Association of State COVID-19 Vaccine Mandates With Staff Vaccination Coverage and Staffing Shortages in US Nursing Homes

Question Are state COVID-19 vaccine mandates for US nursing home employees associated with staff vaccination coverage and reported staff shortages? Findings This cohort study of nursing homes in 38 states found that states with a vaccine mandate experienced an increase in staff vaccination coverage compared with facilities in states with no mandate and no worsening of reported staffing shortages following the mandates. Meaning These findings suggest that given the waning vaccine-induced immunity and low booster dose coverage among nursing home staff in many parts of the US, state mandates for booster doses may be warranted to improve and sustain vaccination coverage in nursing homes. Importance Several states implemented COVID-19 vaccine mandates for nursing home employees, which may have improved vaccine coverage but may have had the unintended consequence of staff departures. Objective To assess whether state vaccine mandates for US nursing home employees are associated with staff vaccination rates and reported staff shortages. Design, Setting, and Participants This cohort study performed event study analyses using National Healthcare Safety Network data from June 6, 2021, through November 14, 2021. Changes in weekly staff vaccination rates and reported staffing shortages were evaluated for nursing homes in states with mandates after the mandate announcement compared with changes in facilities in nonmandate states. An interaction between the mandates and county political leaning was considered. Data analysis was performed from February to March 2022. Exposures Weeks after announcement of a state's COVID-19 vaccine mandate. Main Outcomes and Measures Weekly percentage of all health care staff at a nursing home who received at least 1 COVID-19 vaccine dose, and a weekly indicator of whether a nursing home reported a staffing shortage. Results Among 38 study-eligible states, 26 had no COVID-19 vaccine mandate for nursing home employees, 4 had a mandate with a test-out option, and 8 had a mandate with no test-out option. Ten weeks or more after mandate announcement, nursing homes in states with a mandate and no test-out option experienced a 6.9 percentage point (pp) increase in staff vaccination coverage (95% CI, -0.1 to 13.9); nursing homes in mandate states with a test-out option experienced a 3.1 pp increase (95% CI, 0.5 to 5.7) compared with facilities in nonmandate states. No significant increases were detected in the frequency of reported staffing shortages after a mandate announcement in mandate states with or without test-out options. Increases in vaccination rates in states with mandates were larger in Republican-leaning counties (14.3 pp if no test-out option; 4.3 pp with option), and there was no evidence of increased staffing shortages. Conclusions and Relevance The findings of this cohort study suggest that state-level vaccine mandates were associated with increased staff vaccination coverage without increases in reported staffing shortages. Vaccination increases were largest when mandates had no test-out option and were also larger in Republican-leaning counties, which had lower mean baseline vaccination rates. These findings support the use of state mandates for booster doses for nursing home employees because they may improve vaccine coverage, even in areas with greater vaccine hesitancy. This cohort study of nursing homes in 38 US states examines how state COVID-19 vaccine mandates and test-out options affected staff vaccination coverage and staffing shortages in Republican- and Democratic-leaning counties.