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Federal Register/Vol. 86, No. 212/Friday, November 5, 2021/Rules and Regulations 61555 Authority: 33 U.S.C. 941; 29 U.S.C. 653, (29 U.S.C. 653, 655, 657); Secretary of Labor’s DATES: 655, 657; Secretary of Labor’s Order No. 12– Order No. 12–71 (36 FR 8754), 8–76 (41 FR Effective date: These regulations are 71 (36 FR 8754), 8–76 (41 FR 25059), 9–83 25059), 9–83 (48 FR 35736), 1–90 (55 FR effective on November 5, 2021. (48 FR 35736), 1–90 (55 FR 9033), 6–96 (62 9033), 6–96 (62 FR 111), 3–2000 (65 FR Implementation dates: The FR 111), 3–2000 (65 FR 50017), 5–2002 (67 50017), 5–2002 (67 FR 65008), 4–2010 (75 FR regulations included in Phase 1 [42 CFR FR 65008), 5–2007 (72 FR 31160), 4–2010 (75 55355), or 8–2020 (85 FR 58393), as 416.51(c) through (c)(3)(i) and (c)(3)(iii) FR 55355), 1–2012 (77 FR 3912), or 8–2020 applicable; and 29 CFR 1911. through (x), 418.60(d) through (d)(3)(i) (85 FR 58393), as applicable; and 29 CFR Section 1928.21 also issued under 49 and (d)(3)(iii) through (x), 441.151(c) 1911. U.S.C. 1801–1819 and 5 U.S.C. 553. Sections 1918.90 and 1918.110 also issued through (c)(3)(i) and (c)(3)(iii) through under 5 U.S.C. 553. Subpart B—Applicability of Standards (x), 460.74(d) through (d)(3)(i) and Section 1918.100 also issued under 49 (d)(3)(iii) through (x), 482.42(g) through U.S.C. 5101 et seq. and 5 U.S.C. 553. ■ 16. Amend §1928.21 by adding (g)(3)(i) and (g)(3)(iii) through (x), ■ 12. Add subpart K to part 1918 to read paragraph (a)(8) to read as follows: 483.80(d)(3)(v) and 483.80(i) through as follows: §1928.21 Applicable standards in 29 CFR (i)(3)(i) and (i)(3)(iii) through (x), part 1910. 483.430(f) through (f)(3)(i) and (f)(3)(iii) Subpart K—COVID–19. (a) * * * through (x), 483.460(a)(4)(v), 484.70(d) Sec. (8) COVID–19—§1910.501, but only through (d)(3)(i) and (d)(3)(iii) through 1918.107–1918.109 [Reserved] with respect to— (x), 485.58(d)(4), 485.70(n) through 1918.110 COVID–19. (i) Agricultural establishments where (n)(3)(i) and (n)(3)(iii) through (x), 1918.107 through 1918.109 [Reserved] eleven (11) or more employees are 485.640(f) through (f)(3)(i) and (f)(3)(iii) engaged on any given day in hand-labor through (x), 485.725(f) through (f)(3)(i) §1918.110 COVID–19. operations in the field; and through (f)(3)(iii) through (x), 485.904(c) The requirements applicable to (ii) Agricultural establishments that through (c)(3)(i) and (c)(3)(iii) through longshoring work under this section are maintain a temporary labor camp, (x), 486.525(c) through (c)(3)(i) and identical to those set forth at 29 CFR regardless of how many employees are (c)(3)(iii) through (x), 491.8(d) through 1910.501. engaged on any given day in hand-labor (d)(3)(i) and (d)(3)(iii) through (x), PART 1926—SAFETY AND HEALTH operations in the field. 494.30(b) through (b)((3)(i) and (b)(3)(iii) REGULATIONS FOR CONSTRUCTION * * * * * through (x) must be implemented by [FR Doc. 2021–23643 Filed 11–4–21; 8:45 am] December 6, 2021. ■ 13. The authority citation for part BILLING CODE 4510–26–P The regulations included in Phase 2 1926 is revised to read as follows: [42 CFR 416.51(c)(3)(ii), 418.60(d)(3)(ii), 441.151(c)(3)(ii), 460.74(d)(3)(ii), Authority: 40 U.S.C. 3704; 29 U.S.C. 653, DEPARTMENT OF HEALTH AND 482.42(g)(3)(ii), 483.80(i)(3)(ii), 655, and 657; and Secretary of Labor’s Order HUMAN SERVICES 483.430(f)(3)(ii), 484.70(d)(3)(ii), No. 12–71 (36 FR 8754), 8–76 (41 FR 25059), 485.70(n)(3)(ii), 485.640(f)(3)(ii), 9–83 (48 FR 35736), 1–90 (55 FR 9033), 6– Centers for Medicare & Medicaid 485.725(f)(3)(ii), 485.904(c)(3)(ii), 96 (62 FR 111), 3–2000 (65 FR 50017), 5– Services 486.525(c)(3)(ii), 491.8(d)(3)(ii), 2002 (67 FR 65008), 5–2007 (72 FR 31159), 494.30(b)(3)(ii)] must be implemented 4–2010 (75 FR 55355), 1–2012 (77 FR 3912), 42 CFR Parts 416, 418, 441, 460, 482, by January 4, 2022. Staff who have or 8–2020 (85 FR 58393), as applicable; and 483, 484, 485, 486, 491 and 494 29 CFR part 1911. completed a primary vaccination series Sections 1926.58, 1926.59, 1926.60, and [CMS–3415–IFC] by this date are considered to have met 1926.65 also issued under 5 U.S.C. 553 and these requirements, even if they have 29 CFR part 1911. RIN 0938–AU75 not yet completed the 14-day waiting Section 1926.61 also issued under 49 period required for full vaccination. U.S.C. 1801–1819 and 5 U.S.C. 553. Medicare and Medicaid Programs; Comment date: To be assured Section 1926.62 also issued under sec. Omnibus COVID–19 Health Care Staff consideration, comments must be 1031, Public Law 102–550, 106 Stat. 3672 (42 Vaccination received at one of the addresses U.S.C. 4853). provided below, no later than 5 p.m. on Section 1926.65 also issued under sec. 126, AGENCY: Centers for Medicare & Public Law 99–499, 100 Stat. 1614 (reprinted Medicaid Services (CMS), HHS. January 4, 2022. at 29 U.S.C.A. 655 Note) and 5 U.S.C. 553. ACTION: Interim final rule with comment ADDRESSES: In commenting, please refer Subpart D—Occupational Health and period. to file code CMS–3415–IFC. Environmental Controls Comments, including mass comment SUMMARY: This interim final rule with submissions, must be submitted in one ■ 14. Add §1926.58 to read as follows: comment period revises the of the following three ways (please requirements that most Medicare- and choose only one of the ways listed): §1926.58 COVID–19. Medicaid-certified providers and 1. Electronically. You may submit The requirements applicable to suppliers must meet to participate in the electronic comments on this regulation construction work under this section are Medicare and Medicaid programs. to http://www.regulations.gov. Follow identical to those set forth at 29 CFR These changes are necessary to help the ‘‘Submit a comment’’ instructions. 1910.501 Subpart U. protect the health and safety of 2. By regular mail. You may mail residents, clients, patients, PACE written comments to the following PART 1928—OCCUPATIONAL SAFETY participants, and staff, and reflect address ONLY: Centers for Medicare & AND HEALTH STANDARDS FOR lessons learned to date as a result of the Medicaid Services, Department of AGRICULTURE COVID–19 public health emergency. Health and Human Services, Attention: The revisions to the requirements CMS–3415–IFC, P.O. Box 8016, ■ 15. The authority citation for part establish COVID–19 vaccination Baltimore, MD 21244–8016. 1928 is revised to read as follows: requirements for staff at the included Please allow sufficient time for mailed Authority: Sections 4, 6, and 8 of the Medicare- and Medicaid-certified comments to be received before the Occupational Safety and Health Act of 1970 providers and suppliers. close of the comment period. jspears on DSK121TN23PROD with RULES2VerDate Sep<11>2014 22:27 Nov 04, 2021Jkt 256001PO 00000 Frm 00155 Fmt 4701 Sfmt 4700 E:\FR\FM\05NOR2.SGM 05NOR2 61556 Federal Register/Vol. 86, No. 212/Friday, November 5, 2021/Rules and Regulations 3. By express or overnight mail. You • Ambulatory Surgical Centers (ASCs) Occupational Safety and Health may send written comments to the (§416.51) Administration (OSHA) for certain following address ONLY: Centers for • Hospices (§418.60) employers. Medicare & Medicaid Services, • Psychiatric residential treatment Currently, the United States (U.S.) is Department of Health and Human facilities (PRTFs) (§441.151) responding to a public health Services, Attention: CMS–3415–IFC, • Programs of All-Inclusive Care for the emergency (PHE) of respiratory disease Mail Stop C4–26–05, 7500 Security Elderly (PACE) (§460.74) caused by a novel coronavirus that has Boulevard, Baltimore, MD 21244–1850. • Hospitals (acute care hospitals, now been detected in more than 190 For information on viewing public psychiatric hospitals, hospital swing countries internationally, all 50 States, comments, see the beginning of the beds, long term care hospitals, the District of Columbia, and all U.S. SUPPLEMENTARYINFORMATION section. children’s hospitals, transplant territories. The virus has been named FORFURTHERINFORMATIONCONTACT: centers, cancer hospitals, and ‘‘severe acute respiratory syndrome For press inquiries: CMS Office of rehabilitation hospitals/inpatient coronavirus 2’’ (SARS–CoV–2), and the Communications, Department of Health rehabilitation facilities) (§482.42) disease it causes has been named and Human Services; email press@ • Long Term Care (LTC) Facilities, ‘‘coronavirus disease 2019’’ (COVID– cms.hhs.gov. including Skilled Nursing Facilities 19). On January 30, 2020, the For technical inquiries: Contact CMS (SNFs) and Nursing Facilities (NFs), International Health Regulations Center for Clinical Standards and generally referred to as nursing homes Emergency Committee of the World Quality, Department of Health and (§483.80) Health Organization (WHO) declared Human Services, (410) 786–6633. • Intermediate Care Facilities for the outbreak a ‘‘Public Health Individuals with Intellectual Emergency of International Concern.’’ SUPPLEMENTARYINFORMATION: Disabilities (ICFs–IID) (§483.430) On January 31, 2020, pursuant to Inspection of Public Comments: All • Home Health Agencies (HHAs) section 319 of the Public Health Service comments received before the close of (§484.70) Act (PHSA) (42 U.S.C. 247d), the the comment period are available for • Comprehensive Outpatient Secretary of the Department of Health viewing by the public, including any Rehabilitation Facilities (CORFs) and Human Services (Secretary) personally identifiable or confidential (§§485.58 and 485.70) determined that a PHE exists for the business information that is included in • Critical Access Hospitals (CAHs) U.S. (hereafter referred to as the PHE for a comment. We post all comments (§485.640) COVID–19). On March 11, 2020, the received before the close of the • Clinics, rehabilitation agencies, and WHO publicly declared COVID–19 a comment period on the following public health agencies as providers of pandemic. On March 13, 2020, the website as soon as possible after they outpatient physical therapy and President of the United States declared have been received: http:// speech-language pathology services the COVID–19 pandemic a national www.regulations.gov. Follow the search (§485.725) emergency. The January 31, 2020 instructions on that website to view • Community Mental Health Centers determination that a PHE for COVID–19 public comments. CMS will not post on (CMHCs) (§485.904) exists and has existed since January 27, Regulations.gov public comments that • Home Infusion Therapy (HIT) 2020, lasted for 90 days, and was make threats to individuals or suppliers (§486.525) renewed on April 21, 2020; July 23, institutions or suggest that the • Rural Health Clinics (RHCs)/Federally 2020; October 2, 2020; January 7, 2021; individual will take actions to harm the Qualified Health Centers (FQHCs) April 15, 2021; July 19, 2021; and individual. CMS continues to encourage (§491.8) October 18, 2021. Pursuant to section individuals not to submit duplicative • End-Stage Renal Disease (ESRD) 319 of the PHSA, the determination that comments. We will post acceptable Facilities (§494.30) a PHE continues to exist may be comments from multiple unique This IFC directly applies only to the renewed at the end of each 90-day 1 commenters even if the content is Medicare- and Medicaid-certified period. identical or nearly identical to other providers and suppliers listed above. It COVID–19 has had significant comments. does not directly apply to other health negative health effects—on individuals, I. Background care entities, such as physician offices, communities, and the nation as a whole. that are not regulated by CMS. Most Consequences for individuals who have The Centers for Medicare & Medicaid states have separate licensing COVID–19 include morbidity, Services (CMS) establishes health and requirements for health care staff and hospitalization, mortality, and post- safety standards, known as the health care providers that would be COVID conditions (also known as long Conditions of Participation, Conditions applicable to physician office staff and COVID). As of mid-October 2021, over for Coverage, or Requirements for other staff in small health care entities 44 million COVID–19 cases, 3 million Participation for 21 types of providers that are not subject to vaccination new COVID–19 related hospitalizations, and suppliers, ranging from hospitals to requirements under this IFC. We have and 720,000 COVID–19 deaths have hospices and rural health clinics to long not included requirements for Organ been reported in the U.S.2 Indeed, term care facilities (including skilled Procurement Organizations or Portable COVID–19 has overtaken the 1918 nursing facilities and nursing facilities, X-Ray suppliers, as these only provide influenza pandemic as the deadliest collectively known as nursing homes). services under contract to other health 3 disease in American history. Most of these providers and suppliers care entities and would thus be are regulated by this interim final rule indirectly subject to the vaccination 1https://www.phe.gov/emergency/events/ with comment period (IFC). requirements of this rule, as discussed COVID19/Pages/2019-Public-Health-and-Medical- Specifically, this IFC directly regulates in section II.A.1. of this rule. We note Emergency-Declarations-and-Waivers.aspx. the following providers and suppliers, that entities not covered by this rule 2https://covid.cdc.gov/covid-data- listed in the numerical order of the may still be subject to other State or tracker#datatracker-home. relevant CFR sections being revised in Federal COVID–19 vaccination 3https://www.statnews.com/2021/09/20/covid- requirements, such as those issued by 19-set-to-overtake-1918-spanish-flu-as-deadliest- this rule: disease-in-american-history. jspears on DSK121TN23PROD with RULES2VerDate Sep<11>2014 22:27 Nov 04, 2021Jkt 256001PO 00000 Frm 00156 Fmt 4701 Sfmt 4700 E:\FR\FM\05NOR2.SGM 05NOR2 Federal Register/Vol. 86, No. 212/Friday, November 5, 2021/Rules and Regulations 61557 Given recent estimates of estimated reduction for Black and attributed to healthcare-associated 19 undiagnosed infections and under- Latino populations is 3–4 times the transmission. In outbreaks reported reported deaths, these figures likely estimate for the White population, from acute care settings in the U.S. underestimate the full impact.4 In reversing over 10 years of progress in following implementation of universal addition, these figures fail to capture the reducing the gaps in life expectancy masking, unmasked exposures to other significant, detrimental effects of post- between Black and White populations health care workers were frequently 20 acute illness, including nervous system and reducing the Latino mortality implicated. A retrospective cohort and neurocognitive disorders, advantage by over 70 percent. The study study of health care staff behaviors, cardiovascular disorders, further expects that reductions in life exposures, and cases between June and gastrointestinal disorders, and signs and expectancy may persist because of December 2020 in a large health system symptoms related to poor general well- continued COVID–19 mortality and found more employees were exposed being, including malaise, fatigue, term health, social, and economic via coworkers than patients—and musculoskeletal pain, and reduced 7 secondary cases among employees impacts of the pandemic. Because quality of life. Recent estimates suggest SARS–CoV–2, the virus that causes typically followed unmasked more than half of COVID–19 survivors COVID–19 disease, is highly interactions with infected colleagues experienced post-acute sequelae of transmissible,8 Centers for Disease (for example, convening in breakrooms 5 21 COVID–19 6 months after recovery. Control and Prevention (CDC) has without proper source control). The The individual and public health recommended, and CMS reiterated, that same study found that cases of health ramifications of COVID–19 also extend health care providers and suppliers care worker infection associated with beyond the direct effects of COVID–19 implement robust infection prevention patient exposures could often be infections. Several studies have and control practices, including source attributed to failure to adhere to PPE demonstrated significant mortality control measures, physical distancing, requirements (for example, eye increases in 2020, beyond those universal use of personal protective protection). Past experience with attributable to COVID–19 deaths. In equipment (PPE), SARS–CoV–2 testing, influenza, and available evidence, some percentage, this could be a environmental controls, and patient suggest that vaccination of health care problem of misattribution (for example, 9101112 staff offers a critical layer of protection isolation or quarantine. Available against healthcare-associated COVID–19 the cause of death was indicated as evidence suggests these infection (HA–COVID–19). For example, evidence ‘‘heart disease’’ but in fact the true cause prevention and control practices have has shown that influenza vaccination of was undiagnosed COVID–19), but some been highly effective when health care staff is associated with proportion are also believed to reflect implemented correctly and declines in nosocomial influenza in increases in other causes of death that consistently.1314 222324 are sensitive to decreased access to care Studies have also shown, however, hospitalized patients, and among 25262728293031 and/or increased mental/emotional that consistent adherence to nursing home residents. strain. One paper quantifies the net recommended infection prevention and impact (direct and indirect effects) of control practices can prove 19https://www.medrxiv.org/content/10.1101/ the pandemic on the U.S. population challenging—and those lapses can place 2021.02.16.21251625v1. 20https://jamanetwork.com/journals/jama/full during 2020 using three metrics: excess patients in jeopardy.15161718 A article/2773128. deaths, life expectancy, and total years retrospective analysis from England 21https://www.ncbi.nlm.nih.gov/pmc/articles/ of life lost. The findings indicate there found up to 1 in 6 SARS–CoV–2 PMC8349432/. were 375,235 excess deaths, with 83 infections among hospitalized patients 22Weinstock DM, Eagan J, Malak SA, et al. percent attributable to direct, and 17 with COVID–19 in England during the Control of influenza A on a bone marrow transplant percent attributable to indirect effects of first 6 months of the pandemic could be unit. Infect Control Hosp Epidemiol. 2000; 21:730– 732. COVID–19. The decrease in life 23Salgado CD, Giannetta ET, Hayden FG, Farr expectancy was 1.67 years, translating 7Andrasfay, T., & Goldman, N. (2021). BM. Preventing nosocomial influenza by improving to a reversion of 14 years in historical Reductions in 2020 US life expectancy due to the vaccine acceptance rate of clinicians. Infect life expectancy gains. Total years of life COVID–19 and the disproportionate impact on the Control Hosp Epidemiol 2004; 25:923–928. Black and Latino populations. Proceedings of the 24https://pubmed.ncbi.nlm.nih.gov/31384750/. lost in 2020 was 7,362,555 across the National Academy of Sciences of the United States 25Hayward AC, Harling R, Wetten S, et al. U.S. (73 percent directly attributable, 27 of America, 118(5), e2014746118. https://doi.org/ Effectiveness of an influenza vaccine programme for percent indirectly attributable to 10.1073/pnas.2014746118 Accessed 10/17/2021. care home staff to prevent death, morbidity, and COVID–19), with considerable 8https://www.npr.org/sections/goatsandsoda/ health service use among residents: cluster heterogeneity at the individual State 2021/08/11/1026190062/covid-delta-variant- randomised controlled trial. BMJ 2006; 333: 1241– transmission-cdc-chickenpox. 1246. 6 9 26Potter J, Stott DJ, Roberts MA, et al. Influenza level. https://www.cdc.gov/coronavirus/2019-ncov/ One analysis published in February hcp/infection-control-recommendations.html. vaccination of healthcare workers in long-term-care 2021 found that Black and Latino 10https://www.cms.gov/files/document/qso-21- hospitals reduces the mortality of elderly patients. Americans have experienced a 08-nltc.pdf. J Infect Dis. 1997; 175:1–6. 11https://www.cms.gov/files/document/qso-21- 27Thomas RE, Jefferson TO, Demicheli V, et al. disproportionate burden of COVID–19 07-psych-hospital-prtf-icf-iid.pdf. Influenza vaccination for health-care workers who morbidity and mortality, reflecting 12https://www.cms.gov/files/document/qso-20- work with elderly people in institutions: a persistent structural inequalities that 38-nh-revised.pdf. systematic review. Lancet Infect Dis. 2006; 6:273– increase risk of exposure to COVID–19 13https://jamanetwork.com/journals/jamanet 279. 28Van den Dool C, Bonten MJM, Hak E, Heijne and mortality risk for those infected. workopen/fullarticle/2770287. JCM, Wallinga J. The effects of influenza The authors projected that COVID–19 14https://jamanetwork.com/journals/jamanet vaccination of health care workers in nursing would reduce U.S. life expectancy in workopen/fullarticle/2777317. homes: insights from a mathematical model. PLoS 2020 by 1.13 years. Furthermore, the 15https://www.pnas.org/content/pnas/118/1/ Medicine. 2008; 5:1453–1460. e2015455118.full.pdf. Lemaitre M, Meret T, Rothan-Tondeur M, et al. 16https://jamanetwork.com/journals/ Effect of influenza vaccination of nursing home staff 4https://www.ncbi.nlm.nih.gov/pmc/articles/ jamanetworkopen/article-abstract/2782430. on mortality of residents: a cluster-randomized trial. PMC8354557/. 17https://www.medrxiv.org/content/10.1101/ J Am Geriatr Soc. 2009; 57:1580–1586. 5https://jamanetwork.com/journals/jamanet 2021.09.08.21263057v1. 29Lemaitre M, Meret T, Rothan-Tondeur M, et al. workopen/fullarticle/2784918. 18https://journals.plos.org/plosmedicine/ Effect of influenza vaccination of nursing home staff 6https://pubmed.ncbi.nlm.nih.gov/34469474/. article?id=10.1371/journal.pmed.1003816. Continued jspears on DSK121TN23PROD with RULES2VerDate Sep<11>2014 22:27 Nov 04, 2021Jkt 256001PO 00000 Frm 00157 Fmt 4701 Sfmt 4700 E:\FR\FM\05NOR2.SGM 05NOR2 61558 Federal Register/Vol. 86, No. 212/Friday, November 5, 2021/Rules and Regulations As a result, CDC, the Society for in facilities with lower vaccination for ongoing healthcare-associated Healthcare Epidemiology of America, coverage among staff; specifically, COVID–19 transmission risk is and others recommend—and a number residents of LTC facilities in which sufficiently alarming in and of itself to of states require— annual influenza vaccination coverage of staff is 75 compel CMS to take action. vaccination for health care staff.323334 percent or lower experience higher rates The threats that unvaccinated staff In addition to preventing morbidity 38 Several pose to patients are not, however, of preventable COVID–19. and mortality associated with COVID– articles published in CDC’s Morbidity limited to SARS–CoV–2 transmission. 19, currently approved or authorized and Mortality Weekly Reports Unvaccinated staff jeopardize patient vaccines also demonstrate effectiveness (MMWRs) regarding nursing home access to recommended medical care against asymptomatic SARS–CoV–2 outbreaks have also linked the spread of and services, and these additional risks infection. A recent study of health care COVID–19 infection to unvaccinated to patient health and safety further workers in 8 states found that, between health care workers and stressed that warrant CMS action. December 14, 2020 through August 14, maintaining a high vaccination rate is Fear of exposure to and infection with 2021, full vaccination with COVID–19 important for reducing COVID–19 from unvaccinated health vaccines was 80 percent effective in transmission.394041 care staff can lead patients to preventing RT–PCR–confirmed SARS– There is also some published themselves forgo seeking medically CoV–2 infection among frontline evidence from other settings that suggest necessary care. In a small but workers.35 Emerging evidence also similar dynamics can be expected in informative qualitative study of 33 suggests that vaccinated people who other health care delivery settings. For home health care workers in New York become infected with the SARS–CoV–2 example, a recent analysis from Yale City, one of the key themes to emerge Delta variant have potential to be less New Haven Hospital (YNHH) found from interviews with those workers was infectious than infected unvaccinated health care units with at least 1 a keen recognition that ‘‘providing care people, thus decreasing transmission inpatient case of HA–COVID–19 had to patients placed them in a unique 36 42 position with respect to COVID–19 risk. For example, in a study of lower staff vaccination rates. breakthrough infections among health Similarly, a small study in Israel transmission. They worried . . . about care workers in the Netherlands, SARS– demonstrated that transmission of transmitting the virus to [their clients].’’ CoV–2 infectious virus shedding was COVID–19 was linked to unvaccinated They also noted that care for home lower among vaccinated individuals persons. In 37 cases, patients for whom bound clients might involve other with breakthrough infections than data were available regarding the source health care staff, and they worried about among unvaccinated individuals with of infection, the suspected source was ‘‘transmitting COVID–19 . . . to one 37 another.’’44 primary infections. Fewer infected an unvaccinated person; in 21 patients staff and lower transmissibility equates (57 percent), this person was a Anecdotal evidence suggests health to fewer opportunities for transmission household member; in 11 cases (30 care consumers have drawn similar to patients, and emerging evidence percent), the suspected source was an conclusions—and this, too, has indicates this is the case. The best data unvaccinated fellow health care worker implications for overall health and 43 welfare in health care settings. For come from long term care facilities, as or patient. While similarly early implementation of national comprehensive data are not available for example, CMS has received anecdotal reporting requirements have resulted in all Medicare- and Medicaid-certified reports suggesting individuals in care a comprehensive, longitudinal, high provider types, the available evidence are refusing care from unvaccinated quality data set. Data from CDC’s staff, limiting the extent to which National Healthcare Safety Network 38https://emergency.cdc.gov/han/2021/ providers and suppliers can effectively (NHSN) have shown that case rates han00447.asp. meet the health care needs of their among LTC facility residents are higher 39COVID–19 Outbreak Associated with a SARS– patients and residents. Further, CoV–2 R.1 Lineage Variant in a Skilled Nursing nationwide there are reports of Facility After Vaccination Program — Kentucky, individuals avoiding or forgoing health on mortality of residents: a cluster-randomized trial. March 2021.’’ April 21, 2021. Available at https:// J Am Geriatr Soc. 2009; 57:1580–1586. www.cdc.gov/mmwr/volumes/70/wr/ care due to fears of contracting COVID– Van den Dool C, Bonten MJM, Hak E, Heijne JCM, mm7017e2.htm. 19 from health care workers.454647 Wallinga J. The effects of influenza vaccination of 40Postvaccination SARS–CoV–2 Infections While avoidance of necessary care health care workers in nursing homes: insights from Among Skilled Nursing Facility Residents and Staff appears to have abated somewhat since a mathematical model. PLoS Medicine. 2008; Members — Chicago, Illinois, December 2020– 5:1453–1460. March 2021.’’ April 30, 2021. Available at https:// the first months of the COVID–19 30Oshitani H, Saito R, Seiki N, et al. Influenza www.cdc.gov/mmwr/volumes/70/wr/ pandemic, it remains an area of concern vaccination levels and influenza-like illness in mm7017e1.htm. for many individuals.4849 Because long-term–care facilities for elderly people in 41Effectiveness of the Pfizer-BioNTech COVID–19 Niigata, Japan, during an influenza A (H3N2) Vaccine Among Residents of Two Skilled Nursing epidemic. Infect Control Hosp Epidemiol. 2000; Facilities Experiencing COVID–19 Outbreaks — 44https://jamanetwork.com/journals/ 21:728–730. Connecticut, December 2020–February 2021.’’ jamainternalmedicine/fullarticle/2769096). 31https://pubmed.ncbi.nlm.nih.gov/31384750/. March 19, 2021. Available at: https://www.cdc.gov/ 45J Anxiety Disord. 2020 Oct; 75: 102289. 32https://www.cdc.gov/flu/professionals/ mmwr/volumes/70/wr/mm7011e3.htm. Published online 2020 Aug 19. Doi: 10.1016/ infectioncontrol/healthcaresettings.htm. 42Roberts, S., Aniskiewicz, M., Choi, S., Pettker, j.janxdis.2020.102289 33https://www.cambridge.org/core/journals/ C., & Martinello, R. (2021). Correlation of healthcare 46https://www.cdc.gov/mmwr/volumes/69/wr/ infection-control-and-hospital-epidemiology/ worker vaccination on inpatient healthcare- pdfs/mm6936a4-H.pdf. article/revised-shea-position-paper-influenza- associated COVID–19. Infection Control & Hospital 47https://www.nahc.org/wp-content/uploads/ vaccination-of-healthcare-personnel/E83D4D87 Epidemiology, 1–6. Doi:10.1017/ice.2021.414. 2020/03/NATIONAL-SURVEY-SHOWS-HOME- FBBBD80C66A2A4926D00F4B8. 43Moriah Bergwerk, M.B., B.S., Tal Gonen, B.A., HEALTH-CARE-ON-THE-FRONTLINES-OF-COVID- 34https://www.cdc.gov/phlp/publications/topic/ Yaniv Lustig, Ph.D., Sharon Amit, M.D., Marc 19-AND-CONTINUES-TO-BE-IN-A-FRAGILE- vaccinationlaws.html. Lipsitch, Ph.D., Carmit Cohen, Ph.D., Michal FINANCIAL-STATE.pdf. 35https://www.cdc.gov/mmwr/volumes/70/wr/ Mandelboim, Ph.D., Einav Gal Levin, M.D., Carmit 48https://www.urban.org/sites/default/files/ mm7034e4.htm?s_cid=mm7034e4_w. Rubin, N.D., Victoria Indenbaum, Ph.D., Ilana Tal, publication/103651/delayed-and-forgone-health- 36https://www.cdc.gov/coronavirus/2019-ncov/ R.N., Ph.D., Malka Zavitan, R.N., M.A., et al. Covid– care-for-nonelderly-adults-during-the-covid-19- science/science-briefs/fully-vaccinated- 19 Breakthrough Infections in Vaccinated Health pandemic_1.pdf. people.html#ref43. Care Workers. N Engl J Med 2021; 385:1474–1484. 49Gale R, Eberlein S, Fuller G, Khalil C, Almario 37https://www.medrxiv.org/content/10.1101/ DOI: 10.1056/NEJMoa2109072. https:// CV, Spiegel BM. Public Perspectives on Decisions 2021.08.20.21262158v1.full.pdf. www.nejm.org/doi/full/10.1056/NEJMoa2109072. 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