With two COVID-19 vaccines officially authorized for use, the immunization of health care workers and long-term care facility residents is finally underway in earnest.

The Food and Drug Administration granted emergency use authorizations (EUAs) to Pfizer’s (NYSE: PFE) COVID-19 vaccine on December 11 and to Moderna’s (Nasdaq: MRNA) on December 18.

There are several considerations for skilled nursing facilities to take into account as they prepare for the inoculations, from how to handle staff concerns about taking the vaccine to preparing for the impact side effects could have on scheduling.

Vaccinating staff is the critical first step for facilities, from which all the other considerations about workflow and coordination will spring. A webinar held on December 17 tackled some of those considerations. Hosted by the National Association of Health Care Assistants (NAHCA) and AMDA – The Society for Post-Acute and Long-Term Care Medicine, the virtual event gave an overview of some of the concerns expressed by certified nursing assistants (CNAs), with questions and answers between frontline staff and long-term care physicians.

Ultimately, long-term care workers will not be forced to take COVID-19 vaccines, webinar speakers said, even though an advisory committee for the CDC recommended that health care workers and long-term care residents be first in line.

“I’m not going to get up here and tell you that ‘You have got to take the shot, get the vaccine,'” Lori Porter, the CEO and co-founder of NAHCA, said during the webinar. “That is a choice you will have to make yourself.”

‘They aren’t the nephew of somebody’

Long-term care workers are not used to being prioritized for interventions like the COVID-19 vaccine, stressed Dr. Swati Gaur, a medical director and the chair of AMDA’s Infection Advisory Committee. For many CNAs, this is a particular sticking point; they see being first in line as being effectively guinea pigs for the vaccine.

“There is a lot of background work that has gone on, where we have sat down with [the Department of] Health and Human Services. We have sat down with the CDC,” she said. “And we have told them over and over: This is your priority area. The reason why we are getting offered the vaccine – it’s not because ‘Hey, here’s a group we never thought of before, we’re going to get them the vaccine.’ But because we’re having a lot of advocacy effort behind the scenes.”

Long-term care facilities have seen significant mortality from COVID-19, she noted, making the vaccine especially important for CNAs and frontline health care workers.

But during the webinar – and in a deep dive published by the Wall Street Journal on December 20 – CNAs expressed concerns about the speed of vaccine development and the potential side effects of the shots, which are taken in two doses about three to four weeks apart, according to the NAHCA webinar.

The physicians on the webinar emphasized that the vaccines were so speedily developed in part because they build off existing research and in part because this was a concerted effort by scientists to prioritize COVID-19 vaccines above all other projects. Plus, there were a large number of volunteer trial participants for both Pfizer and Moderna.

Doctors also emphasized that no steps were skipped in the FDA’s EUA process, and that the FDA’s Vaccine and Related Biological Products Advisory Committee (VRBPAC) and the CDC’s Advisory Committee on Immunization Practices (ACIP)both reviewed the vaccine data.

“These two groups are groups of independent scientists and virologists and they are not part of the government. They are not part of the White House,” said Dr. Leslie Eber, a medical director and president of the Colorado chapter of AMDA. “They are not part of Pfizer or Moderna, and they don’t have any conflicts of interest, and they’re vetted for that. They aren’t the nephew of somebody.”

That point may be critical, since as Porter noted in a December 2 interview with Skilled Nursing News, there is a trust gap between CNAs and their leadership, and many CNAs feel that even institutions such as the CDC have lost their credibility when it comes to vaccine questions.

This was a point Porter raised on the webinar, which directed CNAs to find “reliable sources” for accurate information – giving the CDC as an example. Her question was simple: How can frontline workers know that their information sources are reliable?

Dr. Timothy Holahan, a medical director in New York and a member of the AMDA ethics committee, recommended checking claims about the vaccines against the actual vaccine study data and finding a trusted source – such as the CDC, NAHCA or someone in a facility — to ask whether certain vaccine claims are true.

It might end up being more complex than that on the ground, however; Porter noted that in May, she was hospitalized and saw no doctors wearing masks, making it difficult to know who to trust.

But all the doctors on the webinar were emphatic that the vaccine is the best means of protecting residents of facilities, long-term care employees, and families of those employees.

Distribution workflow issues

When it comes to scheduling of the vaccines, many SNF providers have partnered with either CVS Health (NYSE: CVS) or Walgreens Boots Alliance (Nasdaq: WBA) to have COVID-19 vaccines distributed under the Centers for Disease Control and Prevention’s (CDC) Pharmacy Partnership for Long-term Care (LTC) Program.

CVS’s program will involve three pre-selected clinic dates at LTC facilities, with consent forms and posters delivered as part of the process. The first clinic is slated to take place in December, with the second in January of 2021 and the third, if necessary, in February, according to Omnicare’s COVID-19 vaccine resource webpage. Omnicare is the long-term care pharmacy arm of CVS.

But there are concerns about that approach. In a December 16 opinion piece written for the skilled nursing executive conference LTC 100, several authors argued that the rollout of the vaccine “is being overseen by outside entities that don’t fully understand the typical workflow of individual facilities,” which could lead to significant issues for both facility employees and residents.

“If residents are all vaccinated together and have side effects of fever, body aches and other constitutional symptoms, their care needs will increase,” Dr. Michael Wasserman, Chad Worz and Pam Schweitzer wrote. “If staff are all vaccinated at the same time, it is quite possible that a significant number of staff will have to miss one or more days of work.”

Wasserman is the immediate past president of the California Association of Long Term Care Medicine; Worz is the executive director and CEO for the American Society of Consultant Pharmacists; and Schweitzer is a former Assistant Surgeon General.

The vaccine’s side effects can include some short-term discomfort – fatigue, headache, muscle pain, chills, fever and pain at the injection site – and the effects can last for up to 48 hours. As such, Gaur recommended frontline workers get the vaccine before having a couple days off, to allow for recovery of the effects.

In the opinion piece, the authors also advocated staggering the vaccination days to prevent facilities being swamped with call-offs due to the side effects, as well as to accommodate the need for personal protective equipment and infection control procedures for residents who might need to be vaccinated room-by-room. They also suggest engaging medical and pharmacist leadership in SNFs, along with the facility ombudsman, to help with staff and family engagement and coordination.

“We have to pull together to make this work,” the authors wrote. “We have to be prepared to pivot away from an arbitrary deployment strategy that is neither evidence-based nor based on sound operational principles. It’s our firm belief that the success of a vaccine rollout in long-term care requires engaging – not ignoring – the expertise of medical directors, directors of nursing, consultant pharmacists and ombudsmen.”