In parts of the country where covid-19 continues to fill hospitals, a rotating cast of traveling nurses helps keep intensive care units fully staffed. Hospitals have to pay handsomely to get that temporary help, and those higher wages are tempting some staff nurses to hit the road, too.
Nearly two years into the pandemic, there’s some truth in a joke circulating among frustrated ICU nurses: They ask their hospitals for appropriate compensation for the hazards they’ve endured. And the nurses are rewarded with a pizza party instead.
Theresa Adams said that’s what happened at the Ohio hospital where she worked. The facility across town was offering bonuses to keep its nurses from leaving. But not hers. They got a pizza party.
“I heard a lot of noise about ‘Well, this is what you signed up for.’ No, I did not sign up for this,” she said of the unparalleled stress brought on by the pandemic.
Adams is an ICU nurse who helped build and staff covid units in one of Ohio’s largest hospitals. She recently left for a lucrative stint as a travel nurse in California.
Travel nurses take on temporary assignments in hospitals or other healthcare facilities that have staffing shortages. The contracts typically last a few months and usually pay more than staff positions.
Adams hopes to return to her home hospital eventually, though she’s irritated at management at the moment.
“I did not sign up for the facility taking advantage of the fact that I have a calling,” she said. “There is a difference between knowing my calling and knowing my worth.”
Hospitals – and Staff – Reckon with Costs of Hiring Travel Nurses
A reckoning may be on its way as hospitals try to stabilize a worn-out workforce.
The use of traveling nurses took off in the 1980s in response to nursing shortages. Although they’ve always been paid more for their flexibility, some traveling ICU nurses can now pull in as much as $10,000 a week, which can be several times more than staff nurses earn.
While some hospitals have offered retention bonuses or increased pay for permanent staff members, nurses say it doesn’t compare to the financial bonanza of traveling. Hospital managers now find themselves trapped in a pricey hiring cycle — competing for, in particular, the most highly trained critical care nurses who can monitor covid patients on the advanced life-support devices known as ECMO (extracorporeal membrane oxygenation) machines.
The shortage of ECMO nurses has prevented the hospital from admitting additional covid patients who need their blood oxygenated outside their body, he said. No more staff nurses have enough experience to start the training.
“We will train these people and then six months later they will be gone and traveling,” Emling said. “So it’s hard to invest so much in them trainingwise and timewise to see them leave.”
And when they leave, hospitals are often forced to fill the spot with a traveler.
“It’s like a Band-Aid,” said Dr. Iman Abuzeid, co-founder of a San Francisco nurse recruiting company called Incredible Health. “We need it now, but it is temporary.”
Incredible Health helps to quickly place full-time staff nurses in some of the country’s largest health systems. The number of listings for full-time, permanent nurses on the company’s platform has shot up 200% in the past year.
To help hospitals, some states are chipping in to hire travel nurses. But for many hospitals, the higher costs are straining their budgets, which is especially difficult for those that have suspended elective surgeries — often a hospital’s biggest moneymaker — to accommodate covid patients.
“Every executive we interact with is under pressure to reduce the number of traveler nurses on their teams, not just from a cost standpoint but also from a quality-of-care standpoint,” Abuzeid said.
It’s hard on morale as well: Camaraderie suffers when newcomers need help finding syringes or other supplies but may be paid two or three times as much as the staff nurses showing them the ropes.
Some hospitals are trying to stop the turnover by offering big signing bonuses to permanent nurses, as well as loan forgiveness or tuition assistance to pursue additonal education. Hospitals have also hiked pay for nurses as they earn certifications, especially in critical care.
Importing Foreign Nurses to Fill the Gap
Other medical centers are looking outside the U.S.
Henry Ford Health System in Michigan announced plans to bring in hundreds of nurses from the Philippines. Smaller community hospitals are looking abroad, too. City-owned Cookeville Regional Medical Center, in a Tennessee town of 35,000, is now recruiting its first foreign nurses.
“The cost for what we pay for a local recruiter to bring us one full-time staff member is more expensive than what we are going to be spending to bring one foreign nurse,” said Scott Lethi, chief nursing officer at Cookeville Regional.
Lethi hopes the staffers from overseas will decide to stay more than a year or two. He said even new nurses sometimes leave or burn out: Cookeville hired a few recent graduates of U.S. nursing programs who quit after just a few months.
Among ICU nurses of all ages, two-thirds have considered leaving the profession because of the pandemic, according to a survey published in September by the American Association of Critical-Care Nurses.
When a nurse leaves — whether to retire, become a travel nurse or work in another field — the remaining nurses can be stretched dangerously thin, caring for more patients at once. Covid patients are particularly demanding, especially those on ventilators or ECMO machines who may require one-on-one care round-the-clock. Covid patients may be hospitalized for weeks or months.
“My ability to care for people has suffered. I know that I have missed things otherwise I would not have missed had I had the time to spend,” said Kevin Cho Tipton, an advanced practice nurse in the South Florida public health system. “Many of us feel like we’re becoming worse at our jobs.”
The worry about providing substandard care weighs heavily on nurses. But in the end, Tipton said, it’s the patients who suffer.
This story is part of a partnership that includes WPLN, NPR and KHN.
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.
In one recent week, a New Yorker got a free covid-19 test in a jiffy, with results the next day, while a Coloradan had to shell out $50 for a test two cities from her hometown after a frantic round of pharmacy-hopping. A Montanan drove an hour each way to get a test, wondering if, this time, it would again take five days to get results.
While covid testing is much easier to come by than it was early in the pandemic, the ability to get a test — and timely results — can vary widely nationwide. A fragmented testing system, complicated logistics, technician burnout and squirrelly spikes in demand are contributing to this bumpy ride.
“We’re still where we were 18 months ago,” said Rebecca Stanfel, the Montana woman who had to wait five days for test results in Helena last month after being exposed to someone with the virus.
Unpredictable waits can be a problem for those trying to plan travel, return to school from a quarantine — or even get lifesaving monoclonal antibody treatment within the optimal window if they do have covid.
The White House said in early October it plans to buy $1 billion worth of rapid antigen tests to help improve access to the hard-to-find over-the-counter kits. But people are also facing problems getting molecular testing, including the gold-standard PCR tests.
Public health labs are no longer hamstrung by supply bottlenecks on individual test components such as swabs or reagents, said Kelly Wroblewski, director of infectious disease programs for the Association of Public Health Laboratories. But they are still bearing a large testing load, which she had expected to shift more to commercial or hospital-based labs by now.
Testing labs of all stripes are also facing worker shortages just like restaurants, said Mara Aspinall, co-founder of Arizona State University’s biomedical diagnostics program, who also writes a weekly newsletter monitoring national testing capacity and serves on the board of a rapid-testing company.
“The staffing shortage is very, very real and holding people back from increasing capacity,” she said.
Something as simple as proximity also still dictates how quickly test-takers get results.
“Northern Maine is a good example,” Aspinall said. “Anything you do with PCR is going to take an extra day because it’s got to be flown or driven a ways.”
Even in a place such as Longmont, Colorado, near many laboratories and hospitals, PCR samples from the local mass-testing site get shipped by air each evening to a lab in North Carolina.
That mass-testing operation recently moved back to its original location at the county fairgrounds after a summer stint in a small church parking lot. Demand for PCR tests in the county quadrupled from 600 weekly tests in July to 2,500 a week in September. Chris Campbell, emergency manager for Boulder County Public Health, attributes the heavy traffic to schools reopening, an uptick in infections and the difficulty in acquiring over-the-counter rapid tests.
Campbell said it sometimes took residents four or five days to get their PCR results, though that’s dropped to two as the contractor they work with, Mako Medical, has built its laboratory capacity back up.
“It’s pretty inexcusable to have a turnaround time that long. It really does impact our ability to really stop transmission,” Campbell said. “And also, it has an economic impact to businesses, to schools, to early childhood facilities.”
Mako’s lab operates 24/7 and the company uses private planes to speed up shipping, according to a statement from chief operating officer Josh Arant. While Mako’s weekly median turnaround time never exceeded 72 hours last month, the statement said, in recent weeks it has returned results to area residents an average 46 hours after specimen collection.
Portable devices now exist that can eliminate the need for shipping samples. They can do molecular analysis, including PCR, in under an hour — a process that typically takes at least four to five hours in a lab. A Washington, D.C., testing truck has three Cepheid machines on board, each about the size of a printer. Combined, they can give a dozen people PCR results in under an hour, at no cost to test-takers.
Still, demand outweighs supply for such fast molecular tests, due largely to the roller coaster of case surges, said Doug Sharpe, vice president of lab capital sales with Medline Industries, which supplies covid testing components to labs across the country. “I don’t think anybody thought we’d be sitting here,” he added. “We’re selling more assays than we did at the height in 2020.”
Gigi Kwik Gronvall, an immunologist with the Johns Hopkins Center for Health Security who leads the center’s tracking of covid testing, suggested that the variability in how long it takes to get results has created a seller’s market if companies can deliver results by a specific time. “People are going to pay for that sort of guarantee,” she said. “There’s this potential for people to get fleeced, for sure.”
MedRite offers PCR results analyzed in three hours in New York and Florida for those willing to pay more than $200 a pop. The company offers other tests, such as antigen tests and slower lab-based PCR tests, at no out-of-pocket cost.
Celeste Di Iorio felt fleeced after she spent a day driving from pharmacy to pharmacy in Fort Collins, Colorado, in search of a test that would give an answer in less than three days. As a musician, she’d been traveling out of state and wanted to know if she might be infectious before attending, among other things, a memorial for a relative who died of covid. She and her partner eventually found rapid antigen tests at a pharmacy two cities over.
“We just paid $50 apiece for these tests, which pisses me off,” she said. “Because, you know, we’ve all been out of work for a year and a half, and this state has the money.”
In Helena, Montana, Stanfel has gotten a PCR test every week for many months because she takes immune-suppressing drugs for a rare condition called sarcoidosis. Her doctors told her to get the tests regularly because, even though she’s fully vaccinated — and has received an additional “booster” dose — she would likely need a treatment of monoclonal antibodies as soon as possible if she contracted covid to prevent an early infection from “developing into something really bad.”
When Stanfel found out a friend she had visited later tested positive for covid, she immediately got a test at her doctor’s office. It took five days to learn she had tested negative.
Montana’s public health lab is in Stanfel’s city, but state health department spokesperson Jon Ebelt said the volume of tests since early August has regularly exceeded the lab’s capacity. As such, they’ve had to prioritize tests from hospitalized or symptomatic people and send other specimens to private labs, a process that can stretch the wait time for results to up to seven days.
In New York City, where mobile-testing vans are parked in every borough and in-person home testing is offered, residents are reporting quick turnaround for molecular tests because the labs analyzing their samples are close by.
For example, in Manhattan, Justin Peck got back from a road trip to Canada on a Tuesday night, walked about five minutes to a mobile-testing van on Wednesday, and had PCR results by Thursday morning, clearing him just in time to go to work for the first time in 18 months as a dancer in “The Phantom of the Opera” on Broadway.
Aspinall said flu season will likely lead to an increase in demand for covid testing as people with covid-like symptoms seek answers about the cause of their illness, compounding existing staffing issues. “We’re at a very precarious point,” she said. “It’s not enough to go forward if the testing volume continues as I expect it will.”
Dr. Aaron Kheriaty, a University of California-Irvine psychiatry professor, felt he didn’t need to be vaccinated against covid because he’d fallen ill with the disease in July 2020.
So, in August, he sued to stop the university system’s vaccination mandate, saying “natural” immunity had given him and millions of others better protection than any vaccine could.
A judge on Sept. 28 dismissed Kheriaty’s request for an injunction against the university over its mandate, which took effect Sept. 3. While Kheriaty intends to pursue the case further, legal experts doubt that his and similar lawsuits filed around the country will ultimately succeed.
That said, evidence is growing that contracting SARS-CoV-2, the virus that causes covid-19, is generally as effective as vaccination at stimulating your immune system to prevent the disease. Yet federal officials have been reluctant to recognize any equivalency, citing the wide variation in covid patients’ immune response to infection.
Like many disputes during the covid pandemic, the uncertain value of a prior infection has prompted legal challenges, marketing offers and political grandstanding, even as scientists quietly work in the background to sort out the facts.
For decades, doctors have used blood tests to determine whether people are protected against infectious diseases. Pregnant mothers are tested for antibodies to rubella to help ensure their fetuses won’t be infected with the rubella virus, which causes devastating birth defects. Hospital workers are screened for measles and chickenpox antibodies to prevent the spread of those diseases. But immunity to covid seems trickier to discern than those diseases.
The Food and Drug Administration has authorized the use of covid antibody tests, which can cost about $70, to detect a past infection. Some tests can distinguish whether the antibodies came from an infection or a vaccine. But neither the FDA nor the Centers for Disease Control and Prevention recommend using the tests to assess whether you’re, in fact, immune to covid. For that, the tests are essentially useless because there’s no agreement on the amount or types of antibodies that would signal protection from the disease.
“We don’t yet have full understanding of what the presence of antibodies tells us about immunity,” said Kelly Wroblewski, director of infectious diseases at the Association of Public Health Laboratories.
By the same token, experts disagree on how much protection an infection delivers.
In the absence of certainty and as vaccination mandates are levied across the country, lawsuits seek to press the issue. Individuals who claim that vaccination mandates violate their civil liberties argue that infection-acquired immunity protects them. In Los Angeles, six police officers have sued the city, claiming they have natural immunity. In August, law professor Todd Zywicki alleged that George Mason University’s vaccine mandate violated his constitutional rights given he has natural immunity. He cited a number of antibody tests and an immunologist’s medical opinion that it was “medically unnecessary” for him to be vaccinated. Zywicki dropped the lawsuit after the university granted him a medical exemption, which it claims was unrelated to the suit.
Republican legislators have joined the crusade. The GOP Doctors Caucus, which consists of Republican physicians in Congress, has urged people leery of vaccination to instead seek an antibody test, contradicting CDC and FDA recommendations. In Kentucky, the state Senate passed a resolution granting equal immunity status to those who show proof of vaccination or a positive antibody test.
Hospitals were among the first institutions to impose vaccine mandates on their front-line workers because of the danger of them spreading the disease to vulnerable patients. Few have offered exemptions from vaccination to those previously infected. But there are exceptions.
Two Pennsylvania hospital systems allow clinical staff members to defer vaccination for a year after testing positive for covid. Another, in Michigan, allows employees to opt out of vaccination if they present evidence of previous infection and a positive antibody test in the previous three months. In these cases, the systems indicated they were keen to avoid staffing shortages that could result from the departure of vaccine-shunning nurses.
For Kheriaty, the question is simple. “The research on natural immunity is quite definitive now,” he told KHN. “It’s better than immunity conferred by vaccines.” But such categorical statements are clearly not shared by most in the scientific community.
Dr. Arthur Reingold, an epidemiologist at UC-Berkeley, and Shane Crotty, a virologist at the respected La Jolla Institute for Immunology in San Diego, gave expert witness testimony in Kheriaty’s lawsuit, saying the extent of immunity from reinfection, especially against newer variants of covid, is unknown. They noted that vaccination gives a huge immunity boost to people who’ve been ill previously.
Yet not all of those pushing for recognition of past infection are vaccine critics or torchbearers of the anti-vaccine movement.
Dr. Jeffrey Klausner, clinical professor of population and public health sciences at the University of Southern California, co-authored an analysis published last week that showed infection generally protects for 10 months or more. “From the public health perspective, denying jobs and access and travel to people who have recovered from infection doesn’t make sense,” he said.
In his testimony against Kheriaty’s case for “natural” immunity to covid, Crotty cited studies of the massive covid outbreak that swept through Manaus, Brazil, early this year that involved the gamma variant of the virus. One of the studies estimated, based on tests of blood donations, that three-quarters of the city’s population had already been infected before gamma’s arrival. That suggested that previous infection might not protect against new variants. But Klausner and others suspect the rate of prior infection presented in the study was a gross overestimate.
A large August study from Israel, which showed better protection from infection than from vaccination, may help turn the tide toward acceptance of prior infection, Klausner said. “Everyone is just waiting for Fauci to say, ‘Prior infection provides protection,’” he said.
When Dr. Anthony Fauci, the top federal expert on infectious diseases, was asked during a CNN interview last month whether infected people were as well protected as those who’ve been vaccinated, he hedged. “There could be an argument” that they are, he said. Fauci did not immediately respond to a KHN request for further comment.
CDC spokesperson Kristen Nordlund said in an email that “current evidence” shows wide variation in antibody responses after covid infection. “We hope to have some additional information on the protectiveness of vaccine immunity compared to natural immunity in the coming weeks.”
A “monumental effort” is underway to determine what level of antibodies is protective, said Dr. Robert Seder, chief of the cellular immunology section at the National Institute of Allergy and Infectious Diseases. Recent studies have taken a stab at a number.
Antibody tests will never provide a yes-or-no answer on covid protection, said Dr. George Siber, a vaccine industry consultant and co-author of one of the papers. “But there are people who are not going to be immunized. Trying to predict who is at low risk is a worthy undertaking.”
One U.S. child loses a parent or caregiver for every four COVID-19 deaths, a new modeling study published today in Pediatrics reveals. The findings illustrate orphanhood as a hidden and ongoing secondary tragedy caused by the COVID-19 pandemic and emphasizes that identifying and caring for these children throughout their development is a necessary and urgent part of the pandemic response – both for as long as the pandemic continues, as well as in the post-pandemic era.
From April 1, 2020 through June 30, 2021, data suggest that more than 140,000 children under age 18 in the United States lost a parent, custodial grandparent, or grandparent caregiver who provided the child’s home and basic needs, including love, security, and daily care. Overall, the study shows that approximately 1 out of 500 children in the United States has experienced COVID-19-associated orphanhood or death of a grandparent caregiver. There were racial, ethnic, and geographic disparities in COVID-19-associated death of caregivers: children of racial and ethnic minorities accounted for 65% of those who lost a primary caregiver due to the pandemic.
Children’s lives are permanently changed by the loss of a mother, father, or grandparent who provided their homes, basic needs, and care. Loss of a parent is among the adverse childhood experiences (ACEs) linked to mental health problems; shorter schooling; lower self-esteem; sexual risk behaviors; and increased risk of substance abuse, suicide, violence, sexual abuse, and exploitation.
“Children facing orphanhood as a result of COVID is a hidden, global pandemic that has sadly not spared the United States,” said Susan Hillis, CDC researcher and lead author of the study. “All of us – especially our children – will feel the serious immediate and long-term impact of this problem for generations to come. Addressing the loss that these children have experienced – and continue to experience – must be one of our top priorities, and it must be woven into all aspects of our emergency response, both now and in the post-pandemic future.”
The study was a collaboration between the Centers for Disease Control and Prevention (CDC), Imperial College London, Harvard University, Oxford University, and the University of Cape Town, South Africa. Published in the Oct. 7 issue of the journal Pediatrics, it was jointly led by CDC’s COVID Response and Imperial College London, and partly funded by the National Institute on Drug Abuse (NIDA), part of the National Institutes of Health (NIH), as well as Imperial College London.
“The magnitude of young people affected is a sobering reminder of the devastating impact of the past 18 months,” said Dr Alexandra Blenkinsop, co-lead researcher, Imperial College London. “These findings really highlight those children who have been left most vulnerable by the pandemic, and where additional resources should be directed.”
The analysis used mortality, fertility, and census data to estimate COVID-19-associated orphanhood (death of one or both parents) and deaths of custodial and co-residing grandparents between April 1, 2020, and June 30, 2021, for the U.S. broadly, and for every state. “COVID-19-associated deaths” refers to the combination of deaths caused directly by COVID-19 and those caused indirectly by associated causes, such as lockdowns, restrictions on gatherings and movement, decreased access or quality of health care and of treatment for chronic diseases. The data were also separated and analyzed by race and ethnicity, including White, Black, Asian, and American Indian/Alaska Native populations, and Hispanic and non-Hispanic populations.
The study authors estimate that 120,630 children in the U.S. lost a primary caregiver, (a parent or grandparent responsible for providing housing, basic needs and care) due to COVID-19-associated death. In addition, 22,007 children experienced the death of a secondary caregiver (grandparents providing housing but not most basic needs). Overall, 142,637 children are estimated to have experienced the death of at least one parent, or a custodial or other co-residing grandparent caregiver.
“The death of a parental figure is an enormous loss that can reshape a child’s life. We must work to ensure that all children have access to evidence-based prevention interventions that can help them navigate this trauma, to support their future mental health and wellbeing,” said NIDA Director Nora D. Volkow, MD. “At the same time, we must address the many underlying inequities and health disparities that put people of color at greater risk of getting COVID-19 and dying from COVID-19, which puts children of color at a greater risk of losing a parent or caregiver and related adverse effects on their development.”
Racial and ethnic disparities in COVID-related caregiver loss
There were significant racial and ethnic disparities in caregiver deaths due to COVID-19. White people represent 61% of the total U.S. population and people of racial and ethnic minorities represent 39% of the total population. Yet, study results indicate that non-Hispanic White children account for 35% of those who lost a primary caregiver (51,381 children), while children of racial and ethnic minorities account for 65% of those who lost a primary caregiver (91,256 children).
When looking at both primary and secondary caregivers, the study found that findings varied greatly by race/ethnicity: 1 of every 168 American Indian/Alaska Native children, 1 of every 310 Black children, 1 of every 412 Hispanic children, 1 of every 612 Asian children, and 1 of every 753 White children experienced orphanhood or death of caregivers. Compared to white children, American Indian/Alaska Native children were 4.5 times more likely to lose a parent or grandparent caregiver, Black children were 2.4 times more likely, and Hispanic children were nearly 2 times (1.8) more likely.
Overall, the states with large populations – California, Texas, and New York – had the highest number of children facing COVID-19 associated death of primary caregivers. However, when analyzed by geography and race/ethnicity, the authors were able to map how these deaths and disparities varied at the state level.
In southern states along the U.S.-Mexico border, including New Mexico, Texas, and California, between 49% and 67% of children who lost a primary caregiver were of Hispanic ethnicity. In the southeast, across Alabama, Louisiana, and Mississippi, between 45% to 57% of children who lost a primary caregiver were Black. And American Indian/Alaska Native children who lost a primary caregiver were more frequently represented in South Dakota (55%), New Mexico (39%), Montana (38%), Oklahoma (23%), and Arizona (18%).
The current study follows closely in line with a similar study published in The Lancet in July 2021, which found more than 1.5 million children around the world lost a primary or secondary caregiver during the first 14 months of the COVID-19 pandemic. In both the global and US studies, researchers used the UNICEF definition of orphanhood, as including the death of one or both parents6. The definition includes children losing one parent, because they have increased risks of mental health problems, abuse, unstable housing, and household poverty. For children raised by single parents, the COVID-19-associated death of that parent may represent loss of the person primarily responsible for providing love, security, and daily care.
“We often think of the impact of COVID-19 in terms of the number of lives claimed by the disease, but as this study shows, it is critical to also address the broader impact – both in terms of those who have died, and those who have been left behind,” said study co-author Charles A. Nelson III, PhD. who studies the effects of adversity on brain and behavioral development at Boston Children’s Hospital. “We must ensure children who have lost a parent or caregiver have access to the support services they need, and that this additional impact of the COVID-19 pandemic is comprehensively addressed in both our rapid response and our overall public health response.”
There are evidence-based responses that can improve outcomes for children who experience the COVID-associated death of their caregivers:
Maintaining children in their families is a priority. This means families bereaved by the pandemic must be supported, and those needing kinship or foster care must rapidly receive services.
Child resilience can be bolstered via programs and policies that promote stable, nurturing relationships and address childhood adversity. Key strategies include:
Strengthening economic supports to families.
Quality childcare and educational support.
Evidence-based programs to improve parenting skills and family relationships.
All strategies must be age specific for children and must be sensitive to racial disparities and structural inequalities. They must reach the children who need them most.
In the closing words of the paper, “Effective action to reduce health disparities and protect children from direct and secondary harms from COVID-19 is a public health and moral imperative.”
CDC works 24/7 protecting America’s health, safety and security. Whether diseases start at home or abroad, are curable or preventable, chronic or acute, or from human activity or deliberate attack, CDC responds to America’s most pressing health threats. CDC is headquartered in Atlanta and has experts located throughout the United States and the world.
About the National Institute on Drug Abuse (NIDA): NIDA is a component of the National Institutes of Health, U.S. Department of Health and Human Services. NIDA supports most of the world’s research on the health aspects of drug use and addiction. The Institute carries out a large variety of programs to inform policy, improve practice, and advance addiction science. For more information about NIDA and its programs, visit www.nida.nih.gov.
About the National Institutes of Health (NIH): NIH, the nation’s medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit www.nih.gov.
COVID-19 vaccines are highly effective in preventing symptomatic illness among health care workers in real-world settings.
The study, published in the New England Journal of Medicine, found that health care personnel who received a two-dose regimen of Pfizer–BioNTech vaccine had an 89% lower risk for symptomatic illness than those who were unvaccinated. For those who received the two-dose regimen of the Moderna vaccine, the risk was reduced by 96%.
The researchers also found that the vaccines appeared to work just as well for people who are over age 50, are in racial or ethnic groups that have been disproportionately affected by COVID-19, have underlying medical conditions and have greater exposure to patients with COVID-19.
The vaccines’ effectiveness was, however, lower in immunocompromised people.
“That this study demonstrated the effectiveness of the Pfizer–BioNTech and Moderna COVID-19 vaccines to protect health care workers — people who worked tirelessly and at great potential risk to care for their friends and neighbors — is a major statement to address any remaining skepticism about the importance of everyone getting vaccinated,” said Dr. David Talan, a professor of emergency medicine and of medicine and infectious diseases at the David Geffen School of Medicine at UCLA, and the study’s co-lead author.
The project, Preventing Emerging Infections through Vaccine Effectiveness Testing, or PREVENT, was conducted with researchers from the University of Iowa’s Carver College of Medicine. The study evaluated nearly 5,000 health care workers — 1,482 who had tested positive for COVID-19 and displayed symptoms of the disease and 3,449 who had COVID-19–like symptoms but had tested negative for the disease. The participants were from 33 U.S. academic medical centers, including Olive View–UCLA Medical Center in Sylmar, California.
All of the participants completed surveys covering their demographic information, job type and risk factors for severe disease from COVID-19, as well as their vaccination status.
Other findings include:
A two-dose regimen of either of the mRNA vaccines reduced the risk of illness by 95% among Black and African American people, 89% among Hispanic people, 89% among Asian or Pacific Islander people, and 94% among American Indians and Alaskan Native people, compared to unvaccinated people.
Of all those who received a single dose of either of the two-dose mRNA vaccines, the risk of illness was reduced by 86% among Black and African American people, 82% among Hispanic people, 80% among Asian or Pacific Islander people, and 76% among American Indians and Alaskan Native people compared to unvaccinated people.
For people who are obese or overweight, a two-dose regimen reduced the risk of illness by 91%; among the same group, partial vaccination reduced the risk by 76% among partially vaccinated compared to unvaccinated.
For people who have hypertension, a two-dose regimen of either mRNA vaccine reduced the risk of illness by 92%, and partial vaccination reduced the risk by 83% among partially vaccinated compared to unvaccinated.
For people who have asthma, a two-dose regimen of either mRNA vaccine reduced the risk of illness by 91%, and partial vaccination reduced the risk by 78% among partially vaccinated compared to unvaccinated.
For immunocompromised people, the risk of illness was reduced by 39% whether they received a single dose or two doses of either mRNA vaccine.
Sixty-two people in the study were pregnant at the time they were surveyed. Vaccination was 77% effective in preventing symptomatic COVID-19 illness among pregnant people who had received at least one dose of one of the mRNA vaccines.
Because of the relatively short time period of the study — from December 2020 to May 2021 — the research does not address how long vaccines continue to provide protection against COVID-19. In addition, data was collected before the emergence of the delta variant, so the vaccines’ effectiveness today may be different than they would be against earlier variants.
PREVENT is a collaboration between EMERGEncy ID NET — a CDC-supported network led by Talan that comprises 12 U.S. emergency departments and focuses on studying emerging infectious diseases — and a previously assembled group of sites that worked under Project COVERED, another CDC-funded effort to assess the risk to emergency department providers of acquiring COVID-19 through direct contact with patients and to determine ways to mitigate that risk.
As a communication scientist who has studied the effects of media and health campaigns for the past 30 years, I worry that a fevered pitch in vaccine messaging may make the holdouts even more resistant. The direct, blunt messages to go get vaccinated that worked on three-quarters of Americans may not work for the remaining one-quarter. If anything, they might backfire.
Research has shown that some health communication techniques work more effectively than others depending on the audience. It’s a lesson that not only policymakers can apply but also members of the media, industry and even parents and relatives.
When it comes to embracing new ideas and practices, research has identified five categories of people: innovators, early adopters, early majority, late majority and laggards. With COVID-19 vaccination, it’s come down to the last two, and they are the most resistant to change.
Do experts have something to add to public debate?
We think so
This group of unvaccinated people is substantial in number – there are nearly 80 million people in the U.S. who are vaccine eligible yet remain unvaccinated – and they are the ones who could help the U.S. achieve herd immunity. But, research suggests that they are also the ones who will take offense at forceful exhortations to go get vaccinated.
Strong messaging can backfire
Public health messaging can and does often influence people – but not always in the intended direction. Back in 1999, I testified in the U.S. Congress about how powerful anti-drug messages may be turning adolescents on to drugs rather than off of them. Likewise, the strong language of current vaccine messaging may be evoking resistance rather than compliance.
Consider this headline from a recent New York Times editorial: “Get Masked. Get Vaccinated. It’s the Only Way Out of This.” This follows 18 months of public-health messaging urging people to stay home, wash hands and maintain social distancing.
They may be well intentioned, but research in health communication shows that such directive messages can be perceived as “high threat,” meaning they threaten the free will of the message receiver by dictating what they should do. They are likely to trigger what psychologists call “reactance”. In other words, when individuals sense a threat to their freedom of action, they become motivated to restore that freedom, often by attempting to do the very thing that is prohibited or by refusing to adhere to the recommended behavior.
Recent research by my communications colleagues at Penn State shows that even advertisements that include directive slogans such as “No Mask, No Ride” – from Uber – and “Socialize Responsibly to Keep Bars Open” – a Heineken message – can irritate consumers and make them less likely to engage in responsible behaviors.
Reactance to COVID-19 messaging is evident in the form of widespread protests around the world. Many have gone to the streets and social media, with slogans such as “my body, my choice,” “let me call my own shots” and “coercion is not consent.”
These responses demonstrate not simply hesitation to get vaccinated, but rather active resistance to vaccine messaging, reflecting an effort to protect personal agency by asserting one’s freedom of action.
Flipping the script
Freedom is a critical concept in the anti-vaccination rhetoric. “Freedom, not force” is the battle cry of the protesters. “If we lose medical freedom, we lose all freedom,” reads a poster. “Choose freedom,” urged Sen. Rand Paul in a recent op-ed expressing his resistance to mask mandates and lockdowns. “We will make our own health choices. We will not show you a passport, we will not wear a mask, we will not be forced into random screening and testing.”
One way to counter such reactance is by changing the communication strategy. Health communication researchers have found that simple changes to message wording can make a big difference. In one study by my Penn State colleagues who study health persuasion, the researchers tested participants’ responses to sensible health behaviors such as flossing: “If you floss already, don’t stop even for a day. And, if you haven’t been flossing, right now is the time to start. … Flossing: It’s easy. Do it because you have to!” Study participants reacted to such messages by expressing their disagreement through anger and by defying the advocated behavior.
But then the researchers reworded the same advocacy to be less threatening, such as: “If you floss already, keep up the good work. And if you haven’t been flossing, now might be a good time to start.” And “Flossing: It’s easy. Why not give it a try?” They found that the participants’ reactance was significantly lower and their message acceptance higher.
In the same way, softening the message and using less dogmatic language could be the key to persuading some of the unvaccinated. This is because suggestive, rather than directive, messages allow room for people to exercise their own free will. Studies in health communication also suggest several other strategies for reducing reactance, ranging from providing choices to evoking empathy.
Perhaps more important – given people’s reliance on smartphones and social networking – is to make better use of the technological features of interactive media, which includes websites, social media, mobile apps and games. Clever use of digital media can help convey strong health messages without triggering reactance.
Research in our lab shows that people’s responses to media messages can be influenced by the approval of anonymous others on the internet, in the same way that consumers rely on other people’s opinions and star ratings for making purchasing decisions online. In a recent study, we discovered that freedom-threatening health messages can be made more palatable if they are accompanied by a large number of likes on social media from other people. When a lot of others were seen as supporting the advocacy message, the forceful language did not seem any more threatening to their freedom than the gentler version.
In other words, we found that the number of likes has a strong “bandwagon effect” in reducing reactance. We also discovered that providing an option to comment on the health message imbues a higher sense of personal agency and greater acceptance of the message.
In another recent experiment, we found that customization, or the ability to tailor one’s phone or online site to one’s liking, can also aid health communication. Whether it is a phone app, dating site or social media feed, customizing a digital space allows people to reflect their personality. Seeing a health advocacy message in such a personalized space does not pose as much of a threat in such venues because people feel secure in their identity. We found that customization helps reduce negative reactions to health messages by increasing one’s sense of identity.
A communication strategy that is sensitive to psychological reactance could empower the holdouts to willingly get vaccinated instead of grudgingly comply with a mandate.