitz D.S.
      • Dubendris H.
      • et al.
      Surveillance of COVID-19 vaccination in US nursing homes, December 2020-April 2021.
      As of June 13, 2021, SNFs are required to report weekly resident and staff COVID-19 vaccination coverage to NHSN.
      Centers for Medicare & Medicaid Services
      Medicare and Medicaid Programs; COVID-19 vaccine requirements for long-term care (LTC) facilities and intermediate care facilities for individuals with intellectual disabilities (ICFs-IID) residents, clients, and staff.
      Similar vaccination reporting policies for other LTCF settings, including AL/RC communities, could facilitate comprehensive monitoring and evaluation of COVID-19 coverage.
      Consistent with our findings, prior analyses of COVID-19 vaccination coverage among the general population by county of residence identified lower vaccination coverage in counties with higher social vulnerability related to socioeconomic status (including income, employment status, and education level) and household composition/disability (including age, single-parent household status, and disability status) but higher vaccination coverage in counties with higher social vulnerability related to racial or ethnic minority status and limited English language fluency.
      • Barry V.
      • Dasgupta S.
      • Weller D.L.
      • et al.
      Patterns in COVID-19 vaccination coverage, by social vulnerability and urbanicity - United States, December 14, 2020-May 1, 2021.
      Prior analyses examining receipt of COVID-19 vaccine specifically among adults ≥65 years of age also found lower first-dose vaccination coverage associated with social vulnerabilities including poverty, Internet access, and living alone, though no relationship with race or ethnicity.
      • Whiteman A.
      • Wang A.
      • McCain K.
      • et al.
      Demographic and social factors associated with COVID-19 vaccination initiation among adults aged ≥65 years - United States, December 14, 2020-April 10, 2021.
      Notably, our findings indicated higher uptake associated with social vulnerabilities related to housing type and transportation (including multiunit and mobile home housing, crowding, lack of vehicle availability, and prevalence of institutionalized group quarters), whereas this was not identified among the general population.
      • Barry V.
      • Dasgupta S.
      • Weller D.L.
      • et al.
      Patterns in COVID-19 vaccination coverage, by social vulnerability and urbanicity - United States, December 14, 2020-May 1, 2021.
      Providing on-site access to vaccination at place of residence or work may help to mitigate access barriers posed by transportation issues, and individuals with these social vulnerabilities may be more likely to seek vaccination through a vaccine delivery program such as the Pharmacy Partnership. With appropriate planning, promotion, and delivery, on-site vaccination programs such as workforce vaccination programs,
      National Institute of Environmental Health Sciences
      Key elements of a model workplace safety and health COVID-19 vaccination program.
      off-site community clinics,
      Centers for Disease Control and Prevention
      Workplace Vaccination Program.
      or mobile clinics
      Centers for Disease Control and Prevention
      Mobile vaccination resources.
      might similarly increase vaccine uptake across different settings.
      These findings are subject to several notable limitations. Firstly, definitions of AL/RC communities vary across jurisdictions, and there may have been misclassification of LTCF types reported to CDC. Resident census data were only available for 3 states and did not include all AL communities within these states; estimated percentage uptake may not be nationally generalizable. We were unable to assess the percentage of staff vaccinated as staffing ratios (number of staff members employed per resident or total bed capacity) vary widely across AL/RC communities.
      • Carder P.C.
      • O'Keefe J.
      • O'Keefe C.
      • et al.
      State Regulatory Provisions for Residential Care Settings: An Overview of Staffing Requirements.
      In 2014, the national ratio of total nurse and aide staffing hours worked per resident in residential care communities was 2.84 hours per resident per day; state-level estimates ranged from 1.66 to 4.90, indicating wide variability.
      • Rome V.
      • Harris-Kojetin L.D.
      Variation in residential care community nurse and aide staffing levels: United States, 2014.
      Furthermore, our estimates may underestimate staff member vaccine uptake as we only captured staff vaccinated through the Pharmacy Partnership program and could not account for staff working at multiple communities, intentional staggering of staff vaccination, or staff vaccinated at other locations (eg, at a retail pharmacy). As previously described, we could not account for new resident admissions or discharges at AL/RC communities. Finally, we used county-level estimates of social vulnerability; these factors may vary within large counties, and the characteristics of community locations may not reflect those of residents and staff members admitted from or residing in other localities.

      Conclusions and Implications

      COVID-19 vaccination of residents and staff members in LTCFs continues to be a public health priority. Though the on-site component of the Pharmacy Partnership for Long-Term Care Program concluded in May 2021, ensuring steady access to vaccine in AL/RC communities and other LTCFs is critical to maintaining high vaccination coverage as new individuals enter the facilities or wish to be vaccinated.
      Centers for Disease Control and Prevention
      Understanding the Pharmacy Partnership for Long-Term Care Program.
      Additionally, efforts to make vaccine available and accessible to LTCFs and other congregate housing communities with high social vulnerability are critical; delivery strategies such as the on-site clinic model used through the Pharmacy Partnership may help to mitigate access issues related to transportation. Finally, continued, systematic data collection in LTCFs and other high-risk settings is critical to assessing vaccination coverage and impact on COVID-19 disease burden.

      Acknowledgments

      We thank pharmacy partners from CVS Pharmacy, Managed Health Care Associates, Inc, and Walgreens; residents and staff members in enrolled facilities; state, local, and territorial health departments; Smita Chavan, Sam Cincotta, Nicole Coffin, Rachael Cook, Michelle Hughes, Song Lavalais, Lakshmi Malapati, Adria Mathis, Lauren Moccia, Nadine Shehab, Chelsea Slyker, Nimalie Stone, Kirsten Yates, CDC COVID-19 Response Team; Saahil Madge, Palantir Technologies; Curt Nelson, US Army; and Courtney Bishnoi, David Gifford, Urvi Patel, Lindsay Schwartz, American Health Care Association/National Center for Assisted Living.

      Appendix

      Supplementary Table 1Facility Characteristics, Clinic Scheduling, and COVID-19 Vaccine First Doses Administered, by State, Among Assisted Living Communities—Pharmacy Partnership for Long-Term Care Program, December 2020–April 2021
      Assisted Living (AL) Communities
      State/JurisdictionNo. of Participating AL CommunitiesNo. of BedsClinic 1 DatesTotal First Doses Administered From Clinic 1 to Clinic 3Median Vaccinated per 100 Beds
      Total Across StateMedian per ALEarliestLatestRollout Duration, dResidentsStaffResidentsStaff
      AK3602228512/30/20203/10/202170215417018060
      AL1828167351/7/20213/5/202157761649277238
      AR3726427012/29/20201/19/20212118777886825
      AZ64826,394101/15/20213/25/20216921,93510,4657840
      CA110370,158401/2/20213/4/20216146,29937,1827064
      CO60425,0101612/31/20202/2/20213321,53222,3757557
      CT12012,4249612/21/20202/5/20214610,05484477458
      DC7604651/4/20211/16/20211293052115088
      DE302166631/5/20212/5/202131215814127052
      FL178781,8451412/22/20202/12/20215268,85137,5868246
      GA33024,131701/6/20213/4/20215715,82488056030
      HI1720571041/2/20211/28/202126195218668587
      IA26014,8864812/28/20202/12/20214610,84160056233
      ID13969213612/29/20202/15/202148499425707131
      IL55737,4006012/29/20202/24/20215731,38921,3787544
      IN25020,7376612/29/20202/15/20214814,46653436524
      KS19389983612/28/20202/5/202139822446587642
      KY20611,4705012/21/20202/3/20214410,12260908044
      LA11674726012/29/20202/23/202156456625096528
      MA25919,880781/2/20212/9/20213817,78516,5978078
      MD76917,96181/6/20213/24/20217717,11612,7098860
      ME903910231/4/20212/12/202139450021708863
      MI70728,879201/4/20213/16/20217123,80113,3497435
      MN71140,063441/4/20212/18/20214532,25824,7907656
      MO27816,738521/2/20212/21/20215013,47566476631
      MS1476469341/6/20212/7/202132474119847327
      MT13352971812/31/20202/12/202143447139147945
      NC42826,7296012/28/20203/20/20218221,21910,9976933
      ND3216444212/30/20201/28/20212912437987832
      NE12874084612/28/20202/15/202149554534667143
      NH593493561/6/20212/5/202130304026337966
      NJ26325,862971/2/20213/10/20216718,72515,6326648
      NM17540491512/30/20202/11/202143359430537567
      NV29178931012/31/20202/25/202156630741868060
      NY41138,5607912/30/20202/17/20214926,44420,0156841
      OH53747,6257612/18/20202/12/20215631,84820,5356134
      OK1338616581/8/20212/4/202127556441446235
      OR31219,2765112/21/20202/18/20215914,92710,0847548
      PA55941,6416612/29/20202/26/20215931,71123,0776645
      PR90118,535161/4/20213/10/20216516,54112,8819067
      RI6248246712/31/20202/18/202149341523427346
      SC29916,1844812/28/20202/19/20215313,33163057433
      SD6023942912/28/20201/21/2021242262520748
      TN27819,377601/5/20213/2/20215612,66778415934
      TX125067,4184212/28/20203/2/20216455,12241,8337750
      UT1479282551/2/20212/17/202146662253016652
      VA37728,8397212/30/20202/15/20214724,95817,1857049
      VT4920923512/30/20202/3/202135178014258168
      WA36628,6506412/30/20202/16/20214825,40215,3967946
      WI180231,16971/10/20214/6/20218628,62716,5438150
      WY211456611/6/20211/27/2021219673136622
      Supplementary Table 2Facility Characteristics, Clinic Scheduling, and COVID-19 Vaccine First Doses Administered, by State, Among Other Residential Care Communities—Pharmacy Partnership for Long-Term Care Program, December 2020–April 2021
      Residential Care (RC) Communities
      State/JurisdictionNo. of Participating RC CommunitiesNo. of BedsClinic 1 DatesTotal First Doses Administered From Clinic 1 to Clinic 3Median Vaccinated per 10 Beds
      Total Across StateMedian per RCEarliestLatestRollout Duration, dResidentsStaffResidentsStaff
      AK62141/11/20212/10/202130151172
      AL7497621/15/20212/5/2021213438471
      AR73446012/30/20201/15/2021162293371
      AZ113131231/16/20212/10/2021251213839107
      CA531896,505612/28/20204/8/202110166,81476,509810
      CO2937361/6/20211/28/202122224466815
      CT191444261/4/20212/17/20214444603226106
      DE3480441/10/20212/8/202129593424117
      FL312492761/11/20212/17/2021374849339097
      GA113143741/11/20213/4/2021521335760107
      HI81511912/28/20201/30/20213315714579
      IA241162641/5/20212/13/20213929042350128
      ID5358501/14/20211/30/2021162107661
      IL12362861012/29/20202/24/2021574774318195
      IN614804801/12/20212/18/2021373554106471
      KS833290912/30/20202/9/2021412603166286
      KY146534912/23/20202/12/20215171849796
      LA351066181/7/20212/6/20213093459889
      MA130911,86551/2/20213/15/20217213,27519,8961014
      MD494587251/20/20213/24/20216312,00910,1351512
      ME124742412/30/20202/22/202154117916701020
      MI248437,34461/4/20214/21/202110727,35916,15785
      MN412281541/9/20213/19/202169257731541010
      MO21354371212/29/20202/23/2021564061257973
      MS2222941/12/20212/5/20212421483105
      NC3036913612/28/20202/26/2021606284362187
      ND93624212/31/20201/14/20211438317673
      NE11621/17/2021734553
      NH22802151/6/20212/2/202127689748914
      NJ368459341/4/20213/6/202161544285801013
      NM6072741/5/20211/22/202117109715001010
      NV37719912/30/20202/12/20214453546397
      NY386712381/11/20212/26/202146736475451010
      OH3023208312/26/20202/20/20215623331387103
      OK7502431/16/20212/5/20212046112262
      OR4933886512/26/20202/19/2021553850394498
      PA646732131/1/20212/24/202154752410,4291015
      RI615161251/18/20212/14/2021273214108983
      SC1191283412/29/20202/19/2021521330722108
      SD356121/8/20211/19/202111444267
      TN40160561/7/20212/2/202126149445993
      TX1691587412/28/20203/18/20218024771447103
      UT721786512/28/20202/10/202144207125991317
      VA337325641/10/20213/12/20216134233838109
      VT7114731212/23/20202/12/202151991113086
      WA104510,31361/1/20213/9/202167875210,76287
      WI564679141/14/20213/16/2021616469339984
      WY1991/22/202184110911

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