Severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), the virus responsible for COVID‐19, has infected more than 25 million Americans, leading to over 420,000 deaths. 1 The Centers for Disease Control and Prevention reports over 378,000 cases of COVID‐19 in U.S. health care personnel (HCP) with 1,286 deaths. 2 By summer 2020, an estimated 4.6% of academic emergency department (ED) HCPs had contracted COVID‐19. 3 In mid‐December 2020 emergency use authorization COVID‐19 vaccines were administered to U.S. HCPs as a priority group. The objective of this report was to describe differences in vaccination rates among various types of ED HCP at U.S. academic medical centers and reasons for declining vaccination. We hypothesized that groups of ED HCPs with differences in workplace risks might view the benefits of vaccine differently and that vaccine hesitancy would be higher in people of color.
The COVID‐19 Evaluation of Risk in Emergency Departments (COVERED) project is a multicenter, prospective cohort surveillance project for SARS‐CoV‐2 infection among ED HCPs at 20 geographically diverse, high‐volume urban U.S. academic medical centers. 4 We enrolled physicians and advanced practice providers (APPs), nurses, and nonclinical HCPs (e.g., clerks, social workers, and pharmacists) not previously diagnosed with COVID‐19. The project's primary aim was to estimate the attributable risk of occupational acquisition of COVID‐19 during a 20‐week follow‐up. At completion we surveyed participants regarding receipt of vaccines, feelings of personal safety after vaccination, personal protective equipment (PPE) use and, if applicable, reasons for declining vaccination. On January 4, 2021, approximately 3 weeks after vaccination began to be offered at all sites, we surveyed HCPs participating in the project. This project met the requirements of public health surveillance as defined in 45 CFR 46.102(l)(2). Descriptive statistics and difference in proportions with 95% confidence interval (CI) were used, and standard errors were adjusted for clustering by site. Analyses were performed using SAS version 9.4 (SAS Institute, Cary, NC).
We surveyed 1,542 participants, and 1,398 (90.7%) completed the survey. Ninety‐four percent (n = 1,321) had been offered COVID‐19 vaccine and 1,136 of those (86.0%) had received it (four [0.3%] through a vaccine trial). Among 674 physicians/APPs offered vaccine, 37 (5.5%) declined vaccination, compared with 77 of 345 (22.3%) nurses (difference = 16.8%, 95% CI = 9.5% to 24.2%) and 71 of 302 (23.5%) nonclinical HCPs (difference = 18.0%, 95% CI = 11.7% to 24.3%). The primary reason for declining a COVID‐19 vaccine was concern about vaccine safety (45.4%).
After vaccination, 980 of 1,130 (86.7%) recipients reported feeling safer and 984 (87.1%) reported that household members felt safer. Vaccinated recipients planned to use the same amount of PPE at work (1,015 [89.8%]) as well as in public (1,037 [91.8%]; Table 1). By race/ethnicity, the non‐Hispanic Black HCP had the lowest vaccine acceptance rate 53 of 81 (65.4%) of all participants (Table 1).
TABLE 1.
Vaccination rates and effects of vaccine among emergency HCPs and reasons for declining vaccine
| All HCPs (N = 1398) | HCP type | |||
|---|---|---|---|---|
| Physician/APP (n = 691) | Nurse (n = 360) | Nonclinical (n = 347) | ||
| Vaccine status | ||||
| Offered | 1,321 (94.5) | 674 (97.5) | 345 (95.8) | 302 (87) |
| Accepted | 1,136 (86) | 637 (94.5) | 268 (77.7) | 231 (76.5) |
| Declined | 185 (14) | 37 (5.5) | 77 (22.3) | 71 (23.5) |
| Demographics vaccine acceptancea | ||||
| Age (y) | ||||
| 22–29 (n = 265) | 223 (84.2) | 118 (95.2) | 74 (77.1) | 31 (68.9) |
| 30–39 (n = 511) | 441 (86.3) | 286 (94.4) | 88 (72.7) | 67 (77) |
| 40–49 (n = 292) | 248 (84.9) | 131 (94.2) | 73 (83) | 44 (67.7) |
| 50–64 (n = 236) | 208 (88.1) | 94 (95) | 33 (82.5) | 81 (83.5) |
| ≥65 (n = 17) | 16 (94.1) | 8 (88.9) | 0 (0) | 8 (100) |
| Gender | ||||
| Female (n = 824) | 672 (81.6) | 273 (91.6) | 217 (77) | 182 (74.6) |
| Male (n = 490) | 458 (93.5) | 362 (96.8) | 48 (81.4) | 48 (84.2) |
| Other (n = 7)b | 6 (85.7) | 2 (100) | 3 (75) | 1 (100) |
| Race/ethnicityc | ||||
| Non‐Hispanic White (n = 959) | 849 (88.5) | 482 (95.1) | 214 (79.3) | 153 (84.1) |
| Hispanic or Latinx, any race (n = 116) | 89 (76.7) | 37 (94.9) | 20 (66.7) | 32 (68.1) |
| Non‐Hispanic Asian (n = 110) | 96 (87.3) | 62 (92.5) | 18 (81.8) | 16 (76.2) |
| Non‐Hispanic Black (n = 81) | 53 (65.4) | 24 (88.9) | 7 (58.3) | 22 (52.4) |
| Non‐Hispanic other (n = 36)d | 32 (88.9) | 21 (91.3) | 8 (100) | 3 (60) |
| Attitude/behavior after vaccination (n = 1,130)e | ||||
| Comfort/safety | ||||
| HCPs feel safer around household members | 980 (86.7) | 556 (87.8) | 220 (82.4) | 204 (88.7) |
| Household members feel safer around HCPs | 984 (87.1) | 557 (88) | 223 (83.5) | 204 (88.7) |
| Use of PPE at work | ||||
| Same PPE | 1,015 (89.8) | 566 (89.4) | 239 (89.5) | 210 (91.3) |
| Less PPE | 100 (8.9) | 66 (10.4) | 24 (9) | 10 (4.4) |
| More PPE | 15 (1.3) | 1 (0.2) | 4 (1.5) | 10 (4.4) |
| Use of PPE in public | ||||
| Same PPE | 1,037 (91.8) | 583 (92.1) | 244 (91.4) | 210 (91.3) |
| Less PPE | 76 (6.7) | 47 (7.4) | 18 (6.7) | 11 (4.8) |
| More PPE | 17 (1.5) | 3 (0.5) | 5 (1.9) | 9 (3.9) |
| Reasons for declining vaccination (n = 185) | ||||
| Safety of vaccine | 84 (45.4) | 12 (32.4) | 36 (46.8) | 36 (50.7) |
| Health condition | 25 (13.5) | 8 (21.6) | 10 (13) | 7 (9.9) |
| Previous COVID‐19 diagnosis | 25 (13.5) | 3 (8.1) | 16 (20.8) | 6 (8.5) |
| Pregnancy/fertility | 22 (11.9) | 8 (21.6) | 8 (10.4) | 6 (8.5) |
| Religious/ethical/personal reasons | 16 (8.6) | 1 (2.7) | 7 (9.1) | 8 (11.3) |
| Vaccine efficacy | 15 (8.1) | 2 (5.4) | 3 (3.9) | 10 (14.1) |
| Logistics/scheduling | 8 (4.3) | 0 (0) | 4 (5.2) | 4 (5.6) |
| Immune to COVID‐19 | 7 (3.8) | 3 (8.1) | 2 (2.6) | 2 (2.8) |
| Reserving dose for others | 5 (2.7) | 3 (8.1) | 0 (0) | 2 (2.8) |
| Otherf | 15 (8.1) | 4 (10.8) | 6 (7.8) | 5 (7) |
Data are reported as n (%).
Abbreviations: APP, advanced practice provider; HCP, health care provider; PPE, personal protective equipment.
Denominator is those offered vaccination.
Includes HCPs identifying as transgender, gender variant, or nonconforming or who prefer not to answer.
Thirty‐six missing responses to ethnicity were excluded; multiple responses were allowed (totals may exceed 100%).
Includes HCPs identifying as American Indian, Alaska Native, Native Hawaiian, other Pacific Islander, or other race.
Six participants excluded from this section for missing data.
Other reasons for declining coded from open‐response free text.
In this report of COVID‐19 vaccination rates among U.S. ED HCPs at academic U.S. medical centers at the beginning of prioritized HCP immunization, we found a high rate of COVID‐19 vaccine acceptance and receipt, with physicians/APPs having the highest overall proportion. After vaccination, most recipients reported feeling safer at home and that their household members also felt safer with them. The vast majority reported that their PPE use in the ED and in public remained the same after vaccination.
While our vaccine declination rate among ED HCPs was considerably lower than recent national reports of vaccine hesitancy among the public at large, 5 , 6 we nevertheless found that a substantial percentage of ED HCPs declined vaccination. Since the primary reason for declining was concern over safety, efforts at educating HCPs about the safety profile of COVID‐19 vaccines may be warranted, especially in groups who had the most vaccine hesitancy, that is, nonclinical, nursing, and Black HCPs.
CONFLICT OF INTEREST
The authors have no potential conflicts to disclose.
AUTHOR CONTRIBUTIONS
Study concept and design: all authors. Acquisition, analysis, or interpretation of data: Walter A. Schrading, Morgan B. Swanson, Nicholas M. Mohr, and David A. Talan. Drafting of the manuscript: all line authors. Critical revision of the manuscript for important intellectual content: all line authors. Statistical expertise: Morgan B. Swanson and Nicholas M. Mohr. Acquisition of funding: David A. Talan.
ACKNOWLEDGMENTS
The authors thank Anusha Krishnadasan, PhD, and Karisa K. Harland, PhD, MPH, for their tireless work to make Project COVERED a success and William Mower, MD, PhD, for his statistical analysis and review. The authors also thank the COVERED participants, the participating institutions/emergency departments, and individuals. The authors acknowledge the following participating Project COVERED emergency departments: Allegheny General Hospital, Pittsburgh, PA; Baystate Medical Center, Springfield, MA; Denver Health Medical Center, Denver, CO; Detroit Receiving Hospital/Sinai‐Grace Hospital, Detroit, MI; Hennepin County Medical Center, Minneapolis, MN; Jackson Memorial Hospital, Miami, FL; Johns Hopkins Medical Institute, Baltimore, MD; University Medical Center, New Orleans, LA; Mount Sinai Hospital East/Elmhurst Hospital Center, New York, NY; Orlando Regional Medical Center, Orlando, FL; University of Alabama at Birmingham Hospital, Birmingham, AL; Ronald Reagan–UCLA Medical Center/Olive View–UCLA Medical Center, Los Angeles, CA; University of Iowa, Iowa City, IA; University of Massachusetts Memorial Medical Center, Worcester, MA; University of Mississippi Medical Center, Jackson, MS; UCSF Zuckerberg San Francisco General, San Francisco, CA; UT Southwestern Medical Center/Parkland Hospital, Dallas, TX; Truman Medical Center, Kansas City, MO; Thomas Jefferson University, Philadelphia, PA; and Washington University Barnes‐Jewish Hospital, St. Louis, MO. The authors also acknowledge the following individuals: Aishat Adeyemi, BA, Lisa Allen, MPH, Gregory Almonte, Otuwe Anya, MS, Paula Arellano‐Cruz, BS, Ruzana Aronov, Danielle Beckham, RN, MSN, CRC, Lauren Buck, BS, Samuel Ceckowski, BS, Maxime Centeno, Virginia, Chan, BS, Anna Marie Chang, MD, MSCE, Melissa Connor, RN, Gabriella Dashler, BS, Jenna Davis, MSN, Cynthia Delgado, BS, Veronica Delgado PA, MS, Brianna DiFronzo, BS, Radhika L Edpuganti, BS, Alyssa Espinera, MD, Fresa Estevez, Shelly Ann Evans, MBA, RN, Cathy Fairfield, BSN, Phillip Fairweather, MD, Theodore Falcon, BS, Brian Fuller, MD, MSCI, David Gallegos, Samuel Ganier, MD, Stephanie Gravitz, MPH, Jeffrey Harrison, Kyle Herbert MD, Judy Hermans, MPH, Elisabeth Hesse, MD, MTM&H, Emily Hopkins, MSPH, Alan Jones, MD, Kia M. Jones, DrPH, Momina Khan, BS, Karin Hoth, PhD, Laura Iavicoli, MD, Robin Kemball, MPH, Laurie Kemble, BHSRT, CCRC, Stuart Kessler, MD, Preeta K. Kutty, MD, MPH, Catherine Lind RN, NP, Karina Loayza, LCSW, Carol Lynn Lyle, PA, MPH, Virginia B. Mangolds, MS, RN, Hannah Makarevich‐Manilla, MPH, CCRC, Thomas Mazzocco, RN, L. Clifford McDonald, MD, Sarah Meram, MS, Valerie H. Mika, MS, Reynaldo Padilla, BA, Giacomo Passaglia, BS, Rebekah Peacock, BSN, Danielle Perez, BS, Kye E. Poronsky, MA, Eric Raines, EMT‐P, Monica N. Ramage, MSN, RN, Kavita Rampertaap MSN, RN, Sarah Reineck, BS, Nicole Renzi, RN, Erin P. Ricketts, MSPH, Stephanie Rodriguez, Justin Sabol, BS, Valeria Samame, Scott Santibanez, MD, MPHTM, Katie Schneider, MSN, Robert Sellman PA, Kristine Sernulka BSN, CCRP, Jennifer Siller, DNP, RN, Colleen Smith, MD, Timothy Smith, BS, Kelly Szabo, MPH, CCRC, Meghan Tinetti BSN, CCRP, Julia Vargas, BS, Samuel Vargas, Kavey Vidal, Lori Wilkerson, RN, CRC, Darleen Williams, DNP, APRN‐CNS, Sallie Anne Wright, MPH, BSMT, and Isaias Yin, LVN.
The Project COVERED Emergency Department Network includes the following: Monica Bahamon, MPH, Jestin N. Carlson, MD, MSc, Makini Chisolm‐Straker, MD, MPH, Brian Driver, MD, Brett Faine, PharmD, MS, James Galbraith, MD, Philip A. Giordano, MD, John P. Haran, MD, PhD, Amanda Higgins, MS, Jeremiah Hinson, MD, Stacey House, MD, PhD, Ahamed H. Idris, MD, Efrat Kean, MD, Elizabeth Krebs, MD, MSc, Michael C. Kurz, MD, MS, Lilly Lee, SM, MD, Stephen Y. Liang, MD, MPHS, Stephen C. Lim, MD, Gregory Moran, MD, Utsav Nandi, MD, MSCI, Kavitha Pathmarajah, MPH, Yesenia Perez, BS, Richard Rothman, MD, PhD, Jessica Shuck, BA, Patricia Slev, MD, Howard A. Smithline, MD, Kimberly Souffront, PhD, FNP‐BC, RN, Mark Steele, MD, Michelle St. Romain, MD, Amy Stubbs, MD, Josh Tiao, MD, Jesus R. Torres, MD, MPH, Lisandra Uribe, BS, Arvind Venkat, MD, Gregory Volturo, MD, Kelli Wallace, MS, Kurt D. Weber, MD, Brian Fuller, MD, Karisa Harland, PhD, MPH, Anusha Krishnadasan, PhD, Juan Carlos Montoy, MD, PhD, William Mower, MD, PhD, Lynne Richardson, MD, Patrick Eyck, PhD, James Willey, MD.
The members of the Project COVERED Emergency Department Network are provided in the appendix.
CDC disclaimer: The findings and conclusions in this article are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.
Supervising Editor: John H. Burton, MD.
Funding information
This project was funded by a cooperative agreement from the Centers for Disease Control and Prevention (U01CK000480) and was supported by the Institute for Clinical and Translational Science at the University of Iowa through a grant from the National Center for Advancing Translational Sciences at the National Institutes of Health (UL1TR002537).
Contributor Information
Walter A. Schrading, Email: wschrading@uabmc.edu.
Project COVERED Emergency Department Network:
Monica Bahamon, Jestin N Carlson, Makini Chisolm‐Straker, Brian Driver, Brett Faine, James Galbraith, Philip A Giordano, John P Haran, Amanda Higgins, Jeremiah Hinson, Stacey House, Ahamed H Idris, Efrat Kean, Elizabeth Krebs, Michael C. Kurz, Lilly Lee, Stephen Y Liang, Stephen C Lim, Gregory Moran, Utsav Nandi, Kavitha Pathmarajah, Yesenia Perez, Richard Rothman, Jessica Shuck, Patricia Slev, Howard A. Smithline, Kimberly Souffront, Mark Steele, Michelle St. Romain, Amy Stubbs, Josh Tiao, Jesus R Torres, Lisandra Uribe, Arvind Venkat, Gregory Volturo, Kelli Wallace, and Kurt D Weber
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