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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.
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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.
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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
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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.
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vaccination-of-healthcare-personnel/E83D4D87 Epidemiology, 1–6. Doi:10.1017/ice.2021.414. 2020/03/NATIONAL-SURVEY-SHOWS-HOME-
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