OBJECTIVES:

Coronavirus disease 2019 (COVID-19) has had a significant impact on adult residents and staff in long-term care facilities. Little is known, however, about the impact of COVID-19 and the uptake of COVID-19 vaccination in pediatric long-term care facilities (pLTCFs).

METHODS:

A survey was designed, piloted, and e-mailed to facilities participating in the Pediatric Complex Care Association, an organization consisting of 43 pLTCFs. Respondents were sent 1 reminder and given 1 month (April 2021) to report retrospective data from March 2020 to March 2021. In the survey, pLTCFs were asked to report data on COVID-19 infections and outcomes among residents and staff as well as COVID-19 vaccination status among residents and staff.

RESULTS:

Twenty-five centers participated, representing a 56% survey response rate. Of the residents, 7.0% (117 cases) were infected with COVID-19. The proportion of residents with COVID-19 by site varied from 0% to 41%. Among staff members, 22% (1665 cases) were infected with COVID-19, with a range of 8% to 44% of staff by site. Of residents, 1.3% were transferred to acute care. There were 3 resident deaths and 4 staff deaths. Early uptake of COVID-19 vaccination was common for residents (76%), whereas for staff, the rate was lower at 62%. At individual pLTCFs, vaccination ranged from 5 to 83 residents and 46 to 499 staff.

CONCLUSIONS:

Pediatric residents and staff of long-term care facilities were impacted by COVID-19, but mortality was low. COVID-19 vaccination rates among the children and staff were similar and higher than that reported from early national data in skilled nursing facilities.

Coronavirus disease 2019 (COVID-19) has devasted long-term care adult facilities, with rates of staff and resident illness and deaths accounting for >20% of total deaths attributed to COVID-19 in the United States.13  Advanced age, complex chronic medical conditions, and the ease of transmission of viral respiratory infections in congregate care settings are factors contributing to this impact. The prioritization of COVID-19 vaccination to residents and staff of long-term care facilities beginning in December 2020 has dramatically decreased the rate of infection and deaths attributed to COVID-19.4,5  Although the impact of COVID-19 in adult long-term care settings has been widely published, little is known about the impact in pediatric long-term care facilities (pLTCFs), where it is estimated that ∼55 000 children live in the United States.6  Although congregate care settings may pose a greater risk for the spread of infections, children, even those with complex chronic medical conditions, have less morbidity and mortality from COVID-19 than their adult counterparts.7,8  Neu et al8  recently published a single-center review of infection control and prevention strategies for COVID-19 management in pLTCFs. This review detailed the successful implementation of infection prevention and control policies, including surveillance strategies (testing and symptom screens), quarantines, and outbreak management, which resulted in few resident cases of COVID-19.8  Since this article’s publication, COVID-19 vaccination has become an additional strategy to prevent illness among staff and residents in pLTCFs.

Vaccination policies in pLTCFs have been a strategy employed for influenza prevention. In the wake of COVID-19, epidemiologists have been concerned that influenza vaccination would decrease and that vaccine hesitancy driven by COVID-19 would negatively impact this tool of prevention.9,10  We hypothesized, however, that in pLTCFs, influenza vaccination programs would continue to be useful and that sites might be able to use these data to adapt similar policy mandates for COVID-19 containment. COVID-19 vaccinations have been shown to be effective in adult long-term care settings to decrease the impact of COVID-19.11  Data, however, are lacking for pediatric facilities, and thus we sought to describe the impact of COVID-19 on staff and residents in pLTCFs and the early adoption of COVID-19 vaccination among pediatric long-term care staff and residents in the United States.

We established a study team from members of the Pediatric Complex Care Association (PCCA), an organization consisting of 43 facilities, which was established 2012.12,13  The team included an infectious disease expert, an infection control practitioner, 2 pLTCF medical directors, and members of the PCCA research committee. The team created an electronic survey that was piloted among study team members. On April 6, 2021, the PCCA administration e-mailed all members, asking for voluntarily participation in the survey. A reminder e-mail was sent out 2 weeks later, and the survey was closed after 1 month.

Survey respondents were asked to report data from the time period of March 2020 to March 2021. Respondents were asked to identify their facilities based on standardized criteria as follows: (1) acute care, hospital, or specialty hospital: active, short-term treatment; (2) subacute care or rehabilitation: return to home or community; and (3) long-term care, skilled nursing, or intermediate care facilities: custodial or maintenance care. Other key demographic information that was collected included patient-level potential risk factors for severe COVID-19 infection, such as tracheostomy and ventilator status, and age, specifically as it related to eligibility for COVID-19 vaccination (eg, ≥16 years of age). By definition and because of funding and regulatory qualifications, pLTCFs primarily care for residents ≤21 years of age; although some institutions may care for older residents, this is rare. The survey also asked respondents to report infection control practices related to COVID-19, the number of staff and residents with COVID-19 illnesses and associated hospitalizations, and the percentage of residents and staff vaccinated for COVID-19 (before March 2021). Respondents also reported COVID-19–associated deaths among residents and staff. Data were also collected on influenza vaccine policies and rates of resident and staff vaccination from 2019 to 2020 and from 2020 to 2021 because there was concern that the COVID-19 pandemic might impact the influenza vaccination rates. These data were entered into the electronic survey by the respondents at each site. Data were reviewed by the study team, and queries were sent to the respondent if errors were identified or if clarification was required.

Data were collected and analyzed with descriptive statistics by using Qualtrics XM Directory software (Provo, Utah). Vaccination percentage for residents was established on the basis of the number of residents ≥16 years of age in the facilities during the month that the survey was completed. The percentage of staff vaccinated was determined on the basis of the total staff in the facility during the survey response period. This study was approved as an exempted study by the Investigation Review Board of St Mary’s Hospital for Children.

Twenty-four of 43 (56%) members of the PCCA, representing 25 sites, participated in the survey. A dedicated full-time infection control practitioner was available at 88% of the participating facilities. The survey was completed by administrators (40%), infection control practitioners (32%), directors of nursing or nurse managers (12%), quality improvement managers (8%), nurse practitioners (4%), and child-life specialists (4%). Twenty-one surveyed sites identified as long-term care (81%), 4 (15%) as subacute care or rehabilitation, and 1 (4%) as acute care, hospital, or specialty hospital. Although the PCCA is a national organization, the survey participants were located in 15 states (with 4 states having multiple sites) predominantly in the Northeast, where many of the member pLTCFs are located.

In the 25 facilities, there were 1659 residents, 46% (765 of 1659) of whom were 16 or older. The average resident census per facility was 68.4 residents (range: 10–169), with an average bed count (maximum capacity) of 75 beds (range:14–169).

A total of 117 cases of COVID-19 occurred among facility residents from March 2020 to March 2021, representing 7% of the resident population. Of the facilities, 84% had at least 1 resident diagnosed with COVID-19. The range of resident infections by site varied from 0% to 41%. For those sites with ≥10 residents who were ≤15 years of age, the proportion of residents infected with COVID-19 ranged from 0% to 27% by site. Similarly, for sites with ≥10 residents who were ≥16 years of age, the proportion infected with COVID-19 ranged from 0% to 45%. All sites in each age range had <6 cases by site, except for one that had 39 cases in the older age range. Among staff members, 22% (1665 cases) were infected with COVID-19, with a range of staff infections from 8% to 44%, or 10 to 305 staff infected, at individual sites. Twenty-two (1.3%) residents infected with COVID-19 were transferred to acute care for management. There were 3 COVID-19 deaths among residents >16 years of age with COVID-19 and 4 deaths among staff members with COVID-19. Table 1 shows the number of staff and residents who were diagnosed or hospitalized with COVID-19 and whose death was associated with COVID-19.

TABLE 1

Resident Medical Complexity (Tracheostomy and Ventilator Status); Number of Staff and Residents by Age Who Were Diagnosed or Hospitalized With COVID-19 or Whose Death Was Associated With COVID-19; and Numbers Vaccinated Against COVID-19 (March 2020 to March 2021) in 25 pLTCFs

Staff (n = 7687)Residents 0–15 y old (n = 894)Residents ≥16 y old (n = 765)
Facility demographics, n (%)    
 Tracheostomies, nonventilated — 268 (30) 178 (23) 
 Tracheostomies, ventilated — 356 (40) 193 (25) 
COVID-19 data, n (%)    
 Diagnosed with COVID-19 1665 (22) 48 (5.4) 69 (9.0) 
 Hospitalized because of COVID-19 29 (0.4) 9 (1.0) 13 (1.7) 
 Death associated with COVID-19 4 (0.05) 3 (0.39) 
COVID- 19 vaccination, n (%)    
 Received COVID-19 vaccine 4706 (62)a n/a 584 (76) 
Staff (n = 7687)Residents 0–15 y old (n = 894)Residents ≥16 y old (n = 765)
Facility demographics, n (%)    
 Tracheostomies, nonventilated — 268 (30) 178 (23) 
 Tracheostomies, ventilated — 356 (40) 193 (25) 
COVID-19 data, n (%)    
 Diagnosed with COVID-19 1665 (22) 48 (5.4) 69 (9.0) 
 Hospitalized because of COVID-19 29 (0.4) 9 (1.0) 13 (1.7) 
 Death associated with COVID-19 4 (0.05) 3 (0.39) 
COVID- 19 vaccination, n (%)    
 Received COVID-19 vaccine 4706 (62)a n/a 584 (76) 

Residents under 15 years of age were not approved for vaccination at the time of the study. n/a, not applicable to this population; —, not applicable.

a

n = 7561; 1 site was unable to provide staff vaccination information.

Figure 1 shows the percentage of resident and staff who received COVID-19 vaccination by facility. Sixty-two percent of the staff at the 25 facilities had received at least 1 dose of the COVID-19 vaccine within 3 months of the vaccine release (December 2020). In 44% of the pLTCFs, 80% of staff had started or completed the COVID-19 vaccine series. Three sites had 100% of staff vaccinated. In addition, 76% of all eligible study residents (those 16 or older) received at least 1 dose of the vaccine. One site did not have access to staff vaccination status. One pediatric facility did not have residents who were eligible for vaccination because they were all <16 years of age, and 1 site did not have resident vaccination data. In comparison, the average percentages of staff and residents receiving influenza vaccination in the 2019–2020 season were 89% and 97%, respectively. In the 2020–2021 season, the average percentages of staff and residents receiving the influenza vaccine were 85% and 87%, respectively. Only 1 pLTCF did not have data on staff vaccination. These data represent the entire season for influenza, which is a longer time than what was studied for COVID-19 vaccination.

FIGURE 1

March 2021: percentage of residents and staff vaccinated for COVID-19 by survey site. This figure represents the percentage of residents and staff from the 25 pLTCFs who received at least 1 dose of the COVID-19 vaccine by March 2021. Site 10 did not have access to staff COVID-19 vaccine information. Site 22 did not have access to resident vaccination data, and site 23 did not have residents who were eligible for vaccination at the time of the survey.

FIGURE 1

March 2021: percentage of residents and staff vaccinated for COVID-19 by survey site. This figure represents the percentage of residents and staff from the 25 pLTCFs who received at least 1 dose of the COVID-19 vaccine by March 2021. Site 10 did not have access to staff COVID-19 vaccine information. Site 22 did not have access to resident vaccination data, and site 23 did not have residents who were eligible for vaccination at the time of the survey.

This is a unique report of the impact of COVID-19 infection and the early uptake of COVID-19 vaccination among staff and residents in pLTCFs. These facilities house high-risk residents, 60% of whom had tracheostomies or were ventilator dependent. Yet few were infected, were hospitalized, or died with COVID-19 compared to data reported for adult long-term care facility staff and their residents. Those residents infected with COVID-19 were more likely to be ≥16 years of age (9% vs 5.4%). The low prevalence of COVID-19 infection in this population and limited clinical impact is consistent with the comparatively low rate of COVID-19 infections and deaths among pediatric populations.3  Given the medical complexity and the rates of other viral infections among this population, we were surprised that these children and young adults were not more likely to be infected with COVID-19. What was also surprising was the variability in the proportion of residents infected by site (0% to 41%). The low incidence of COVID-19 might have been due to the quick infection control response by the facilities and their experience with viral infections and outbreaks. However, variability in infection prevention and control practices and staff infection rates might have also led to variability of infection among residents. In addition, state and federal mandates, including masking, social distancing, and changes to visitor policies, also might have protected the pediatric populations in long-term care. Finally, because ill children infected and hospitalized with COVID-19 rarely required transfer to long-term care facilities, it is possible that these pediatric institutions did not face the discharge impact of acute COVID-19 as happened in some of the adult facilities.

Early receipt of COVID-19 vaccination among staff and residents in our study was high. This is in contrast to the data on early vaccine adoption presented by the Centers for Disease Control and Prevention, in which it was reported that among the skilled nursing facilities in the United States that participated in the Pharmacy Partnership for Long-Term Care Program (December 2020 to January 2021), an estimated median of 77.8% of residents and 37.5% of payroll staff members received at least 1 dose of the COVID-19 vaccine.4  Although the time period is different, our study did show that twice as many staff participated in vaccination over an additional 2-month time period (December to March). There are many articles discussing COVID-19 vaccine hesitancy among long-term care staff.11,13  This, however, seemed to have less impact among these 25 facilities. Unfortunately, we did not ask the facilities if the COVID-19 vaccine was mandated or what types of educational programs occurred in the facilities to encourage vaccination among staff members.

This trend in compliance with vaccination recommendations in pLTCFs is also true for influenza, with >85% of staff both in 2019–2020 and 2020–2021 receiving the influenza vaccine. This too, is in contrast to national data on long-term care facilities, in which rates for influenza vaccination are lowest for health care personal in long-term care facilities compared with hospital workers (69.3% vs 80.6% of health care personnel in 2019–2020 season).14  There are many factors that may influence compliance with vaccination and infection prevention and control policies that may be specific to pediatric facilities. Evaluating these factors is beyond the scope of this study, but it would be important to understand such influences to increase COVID-19 vaccine acceptance in health care facilities in general.

There are several limitations of the study. Although >50% of the PCCA sites participated in the study, the data may be biased because they primarily reflect practices of facilities in the Northeast, which saw greater numbers of COVID-19 cases in the spring of 2020. In addition, although survey responses were clarified by the study team, data were entered by self-selected site representatives and no documentation was requested to verify answers. Another limitation is that we did not ask facilities to report the upper age limit of their resident population. Although this may limit the generalizability of our findings, we feel that our study population was more likely exclusively pediatrics because most facilities have either regulatory or funding limitations that impact admission to the facility. This study reflects a small sample of the total pLTCFs in the United States, and most of the residents were from long-term care sites, with approximately half of the resident population being >16 years of age. Thus, these data may not be generalizable to pLTCFs, but no national data are available for these facilities to make that determination.

FUNDING: No external funding.

1
McMichael
TM
,
Currie
DW
,
Clark
S
, et al
;
Public Health–Seattle and King County, EvergreenHealth, and CDC COVID-19 Investigation Team
.
Epidemiology of Covid-19 in a long-term care facility in King County, Washington
.
N Engl J Med
.
2020
;
382
(
21
):
2005
2011
[PubMed]
2
Centers for Medicare & Medicaid Services
. COVID-19 nursing home data. Available at: https://data.cms.gov/stories/s/bkwz-xpvg. Accessed May 16, 2021
3
Centers for Disease Control and Prevention
. COVID data tracker. Available at: https://covid.cdc.gov/covid-data-tracker/#cases_casesper100klast7days. Accessed May 16, 2021
4
Gharpure
R
,
Guo
A
,
Bishnoi
CK
, et al
.
Early COVID-19 first-dose vaccination coverage among residents and staff members of skilled nursing facilities participating in the Pharmacy Partnership for Long-Term Care Program - United States, December 2020-January 2021
.
MMWR Morb Mortal Wkly Rep
.
2021
;
70
(
5
):
178
182
[PubMed]
5
Britton
A
,
Jacobs Slifka
KM
,
Edens
C
, et al
.
Effectiveness of the Pfizer-BioNTech COVID-19 vaccine among residents of two skilled nursing facilities experiencing COVID-19 outbreaks - Connecticut, December 2020-February 2021
.
MMWR Morb Mortal Wkly Rep
.
2021
;
70
(
11
):
396
401
[PubMed]
6
National Conference of State Legislatures
.
Congregate Care, Residential Treatment and Group Home State Legislative Enactments 2009-2013
.
Washington, DC
:
National Conference of State Legislatures
;
2015
7
Preston
LE
,
Chevinsky
JR
,
Kompaniyets
L
, et al
Characteristics and disease severity of US children and adolescents diagnosed with COVID-19
.
JAMA Netw Open
.
2021
;
4
(
4
):
e215298
[PubMed]
8
Neu
N
,
Nee
M
,
Savitt
J
,
Schneider Connelly
L
,
Choi
J
,
Mosiello
L
.
COVID-19 in pediatric long-term care: how infection control and prevention practices minimized the impact of the pandemic on healthcare providers and residents
.
J Pediatric Infect Dis Soc
.
2020
;
9
(
5
):
626
629
[PubMed]
9
Wang
X
,
Kulkarni
D
,
Dozier
M
, et al
;
Usher Network for COVID-19 Evidence Reviews (UNCOVER) group
.
Influenza vaccination strategies for 2020-21 in the context of COVID-19
.
J Glob Health
.
2020
;
10
(
2
):
021102
[PubMed]
10
Chotpitayasunondh
T
,
Fischer
TK
,
Heraud
JM
, et al
.
Influenza and COVID-19: what does co-existence mean?
Influenza Other Respir Viruses
.
2021
;
15
(
3
):
407
412
[PubMed]
11
Unroe
K.
,
Evans
R
,
Weaver
L
,
Rusyniak
D
,
Blackburn
J
.
Willingness of long-term care staff to receive a COVID-19 vaccine a single state survey
.
J Am Geriatr Soc
.
2021
;
69
(
3
):
593
599
[PubMed]
12
Pediatric Complex Care Association
. About us. Available at: https://pediatriccomplexcare.org/about-us. Accessed May 24, 2021
13
Harrison
J
,
Berry
S
,
Mor
V
,
Gifford
D
.
“Somebody like me”: understanding COVID-19 vaccine hesitancy among staff in skilled nursing facilities
.
J Am Med Dir Assoc
.
2021
;
22
(
6
):
1133
1137
[PubMed]
14
Centers for Disease Control and Prevention
. Seasonal influenza vaccination resources for health professionals. https://www.cdc.gov/flu/professionals/healthcareworkers.htm?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fflu%2Fhealthcareworkers.htm. Accessed August 24, 2021

Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.