Identifying strategies that promote staff and resident influenza and COVID-19 vaccination in nursing homes: Perspectives from nursing home staff.

Resident and staff influenza and COVID-19 vaccination are critical components of infection prevention in nursing homes. Our study sought to characterize strategies that nursing home staff use to promote vaccination. Twenty-six telephone/videoconference interviews were conducted with administrators, directors of nursing, infection preventionists, and Minimum Data Set coordinators at 14 nursing homes across the US. Transcripts were analyzed using content analysis and a detailed audit trail was maintained. Staff described resident and staff influenza and COVID-19 vaccine hesitancy and confidence as well as varying approaches to promote vaccination. These included incentives, education efforts, and having a "vaccine champion" responsible for vaccine promotion. While many strategies had been in place prior to COVID-19 in support of improving influenza vaccination, participants reported implementing additional approaches to promote COVID-19 vaccination. Findings may inform future efforts to promote vaccination, which will be critical to mitigate the burden of influenza and COVID-19 in nursing homes.

Self-reported measures of limitation in physical function in late midlife are associated with incident Alzheimer's disease and related dementias.

BACKGROUND: Even small improvements in modifiable Alzheimer's disease and related dementias (ADRD) risk factors could lead to a substantial reduction of dementia cases. AIMS: To determine if self-reported functional limitation associates with ADRD symptoms 4-18 years later. METHODS: We conducted a prospective longitudinal study using the Health and Retirement Study of adults aged 51-59 years in 1998 without symptoms of ADRD by 2002 and followed them to 2016. Main exposure variables were difficulty with activities of daily living, mobility, large muscle strength, gross motor and upper limb activities. The outcome was incident ADRD identified by the Lange-Weir algorithm, death, or alive without ADRD. We fit two GEE multinomial models for each measure: (1) baseline measure of function and (2) change in function over time. RESULTS: In the model with baseline only and outcome, only difficulty with mobility associated with future ADRD across levels of difficulty with near dose-response effect (risk ratios (RR) difficulty with 1-5 functions respectively, compared with no difficulty: 1.82; 2.70; 1.73 2.81; 4.03). Mobility also significantly associated with ADRD when allowing for change over time among those with 3, 4 or 5 versus no mobility limitations (RR 1.76; 2.36; 2.37). DISCUSSION: The results infer that an adult in midlife reporting difficulty with mobility as well as those with no mobility limitations in midlife but who later report severe limitations may be at increased risk of incident ADRD. CONCLUSIONS: Self-reported measures of mobility limitation may be early indicators of ADRD and may be useful for public health planning.

Profiles of Caregiving Arrangements of Community-dwelling People Living with Probable Dementia.

People living with dementia receive care from multiple caregivers, but little is known about the structure of their caregiving arrangements. This study used the Health and Retirement Study and latent class analyses to identify subgroups of caregiving arrangements based on caregiving hours received from spouses, children, other family/friends, and paid individuals among married (n = 361) and unmarried (n = 473) community-dwelling people with probable dementia. Three classes in the married sample (class 1 "low hours with shared care," class 2 "spouse-dominant care," and class 3 "children-dominant care") were identified. In class 1, spouses, children, and paid individuals provided 53%, 22%, and 26% of the caregiving hours, respectively. Three classes in the unmarried sample (class 1 "low hours with shared care," class 2 "children-dominant care," and class 3 "paid-dominant care") were identified. In unmarried class 1, children, other family/friends, and paid individuals provided 35%, 41% and 24% of the caregiving hours, respectively.

Persistence of Racial Inequities in Receipt of Influenza Vaccination Among Nursing Home Residents in the United States.

BACKGROUND: We sought to determine if racial differences in influenza vaccination among nursing home (NH) residents during the 2008-2009 influenza season persisted in 2018-2019. METHODS: We conducted a cross-sectional study of NHs certified by the Centers for Medicare & Medicaid Services during the 2018-2019 influenza season in US states with ≥1% Black NH residents and a White-Black gap in influenza vaccination of NH residents (N = 2 233 392) of at least 1 percentage point (N = 40 states). NH residents during 1 October 2018 through 31 March 2019 aged ≥18 years and self-identified as being of Black or White race were included. Residents' influenza vaccination status (vaccinated, refused, and not offered) was assessed. Multilevel modeling was used to estimate facility-level vaccination status and inequities by state. RESULTS: The White-Black gap in influenza vaccination was 9.9 percentage points. In adjusted analyses, racial inequities in vaccination were more prominent at the facility level than at the state level. Black residents disproportionately lived in NHs that had a majority of Blacks residents, which generally had the lowest vaccination. Inequities were most concentrated in the Midwestern region, also the most segregated. Not being offered the vaccine was negligible in absolute percentage points between White residents (2.6%) and Black residents (4.8%), whereas refusals were higher among Black (28.7%) than White residents (21.0%). CONCLUSIONS: The increase in the White-Black vaccination gap among NH residents is occurring at the facility level in more states, especially those with the most segregation.

Vital Signs: Burden and Prevention of Influenza and Pertussis Among Pregnant Women and Infants - United States.

INTRODUCTION: Vaccinating pregnant women with influenza vaccine and tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) can reduce influenza and pertussis risk for themselves and their infants. METHODS: Surveillance data were analyzed to ascertain influenza-associated hospitalization among pregnant women and infant hospitalization and death associated with influenza and pertussis. An Internet panel survey was conducted during March 27-April 8, 2019, among women aged 18-49 years who reported being pregnant any time since August 1, 2018. Influenza vaccination before or during pregnancy was assessed among respondents with known influenza vaccination status who were pregnant any time during October 2018-January 2019 (2,097). Tdap receipt during pregnancy was assessed among respondents with known Tdap status who reported a live birth by their survey date (817). RESULTS: From 2010-11 to 2017-18, pregnant women accounted for 24%-34% of influenza-associated hospitalizations per season among females aged 15-44 years. From 2010 to 2017, a total of 3,928 pertussis-related hospitalizations were reported among infants aged <2 months (annual range = 262-743). Maternal influenza and Tdap vaccination coverage rates reported as of April 2019 were 53.7% and 54.9%, respectively. Among women whose health care providers offered vaccination or provided referrals, 65.7% received influenza vaccine and 70.5% received Tdap. The most commonly reported reasons for nonvaccination were believing the vaccine is not effective (influenza; 17.6%) and not knowing that vaccination is needed during each pregnancy (Tdap; 37.9%), followed by safety concerns for the infant (influenza =15.9%; Tdap = 17.1%). CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Many pregnant women do not receive the vaccines recommended to protect themselves and their infants, even when vaccination is offered. CDC and provider organizations' resources are available to help providers convey strong, specific recommendations for influenza and Tdap vaccination that are responsive to pregnant women's concerns.

Age-Period-Cohort Analyses of Tuberculosis Incidence Rates by Nativity, United States, 1996-2016.

OBJECTIVES: To assess changes in US tuberculosis (TB) incidence rates by age, period, and cohort effects, stratified according to race/ethnicity and nativity. METHODS: We used US National Tuberculosis Surveillance System data for 1996 to 2016 to estimate trends through age-period-cohort models. RESULTS: Controlling for cohort and period effects indicated that the highest rates of TB incidence occurred among those 0 to 5 and 20 to 30 years of age. The incidence decreased by age for successive birth cohorts. There were greater estimated annual percentage decreases among US-born individuals (-7.3%; 95% confidence interval [CI] = -7.5, -7.1) than among non-US-born individuals (-4.3%; 95% CI = -4.5, -4.1). US-born individuals older than 25 years exhibited the largest decreases, a pattern that was not reflected among non-US-born adults. In the case of race/ethnicity, the greatest decreases by nativity were among US-born Blacks (-9.3%; 95% CI = -9.6, -9.1) and non-US-born Hispanics (-5.7%; 95% CI = -6.0, -5.5). CONCLUSIONS: TB has been decreasing among all ages, races and ethnicities, and consecutive cohorts, although these decreases are less pronounced among non-US-born individuals.

Risk of Nontargeted Infectious Disease Hospitalizations Among US Children Following Inactivated and Live Vaccines, 2005-2014.

Background: Recent studies have shown that some vaccines have beneficial effects that cannot be explained solely by the prevention of their respective targeted disease(s). Methods: We used the MarketScan US Commercial Claims Databases for 2005 to 2014 to assess the risk of hospital admission for nontargeted infectious (NTI) diseases in children aged 16 through 24 months according to the last vaccine type (live and/or inactivated). We included children continuously enrolled within a month of birth through 15 months who received at least 3 doses of diphtheria-tetanus-acellular pertussis vaccine by the end of 15 months of age. We used Cox regression to estimate hazard ratios (HRs), stratifying by birthdate to control for age, year, and seasonality and adjusting for sex, chronic diseases, prior hospitalizations, number of outpatient visits, region of residence, urban/rural area of domicile, prematurity, low birth weight, and mother's age. Results: 311663 children were included. In adjusted analyses, risk of hospitalization for NTI from ages 16 through 24 months was reduced for those who received live vaccine alone compared with inactivated alone or concurrent live and inactivated vaccines (HR, 0.50; 95% confidence interval [CI], 0.43, 0.57 and HR, 0.78; 95% CI, 0.67, 0.91, respectively) and for those who received live and inactivated vaccines concurrently compared with inactivated-only (HR, 0.64; 95% CI, 0.58, 0.70). Conclusions: We found lower risk of NTI disease hospitalizations from age 16 through 24 months among children whose last vaccine received was live compared with inactivated vaccine, as well as concurrent receipt compared with inactivated vaccine.

Development and demonstration of a state model for the estimation of incidence of partly undetected chronic diseases.

BACKGROUND: Estimation of incidence of the state of undiagnosed chronic disease provides a crucial missing link for the monitoring of chronic disease epidemics and determining the degree to which changes in prevalence are affected or biased by detection. METHODS: We developed a four-part compartment model for undiagnosed cases of irreversible chronic diseases with a preclinical state that precedes the diagnosis. Applicability of the model is tested in a simulation study of a hypothetical chronic disease and using diabetes data from the Health and Retirement Study (HRS). RESULTS: A two dimensional system of partial differential equations forms the basis for estimating incidence of the undiagnosed and diagnosed disease states from the prevalence of the associated states. In the simulation study we reach very good agreement between the estimates and the true values. Application to the HRS data demonstrates practical relevance of the methods. DISCUSSION: We have demonstrated the applicability of the modeling framework in a simulation study and in the analysis of the Health and Retirement Study. The model provides insight into the epidemiology of undiagnosed chronic diseases.

Trends in prevalence of diabetes among delivery hospitalizations, United States, 1993-2009.

To describe recent trends in prevalence of pre-existing diabetes mellitus (PDM) (i.e., type 1 or type 2 diabetes) and gestational diabetes mellitus (GDM) among delivery hospitalizations in the United States. Data on delivery hospitalizations from 1993 through 2009 were obtained from the Health Care Cost and Utilization Project (HCUP) Nationwide Inpatient Sample. Diagnosis-Related Group codes were used to identify deliveries and diagnosis codes on presence of diabetes. Rates of hospitalizations with diabetes were calculated per 100 deliveries by type of diabetes, hospital geographic region, patient's age, degree of urbanicity of patient's residence, categorized median household income for patient's ZIP Code, expected primary payer, and type of delivery. From 1993 to 2009, age-standardized prevalence of diabetes per 100 deliveries increased from 0.62 to 0.90 for PDM (trend p < 0.001) and from 3.09 to 5.57 for GDM (trend p < 0.001). In 2009, correlates of PDM at delivery included older age [40-44 vs. 15-24: odds ratio 6.45 (95 % CI 5.27-7.88)], Medicaid/Medicare versus private payment sources [1.77 (95 % CI 1.59-1.98)], patient's ZIP Code with a median household income in bottom quartile versus other quartiles [1.54 (95 % CI 1.41, 1.69)], and C-section versus vaginal delivery [3.36 (95 % CI 3.10-3.64)]. Correlates of GDM at delivery were similar. Among U.S. delivery hospitalizations, the prevalence of diabetes is increasing. In 2009, the prevalence of diabetes was higher among women in older age groups, living in ZIP codes with lower household incomes, or with public insurance.

The relationship between county-level contextual characteristics and use of diabetes care services.

OBJECTIVES: To examine the relationship between county-level measures of social determinants and use of preventive care among US adults with diagnosed diabetes. To inform future diabetes prevention strategies. METHODS: Data are from the Behavioral Risk Factor Surveillance System (BRFSS) 2004 and 2005 surveys, the National Diabetes Surveillance System, and the Area Resource File. Use of diabetes care services was defined by self-reported receipt of 7 preventive care services. Our study sample included 46 806 respondents with self-reported diagnosed diabetes. Multilevel models were run to assess the association between county-level characteristics and receipt of each of the 7 preventive diabetes care service after controlling for characteristics of individuals. Results were considered significant if P < .05. RESULTS: Controlling for individual-level characteristics, our analyses showed that 7 of the 8 county-level factors examined were significantly associated with use of 1 or more preventive diabetes care services. For example, people with diabetes living in a county with a high uninsurance rate were less likely to have an influenza vaccination, visit a doctor for diabetes care, have an A1c test, or a foot examination; people with diabetes living in a county with a high physician density were more likely to have an A1c test, foot examination, or an eye examination; and people with diabetes living in a county with more people with less than high-school education were less likely to have influenza vaccination, pneumococcal vaccination, or self-care education (all P < .05). CONCLUSIONS: Many of the county-level factors examined in this study were found to be significantly associated with use of preventive diabetes care services. County policy makers may need to consider local circumstances to address the disparities in use of these services.

Geographic Variation in Racial Disparities in Receipt of High-Dose Influenza Vaccine Among US Older Adults.

BACKGROUND: Racial disparities in receipt of high-dose influenza vaccine (HDV) have been documented nationally, but whether small-area geographic variation in such disparities exists remains unknown. We assessed the distribution of disparities in HDV receipt between Black and White traditional Medicare beneficiaries vaccinated against influenza within states and hospital referral regions (HRRs). METHODS: We conducted a nationally representative retrospective cohort study of 11,768,724 community-dwelling traditional Medicare beneficiaries vaccinated against influenza during the 2015-2016 influenza season (94.3% White and 5.7% Black). Our comparison was marginalized versus privileged racial group measured as Black versus White race. Vaccination and type of vaccine were obtained from Medicare Carrier and Outpatient files. Differences in the proportions of individuals who received HDV between Black and White beneficiaries within states and HRRs were used to measure age- and sex-standardized disparities in HDV receipt. We restricted to states and HRRs with ≥ 100 beneficiaries per age-sex strata per racial group. RESULTS: We detected a national disparity in HDV receipt of 12.8 percentage points (pps). At the state level, the median standardized HDV receipt disparity was 10.7 pps (minimum, maximum: 2.9, 25.6; n = 30 states). The median standardized HDV receipt disparity among HRRs was 11.6 pps (minimum, maximum: 0.4, 24.7; n = 54 HRRs). CONCLUSION: Black beneficiaries were less likely to receive HDV compared to White beneficiaries in almost every state and HRR in our analysis. The magnitudes of disparities varied substantially across states and HRRs. Local interventions and policies are needed to target geographic areas with the largest disparities to address these inequities.

Geospatial Distribution of Racial Disparities in Influenza Vaccination in Nursing Homes.

OBJECTIVES: This study aimed to assess the distribution of racial disparities in influenza vaccination between White and Black short-stay and long-stay nursing home residents among states and hospital referral regions (HRRs). DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: We included short-stay and long-stay older adults residing in US nursing homes during influenza seasons between 2011 and 2018. Included residents were aged ≥65 years and enrolled in Traditional Medicare. Analyses were conducted using resident-seasons, whereby residents could contribute to one or more influenza seasons if they resided in a nursing home across multiple seasons. METHODS: Our comparison of interest was marginalized vs privileged racial group membership measured as Black vs White race. We obtained influenza vaccination documentation from resident Minimum Data Set assessments from October 1 through June 30 of a particular influenza season. Nonparametric g-formula was used to estimate age- and sex-standardized disparities in vaccination, measured as the percentage point (pp) difference in the proportions of individuals vaccinated between Black and White nursing home residents within states and HRRs. RESULTS: The study included 7,807,187 short-stay resident-seasons (89.7% White and 10.3% Black) in 14,889 nursing homes and 7,308,111 long-stay resident-seasons (86.7% White and 13.3% Black) in 14,885 nursing homes. Among states, the median age- and sex-standardized disparity between Black and White residents was 10.1 percentage points (pps) among short-stay residents and 5.3 pps among long-stay residents across seasons. Among HRRs, the median disparity was 8.6 pps among short-stay residents and 5.0 pps among long-stay residents across seasons. CONCLUSIONS AND IMPLICATIONS: Our analysis revealed that the magnitudes of vaccination disparities varied substantially across states and HRRs, from no disparity in vaccination to disparities in excess of 25 pps. Local interventions and policies should be targeted to high-disparity geographic areas to increase vaccine uptake and promote health equity.

Combining estimates from two surveys: an example from monitoring 2009 influenza A (H1N1) pandemic vaccination.

During the 2009 influenza A (H1N1) pandemic, there was an ongoing need to monitor 2009 H1N1 vaccination coverage at the national and state level to evaluate the vaccination campaign; thus, precise vaccination coverage estimates were needed in a timely fashion. The current objective is to describe and evaluate the methodology used to combine 2009 H1N1 vaccination coverage estimates from the Behavioral Risk Factor Surveillance System (BRFSS) and the National 2009 H1N1 Flu Survey (NHFS). H1N1 state level vaccination coverage estimates were combined by taking weighted averages of the BRFSS and NHFS estimates, with more weight given to the estimate with the larger effective sample size (sample size/design effect). The impact of the choice of weights was evaluated by comparing estimates when the design effect was removed from the weights. Combined vaccination coverage estimates for children generally fell midway between NHFS and BRFSS estimates because of larger NHFS sample sizes but smaller BRFSS design effects. Adult estimates were more closely weighted to BRFSS estimates because of larger BRFSS sample sizes. Combined standard errors were smaller than the survey-specific standard errors. When removing the design effect from the weights, the child combined estimates were more closely weighted to those from NHFS, resulting in larger standard errors. Adult combined estimates were similar regardless of choice of weight because of similar design effects across the two surveys. Combining estimates by weighting by the effective sample size allowed timely release of more precise estimates in all states during the 2009 H1N1 pandemic.

US nursing home residents receiving PCV13 in the SNF by recorded pneumococcal vaccination up-to-date status, 2014-2018.

BACKGROUND: Since PCV13 was recommended in 2014, the characteristics of nursing home (NH) residents (and their facilities) recorded by facilities as not up-to-date with pneumococcal vaccination upon admission were unknown, and it is unknown if they received PCV13 in the NH. METHODS: We conducted a retrospective cohort of NH residents of Centers for Medicare and Medicaid (CMS)-certified skilled nursing facilities from October 1, 2014, through September 22, 2018. CMS' Minimum Data Set (MDS) was linked to Medicare Part B Carrier claims to corroborate pneumococcal vaccination up-to-date status in the MDS with pneumococcal vaccination claims. The primary outcome of interest was vaccination with PCV13 versus nonreceipt among those identified as "not up to date" according to facility MDS records. We estimated generalized estimating equation (GEE) models. RESULTS: Of the 1,459,814 residents recorded not up-to-date, (78.2%) had no Part B claims for PCV13 before or in the NH, the majority of whom (71.5%) were reported to have refused the vaccine when offered. Only 1.3% subsequently received PCV13 within 99 days after NH admission. In adjusted analyses, residents less likely to receive PCV13 in the NH than those who did included: residence in a for-profit facility (OR: 0.94 [95% CI: 0.89, 0.99]); male (OR: 0.92 [95% CI:0.89, 0.95]); black race (OR: 0.71 (95%CI: 0.66, 0.77); Hispanic ethnicity (OR: 0.69 [95%CI: 0.59, 0.75]); severely cognitively impaired compared with any lesser degree of impairment; had diabetes (OR: 0.93 [95%CI: 0.89, 0.97]); long-stay (≥100 days) compared with short-stay residents (OR: 0.17 (95%CI: 0.15, 0.20); and did not receive the influenza vaccine (OR: 0.74 (95%CI: 0.71, 0.77). CONCLUSIONS: Due to refusals, few NH residents recorded not up-to-date on pneumococcal vaccinations from 2014 to 2018 received PCV13 within three months of admission. Strategies to promote newly recommended PCV15 or PCV20 vaccination upon NH admission may be needed.

Patterns of Limitation in Physical Function in Late Midlife Associated with Late-Onset Alzheimer's Disease and Related Dementias: A Cluster Analysis.

BACKGROUND: To reduce the increasing societal and financial burden of Alzheimer's disease and related dementias (ADRD), prevention is critical. Even small improvements of the modifiable dementia risk factors on the individual level have the potential to lead to a substantial reduction of dementia cases at the population level. OBJECTIVE: To determine if pattern(s) of functional decline in midlife associate with late-onset ADRD years later. METHODS: Using a longitudinal study of adults aged 51-59 years in 1998 without symptoms of ADRD by 2002 and followed them from 2002 to 2016 (n = 5404). The outcome was incident ADRD identified by the Lange-Weir algorithm, death, or alive with no ADRD. We used cluster analysis to identify patterns of functional impairment at baseline and multinomial regression to assess their association with future ADRD. RESULTS: Three groups of adults with differing patterns of functional impairment were at greater risk of future ADRD. Difficulty with climbing one flight of stairs was observed in all adults in two of these groups. In the third group, 100% had difficulty with lifting 10 pounds and pushing or pulling a large object, but only one-fourth had difficulty in climbing stairs. CONCLUSION: Results imply that improved large muscle strength could decrease future risk of ADRD. If confirmed in other studies, screening for four self-reported measures of function among adults in midlife may be used for targeted interventions.

Variation in influenza vaccine assessment, receipt, and refusal by the concentration of Medicare Advantage enrollees in U.S. nursing homes.

BACKGROUND: More older adults enrolled in Medicare Advantage (MA) are entering nursing homes (NHs), and MA concentration could affect vaccination rates through shifts in resident characteristics and/or payer-related influences on preventive services use. We investigated whether rates of influenza vaccination and refusal differ across NHs with varying concentrations of MA-enrolled residents. METHODS: We analyzed 2014-2015 Medicare enrollment data and Minimum Data Set clinical assessments linked to NH-level characteristics, star ratings, and county-level MA penetration rates. The independent variable was the percentage of residents enrolled in MA at admission and categorized into three equally-sized groups. We examined three NH-level outcomes including the percentages of residents assessed and appropriately considered for influenza vaccination, received influenza vaccination, and refused influenza vaccination. RESULTS: There were 936,513 long-stay residents in 12,384 NHs. Categories for the prevalence of MA enrollment in NHs were low (0% to 3.3%; n = 4131 NHs), moderate (3.4% to 18.6%; n = 4127 NHs) and high (>18.6%; n = 4126 NHs). Overall, 81.3% of long-stay residents received influenza vaccination and 14.3% refused the vaccine when offered. Adjusting for covariates, influenza vaccination rates among long-stay residents were higher in NHs with moderate (1.70 percentage points [pp], 95% confidence limits [CL]: 1.15 pp, 2.24 pp), or high (3.05 pp, 95% CL: 2.45 pp, 3.66 pp) MA versus the lowest prevalence of MA. Influenza vaccine refusal was lower in NHs with moderate (-3.10 pp, 95% CL: -3.53 pp, -2.68 pp), or high (-4.63 pp, 95% CL: -5.11 pp, -4.15 pp) MA compared with NHs with the lowest prevalence of MA. CONCLUSION: A higher concentration of long-stay NH residents enrolled in MA was associated with greater influenza vaccine receipt and lower vaccine refusal. As MA becomes a larger share of the Medicare program, and more MA beneficiaries enter NHs, decisionmakers need to consider how managed care can be leveraged to improve the delivery of preventive services like influenza vaccinations in NH settings.

Adverse events following third dose of mRNA COVID-19 vaccination among nursing home residents who received the primary series.

BACKGROUND: We sought to compare rates of adverse events among nursing home residents who received an mRNA COVID-19 vaccine booster dose with those who had not yet received their booster. METHODS: We assessed a prospective cohort of 11,200 nursing home residents who received a primary COVID-19 mRNA vaccine series at least 6 months prior to September 22, 2021 and received a third "booster dose" between September 22, 2021 and February 2, 2022. Residents lived in 239 nursing homes operated by Genesis HealthCare, spanning 21 U.S. states. We screened electronic health records for 20 serious vaccine-related adverse events that are monitored following receipt of COVID-19 vaccination by the CDC's Vaccine Safety Datalink. We matched boosted and yet-to-be boosted residents during the same time period, comparing rates of events occurring 14 days after booster administration with those occurring 14 days prior to booster administration. To supplement previously reported background rates of adverse events, we report background rates of medical conditions among nursing home residents during 2020, before COVID-19 vaccines were administered in nursing homes. Events occurring in 2021-2022 were confirmed by physician chart review. We report unadjusted rates of adverse events and used a false discovery rate procedure to adjust for multiplicity of events tested. RESULTS: No adverse events were reported during the 14 days post-booster. A few adverse events occurred prior to booster (ischemic stroke: 49.4 per 100,000 residents, 95% CI: 21.2, 115.7; venous thromboembolism: 9.9 per 100,000 residents, 95% CI: 1.7, 56.0), though differences in event rates pre- versus post-booster were not statistically significant (p < 0.05) after adjusting for multiple comparisons. No significant differences were detected between post-booster vaccination rates and prior year 14-day background rates of medical conditions. CONCLUSIONS: No safety signals were detected following a COVID-19 mRNA vaccine booster dose in this large multi-state sample of nursing home residents.

Causes and timing of 30-day rehospitalization from skilled nursing facilities after a hospital admission for pneumonia or sepsis.

BACKGROUND: Pneumonia and sepsis are among the most common causes of hospitalization in the United States and often result in discharges to a skilled nursing facility (SNF) for rehabilitation. We described the timing and most common causes of 30-day unplanned hospital readmission following an index hospitalization for pneumonia or sepsis. METHODS AND FINDINGS: This national retrospective cohort study included adults ≥65 years who were hospitalized for pneumonia or sepsis and were discharged to a SNF between July 1, 2012 and July 4, 2015. We quantified the ten most common 30-day unplanned readmission diagnoses and estimated the daily risk of first unplanned rehospitalization for four causes of readmission (circulatory, infectious, respiratory, and genitourinary). The index hospitalization was pneumonia for 92,153 SNF stays and sepsis for 452,254 SNF stays. Of these SNF stays, 20.9% and 25.9%, respectively, resulted in a 30-day unplanned readmission. Overall, septicemia was the single most common readmission diagnosis for residents with an index hospitalization for pneumonia (16.7% of 30-day readmissions) and sepsis (22.4% of 30-day readmissions). The mean time to unplanned readmission was approximately 14 days overall. Respiratory causes displayed the highest daily risk of rehospitalization following index hospitalizations for pneumonia, while circulatory and infectious causes had the highest daily risk of rehospitalization following index hospitalizations for sepsis. The day of highest risk for readmission occurred within two weeks of the index hospitalization discharge, but the readmission risk persisted across the 30-day follow-up. CONCLUSION: Among older adults discharged to SNFs following a hospitalization for pneumonia or sepsis, hospital readmissions for infectious, circulatory, respiratory, and genitourinary causes occurred frequently throughout the 30-day post-discharge period. Our data suggests further study is needed, perhaps on the value of closer monitoring in SNFs post-hospital discharge and improved communication between hospitals and SNFs, to reduce the risk of potentially preventable hospital readmissions.

Infections, Hospitalizations, and Deaths Among US Nursing Home Residents With vs Without a SARS-CoV-2 Vaccine Booster.

Importance: A SARS-CoV-2 vaccine booster dose has been recommended for all nursing home residents. However, data on the effectiveness of an mRNA vaccine booster in preventing infection, hospitalization, and death in this vulnerable population are lacking. Objective: To evaluate the association between receipt of a SARS-CoV-2 mRNA vaccine booster and prevention of infection, hospitalization, or death among nursing home residents. Design, Setting, and Participants: This cohort study emulated sequentially nested target trials for vaccination using data from 2 large multistate US nursing home systems: Genesis HealthCare, a community nursing home operator (system 1) and Veterans Health Administration community living centers (VHA CLCs; system 2). The cohort included long-term (≥100 days) nursing home residents (10 949 residents from 202 community nursing homes and 4321 residents from 128 VHA CLCs) who completed a 2-dose series of an mRNA vaccine (either BNT162b2 [Pfizer-BioNTech] or mRNA-1273 [Moderna]) and were eligible for a booster dose between September 22 and November 30, 2021. Residents were followed up until March 8, 2022. Exposures: Receipt of a third mRNA vaccine dose, defined as a booster dose (boosted group), or nonreceipt of a booster dose (unboosted group) on an eligible target trial date. If participants in the unboosted group received a booster dose on a later target trial date, they were included in the booster group for that target trial; thus, participants could be included in both the boosted and unboosted groups. Main Outcomes and Measures: Test-confirmed SARS-CoV-2 infection, hospitalization, or death was followed up to 12 weeks after booster vaccination. The primary measure of estimated vaccine effectiveness was the ratio of cumulative incidences in the boosted group vs the unboosted group at week 12, adjusted with inverse probability weights for treatment and censoring. Results: System 1 included 202 community nursing homes; among 8332 boosted residents (5325 [63.9%] female; 6685 [80.2%] White) vs 10 886 unboosted residents (6865 [63.1%] female; 8651 [79.5%] White), the median age was 78 (IQR, 68-87) years vs 78 (IQR, 68-86) years. System 2 included 128 VHA CLCs; among 3289 boosted residents (3157 [96.0%] male; 1950 [59.3%] White) vs 4317 unboosted residents (4151 [96.2%] male; 2434 [56.4%] White), the median age was 74 (IQR, 70-80) vs 74 (IQR, 69-80) years. Booster vaccination was associated with reductions in SARS-CoV-2 infections of 37.7% (95% CI, 25.4%-44.2%) in system 1 and 57.7% (95% CI, 43.5%-67.8%) in system 2. For hospitalization, reductions of 74.4% (95% CI, 44.6%-86.2%) in system 1 and 64.1% (95% CI, 41.3%-76.0%) in system 2 were observed. Estimated vaccine effectiveness for death associated with SARS-CoV-2 was 87.9% (95% CI, 75.9%-93.9%) in system 1; however, although a reduction in death was observed in system 2 (46.6%; 95% CI, -34.6% to 94.8%), this reduction was not statistically significant. A total of 45 SARS-CoV-2-associated deaths occurred in system 1 and 18 deaths occurred in system 2. For the combined end point of SARS-CoV-2-associated hospitalization or death, boosted residents in system 1 had an 80.3% (95% CI, 65.7%-88.5%) reduction, and boosted residents in system 2 had a 63.8% (95% CI, 41.4%-76.1%) reduction. Conclusions and Relevance: In this study, during a period in which both the Delta and Omicron variants were circulating, SARS-CoV-2 booster vaccination was associated with significant reductions in SARS-CoV-2 infections, hospitalizations, and the combined end point of hospitalization or death among residents of 2 US nursing home systems. These findings suggest that administration of vaccine boosters to nursing home residents may have an important role in preventing COVID-19-associated morbidity and mortality.