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Vaccine Hesitancy Among Health Care Workers Raises Concerns

Gov. Roy Cooper watches while Tracy Toner gives a COVID-19 vaccination to Duke nurse Arianna Motsinger at the Duke University School of Medicine in Durham on Monday, December 21, 2020.
Shawn Rocco
/
Duke Health
Gov. Roy Cooper watches while Tracy Toner gives a COVID-19 vaccination to Duke nurse Arianna Motsinger at the Duke University School of Medicine in Durham on Monday, December 21, 2020.

Thousands of health care workers across North Carolina, charged with the care of patients, have declined to get COVID-19 vaccinations, even as eligibility has opened to the entire state.

Hospitals that were willing to disclose employee vaccination rates reported between 40% and 75% of hospital staff members have been vaccinated, a NC Watchdog Reporting Network survey shows.

The informal survey was sent to 32 health systems, representing about 100 hospitals across the state. Fifteen health systems were willing to provide at least some data on the number of vaccinated employees.

The overall uptake rate among the state's roughly 200,000 hospital employees surprised even state health care leaders.

"I thought it would have been much higher than that," said Dr. Dennis Taylor, the president of the North Carolina Nurses Association.

North Carolina's numbers are similar to the national trend. Just over half of front-line health care workers who participated in a Washington Post and Kaiser Family Foundation poll had received a first dose of the vaccine.

The national survey found hesitancy highest among Black health care workers and women, consistent with what some North Carolina hospitals are reporting among their ranks.

The numbers feed concerns that vaccine hesitancy may ultimately keep not just hospital staff, but enough of the population at large from taking the shot and reaching herd immunity.

Already top state officials say North Carolina is reaching a point where demand, not limited supply, will determine what percentage of people ultimately get vaccinated.

"I think we're, pretty quickly, going to reach the point where supply will exceed demand," Gov. Roy Cooper said in a press conference earlier this week. "We need to flip it over to make sure we're encouraging people to get vaccinated."

Who has received the vaccine

Front-line health care workers have watched COVID-19's effects on families and communities since March 2020. Some who work in the field remain unsettled about getting the vaccine. Those people include everyone from infectious disease specialists to support staff.

The rates could be falling behind in some areas due to access or prioritization.

UNC Health noted the vaccination rate among all health workers across its hospitals is about 60%. That's because many of those employees work from home and recently became eligible.

"They were young, they were working remotely, they weren't in patient care areas. And we asked them to wait so that we could get more vaccines into our communities, to older folks, to underrepresented groups," said Dr. Matt Ewend, chief clinical officer at UNC Health.

But for direct clinical workers at UNC Health, who have long been eligible for the vaccine, about 80% have been vaccinated. Ewend said the remaining 20% remain unvaccinated by choice, not because of a lack of access.

There's more work to do, he said, but he called a rate that high a "meaningful achievement."

"If you'd have grabbed me in November and said, 'Hey, you're only going to get 80% of your people vaccinated by April,' we would have been ecstatic," Ewend said. "We would have said that's a fabulous outcome."

WakeMed Health and Hospitals boasted the highest total vaccination rate among hospitals responding to the Watchdog Network survey, with 75% of employees already vaccinated, according to health system spokeswoman Kristin Kelly. The health system, Kelly said, has had clinical nurse specialists host vaccine education events where staff could get research-based answers about the vaccine.

Cape Fear Valley health system, based in Fayetteville, and Wake Forest Baptist Health in Winston-Salem each reported total employee vaccination rates of 65%.

Of the hospitals that responded, Martin General, in Williamston, has the lowest rate. Only four out of every 10 staff members have opted in to receive the vaccine and are fully vaccinated now. However, the hospital's vaccination rate is more than double that of Martin County overall, according to state data.

"We know the importance of vaccinating health care workers but respect that individuals must make a personal choice to be vaccinated," Martin General spokesperson Heather Wilkerson said in a statement. "We have focused efforts on educating staff about the effectiveness and safety of the vaccine."

Exactly how much of the state's total health care workforce is vaccinated, however, remains unclear.

"It's both a tough numerator and a tough denominator," Kody Kinsley, operations lead for COVID-19 response at the North Carolina Department of Health and Human Services, said. "And so really the best feedback we get is through direct conversations with our providers."

But the reporting network's survey of hospital systems – a subset of the larger health care workforce – shows those that responded report between 50% and 65% for vaccination rates.

Employers with legal concerns are not likely to require their workforce to receive the vaccine as long as it is under FDA's Emergency Use Authorization.

"Once it's under biology license application, just like the flu shot, then we may require it for our health care workers, but that hasn't been discussed yet," said Nancy Lindell, a spokeswoman for Asheville-based Mission Health, whose system has vaccinated just under 60% of all staff.

Employees who are skeptical of the safety and efficacy may not approve. About 16% of health care workers nationally reported they'd rather lose their jobs than be required to get the vaccine, according to the Washington Post survey.

Preventing the spread of the virus

Taylor, the president of the statewide nurses association, received the vaccine as soon as he could.

"I take care of COVID patients on a daily basis," said Taylor, who works at Wake Forest Baptist Health. "When I see what kind of damage it can do to the lungs and to the body ... I would not want my family to have to go through that."

Still, he sees hesitancy among his colleagues. The North Carolina Nurses Association surveyed members in December 2020, once the vaccine was available to them. At that point, more than two out of every five nurses said they were not willing to or were unsure about taking the vaccine.

In the months since that survey, more than 3.3 million first or single doses have been administered statewide. Still, according to the survey by the Watchdog Network, vaccination rates among all health care workers have not changed much.

"We talk about it being an ethical responsibility and showing leadership," said Stephen Lawler, the president of the North Carolina Healthcare Association.

Concerns about staff members not getting vaccinated or carrying the virus increased at Duke Raleigh Hospital after more than 20 employees and patients on a cancer ward tested positive for COVID-19 last month.

Vaccinating health care workers not only results in fewer cases among workers but also preserves the workforce as fully immunized employees who come in contact with COVID-19 positive patients or colleagues do not have to self-isolate, according to researchers from the University of Texas Southwestern Medical Center. Vaccination efforts and the research coincided with a surge in cases and deaths in Texas. Yet, the Texas study showed that the number of positive cases among medical center staff members was consistently lower than projected.

By early March, the Texas medical center had vaccinated 78% of all staff members – a higher rate than any of the North Carolina hospitals that responded to the reporting network's survey.

"Addressing the factors underlying this reluctance through insights gained from experience will be essential if the full potential benefit of vaccination in creating a path to normalcy is to be achieved," the researchers wrote in the report.

Hesitancy halts road to herd immunity

One out of every four adult North Carolinians is now fully vaccinated, and nearly three-quarters of those aged 65 and older, considered high risk, have received at least one shot.

Medical professionals say increasing the number of people with antibodies - whether through the vaccine or infection - is crucial to turning the corner in the pandemic.

The exact percentage for COVID-19 herd immunity is unknown as it varies for each disease, but health experts have estimated it to be at least 60%. For highly contagious diseases, such as measles, experts at the Mayo Clinic estimate herd immunity isn't reached until 94% of a population is vaccinated.

"I would say 50% would have to get vaccinated before you start to see an impact," Dr. Anthony Fauci, director of the National Institute of Allergies and Infectious Diseases, told NPR in December. "But I would say 75% to 85% would have to get vaccinated if you want to have that blanket of herd immunity."

As long as large groups of people remain skeptical of receiving their COVID dose, the virus will remain prevalent and circulating among society with the ability to mutate, according to the World Health Organization.

North Carolina hospitals responding to the survey discussed efforts to combat hesitancy ranging from regular discussions with infectious disease experts to distributing educational resources and materials and webinars with specialists like OBGYNs or internal medicine. Both the state's health care and nurses' associations also share resources with their members.

"We've seen among a lot of our workforce that education has worked. We started early, and the education we did to our workforce early became the education that we've tried to do to our communities later," said Ewend, with UNC Health.

On the national level, the American Medical Association also addressed the topic last month. In addition to sharing resources, that group suggested monitoring social media sites and refuting falsehoods.

"I don't think the health care workforce is as amenable to anti-vax propaganda, but, you know, it's omnipresent," said Dr. Arthur Caplan, head of the medical ethics division at NYU Grossman School of Medicine. "So it could be corroding some of the trust that health care workers have in vaccination."

The Washington Post-Kaiser Family Foundation study shows skepticism surrounding the vaccine is centered around three core ideas: safety, efficacy and trust.

More than one-third of health care workers surveyed reported they lack confidence in the vaccine – an opinion which has a nearly identical rate among the general population.

While there is limited scientific research on the effects for some groups including pregnant women, overall the vaccine has been proven to be safe and effective.

"As someone who works in health care, I've seen what that safety profile is," said Taylor, with the N.C. Nurses Association. "If I had any concerns or questions about the safety of it, I certainly wouldn't now."

This story was jointly reported and edited by Laura Lee, Kate Martin and Frank Taylor, of Carolina Public Press; Gavin Off, of The Charlotte Observer; Tyler Dukes and Dave Hendrickson, of The News & Observer; Nick Ochsner, of WBTV; Michael Praats of WECT; Travis Fain, Ali Ingersoll and Ashley Talley, of WRAL; and Jason deBruyn, of WUNC.

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