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COVID-19 Vaccination and Intent Among Healthcare Personnel, U.S.

Published:December 05, 2021DOI:https://doi.org/10.1016/j.amepre.2021.11.001

      Introduction

      Healthcare personnel are at increased risk for COVID-19 from workplace exposure. National estimates on COVID-19 vaccination coverage among healthcare personnel are limited.

      Methods

      Data from an opt-in Internet panel survey of 2,434 healthcare personnel, conducted on March 30, 2021–April 15, 2021, were analyzed to assess the receipt of ≥1 dose of a COVID-19 vaccine and vaccination intent. Multivariable logistic regression was used to assess the factors associated with COVID-19 vaccination and intent for vaccination.

      Results

      Overall, 68.2% of healthcare personnel reported a receipt of ≥1 dose of a COVID-19 vaccine, 9.8% would probably/definitely get vaccinated, 7.1% were unsure, and 14.9% would probably/definitely not get vaccinated. COVID-19 vaccination coverage was highest among physicians (89.0%), healthcare personnel working in hospitals (75.0%), and healthcare personnel of non-Hispanic White or other race (75.7%–77.4%). Healthcare personnel who received influenza vaccine in 2020–2021 (adjusted prevalence ratio=1.92) and those aged ≥60 years (adjusted prevalence ratio=1.37) were more likely to report a receipt of ≥1 dose of a COVID-19 vaccine. Non-Hispanic Black healthcare personnel (adjusted prevalence ratio=0.74), nurse practitioners/physician assistants (adjusted prevalence ratio=0.55), assistants/aides (adjusted prevalence ratio=0.73), and nonclinical healthcare personnel (adjusted prevalence ratio=0.79) were less likely to have received a COVID-19 vaccine. The common reasons for vaccination included protecting self (88.1%), family and friends (86.3%), and patients (69.2%) from COVID-19. The most common reason for nonvaccination was concern about side effects and safety of COVID-19 vaccine (59.7%).

      Conclusions

      Understanding vaccination status and intent among healthcare personnel is important for addressing barriers to vaccination. Addressing concerns on side effects, safety, and effectiveness of COVID-19 vaccines as well as their fast development and approval may help improve vaccination coverage among healthcare personnel.

      INTRODUCTION

      Healthcare personnel (HCP) have been at an increased risk for coronavirus disease 2019 (COVID-19) from workplace exposure since the beginning of the COVID-19 pandemic. As of July 2021, >516,000 cases and 1,600 deaths owing to COVID-19 among HCP in the U.S. have been reported to the Centers for Disease Control and Prevention (CDC), which is most likely an underestimation of the actual number of cases and deaths given that only approximately 19% of reported cases have known HCP occupation status.

      Cases & deaths among healthcare personnel. Centers for Disease Control and Prevention. https://covid.cdc.gov/covid-data-tracker/#health-care-personnel. Updated December 19, 2021. Accessed July 15, 2021.

      Earlier studies have documented a high number of COVID-19 cases among healthcare support workers, nurses, administrative staff members, environmental services workers, and physicians as well as in settings, including nursing homes and residential care facilities and hospitals.
      • Hughes MM
      • Groenewold MR
      • Lessem SE
      • et al.
      Update: characteristics of health care personnel with COVID-19 - United States, February 12 - July 16, 2020.
      ,
      CDC COVID-19 Response Team
      Characteristics of health care personnel with COVID-19 - United States, February 12 - April 9, 2020.
      Assessing the burden of COVID-19 disease among HCP is difficult because occupation is not reported to CDC for all COVID-19 cases.
      Vaccines for COVID-19 have been available in the U.S. under Emergency Use Authorization since December 2020.

      Emergency use authorization. U.S. Food & Drug Administration.https://www.fda.gov/emergency-preparedness-and-response/mcm-legal-regulatory-and-policy-framework/emergency-use-authorization#covid19euas. Updated December 17, 2021. Accessed July 1, 2021.

      Given that HCP are on the front lines of the healthcare system, the Advisory Committee on Immunization Practices recommended that HCP be among the first group to be offered COVID-19 vaccines in the initial phase of the vaccination program beginning in December 2020.
      • Dooling K
      • McClung N
      • Chamberland M
      • et al.
      The Advisory Committee on Immunization Practices’ interim recommendation for allocating initial supplies of COVID-19 vaccine - United States, 2020.
      The extent of vaccine uptake and coverage in this population is difficult to assess owing to the lack of occupation information in the vaccine administration data being reported to CDC. A survey conducted by the Kaiser Family Foundation in early March 2021 reported that 52% of 1,327 frontline healthcare workers—those who have direct contact with patients and their bodily fluids—reported having received ≥1 dose of a COVID-19 vaccine.
      Kaiser Family Foundation
      KFF/post survey of frontline health care workers finds nearly half remain unvaccinated.
      However, national estimates on COVID-19 vaccination coverage among all HCP, including those without direct patient contact, are lacking.

      METHODS

      Study Sample

      Internet panel surveys have been conducted by CDC annually since 2011 to provide end-of-season influenza vaccination coverage estimates among HCP.
      Influenza vaccination coverage among health care personnel—United States; 2019–20 influenza season.
      To assess a receipt of COVID-19 vaccine and intent for vaccination, additional questions were added to the survey fielded during March 31, 2021–April 15, 2021. Respondents were recruited from 2 pre-existing national opt-in Internet sources: Medscape (https://www.medscape.com) and Dynata (https://www.dynata.com). Current membership of Medscape, a medical website managed by WebMD Health Professional Network, was used to recruit physicians, nurse practitioners, physician assistants, nurses, dentists, pharmacists, allied health professionals, technicians, and technologists. Other HCP, including assistants, aides, and nonclinical personnel, were recruited from a general population Internet panel survey operated by Dynata. This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy (e.g., 45 C.F.R. part 46, 21 C.F.R. part 56; 42 U.S.C. §241[d]; 5 U.S.C. §552a; 44 U.S.C. §3,501 et seq.).

      Measures

      For recruitment through the Medscape Panel, 68,894 e-mail invitations were sent; 7,606 (11.0%) panelists clicked on the invitation link and were presented with the survey. Of those, 4,581 (60.2%) answered the screening questions, and 1,571 were found to be eligible. A total of 1,525 (97.1%) of these panelists completed the survey. For recruitment through the Dynata panel, 198,213 panelists completed the screening question through the intercept method. Of these, 5,577 (2.8%) were eligible on the basis of the screening question, and 4,540 (81.4%) clicked on the invitation link to the survey. A total of 3,058 (67.4%) answered the screening questions, and 1,017 (33.3%) were found to be eligible. At last, 909 (89.4%) of these panelists completed the survey. Among 2,588 eligible participants, a total of 2,434 completed the survey (completion rate=94.0%). A total of 45 HCP were excluded from the analyses for either not meeting the study definition of HCP (n=43) or for having incomplete information about their COVID-19 vaccination status (n=2), resulting in an analytical sample of 2,389.
      Quota sampling was utilized to reduce the initial recruitment imbalance by occupation. Data were weighted to the distribution of HCP by occupation, age, sex, race/ethnicity, work setting, and U.S. Census region.
      • DiSogra C
      • Black CL
      • Greby SM
      • et al.
      Matching an Internet panel sample of health care personnel to a porbability sample.
      A poststratification weight for each participant was developed through a raking calibration procedure to minimize bias in the estimates because of the disproportional representation of controlled subgroups.
      • Vehovar V
      • Toepoel V
      • Steinmetz S.
      Non-probability sampling.
      The population totals used in raking were estimated using the most recent Bureau of Labor Statistics Occupational Employment and Wage Estimates (https://www.bls.gov/oes/current/oessrci.htm) and Current Population Survey data (https://www.bls.gov/cps/data.htm).
      Respondents were considered vaccinated against COVID-19 if they answered yes to the question: Have you received a COVID-19 vaccine?. Respondents who reported not receiving a COVID-19 vaccine were asked: How likely are you to get a COVID-19 vaccine if it were available to you today? Response options included: will definitely get a vaccine, will probably get a vaccine, am unsure about getting a vaccine, will probably not get a vaccine, and will definitely not get a vaccine. Respondents were grouped by vaccination and intent status as follows: (1) HCP who had received a COVID-19 vaccine, (2) HCP who were definitely or probably getting vaccinated, (3) HCP who were unsure about getting vaccinated, and (4) HCP who probably or definitely did not intend to get vaccinated.
      Information on sociodemographic characteristics, place of vaccination, influenza vaccination during the 2020–2021 influenza season, reasons for getting and not getting a COVID-19 vaccine, and attitudes toward COVID-19 illness and vaccination were also collected. For analyses regarding attitudes, answer options agree and strongly agree as well as disagree and strongly disagree were combined; not sure and do not know responses were set to missing.

      Statistical Analysis

      Weighted proportions and corresponding CIs for vaccination and each intent category are presented by work setting (respondents could select >1 work setting), occupation, demographic characteristics, and influenza vaccination status in 2020–2021. For descriptive analysis, the authors used any work setting, but HCP's primary work setting was included in regression models because approximately 20% of HCP reported working in multiple settings. To calculate the CIs for proportions in descriptive analysis, the Korn–Graubard method was used.
      • Korn EL
      • Graubard BI.
      Confidence intervals for proportions with small expected number of positive counts estimated from survey data.
      The CI assumes that the weighted estimates are approximately unbiased, which is based on the assertion that any differences between the survey sample and the target population on key survey outcomes are corrected by the sampling weight. National Center for Health Statistics reliability criteria for proportions were applied to the estimates in the descriptive analyses of HCP characteristics, reasons for getting and not getting a COVID-19 vaccine, and attitudes toward COVID-19 illness and COVID-19 vaccination.
      • Parker JD
      • Talih M
      • Malec DJ
      • et al.
      National Center for Health Statistics data presentation standards for proportions.
      Chi-square tests were utilized to assess the differences between groups and to compare the attitudes toward COVID-19 illness and COVID-19 vaccination; p<0.05 was considered significant.
      Multivariable logistic regression was used to determine the variables simultaneously associated with a receipt of a COVID-19 vaccine. The association was measured by adjusted prevalence ratios (APRs) calculated using average marginal predictions from the fitted logistic regression.
      • Bieler GS
      • Brown GG
      • Williams RL
      • Brogan DJ.
      Estimating model-adjusted risks, risk differences, and risk ratios from complex survey data.
      CIs for the model-adjusted prevalence ratios were obtained using a survey design–based estimate of the variance–covariance matrix of average marginal predictions and by delta method. A change-in-estimate procedure with a cut off value of 20% was employed to select the covariates for the final model.
      • Hosmer DW
      • Lameshow S.
      Applied Logistic Regression.
      Statistical significance of logistic regression parameter estimates was assessed by Wald F-test; p-values <0.05 were considered statistically significant. For all analyses, SAS, version 9.4, and SUDAAN, version 11.0.1, were used.

      RESULTS

      Overall, 68.2% of HCP reported having received ≥1 dose of a COVID-19 vaccine (61.3% were fully vaccinated), 9.8% would probably/definitely get vaccinated, 7.1% were unsure, and 14.9% would probably/definitely not get vaccinated (Table 1). Vaccination coverage was high among HCP aged 45–59 years (71.4%) and ≥60 years (88.2%), HCP with an associate or bachelor's degree (71.9%), HCP with more than a college degree (77.3%), HCP working in hospitals (75.0%), physicians (89.0%) and pharmacists (86.4%), and HCP who received an influenza vaccination during the 2020–2021 season (78.7%). Vaccination coverage was low among non-Hispanic Black (47.7%) and Hispanic (55.4%) HCP, assistants/aides (52.3%), nonclinical personnel (62.2%), HCP working in long-term care facilities/home health agencies (61.1%), and HCP with a primary workplace in the South region of the U.S. (63.4%). A larger proportion of Black HCP (25.7%) and HCP with primary workplace in the South region (18.0%) reported that they would probably/definitely not receive a COVID-19 vaccine (Table 1).
      Table 1COVID-19 Vaccination and Intent Among Healthcare Personnel by Selected Characteristics‒U.S., April 2021
      CharacteristicsTotal,Vaccinated (n=1,780),Definitely/probably will get a vaccine (n=202),Unsure (n=154),Definitely/probably will not get a vaccine (n=253),
      N (weighted %)weighted % (95% CI)
      Korn-Graubard 95% CI.
      weighted % (95% CI)weighted % (95% CI)weighted % (95% CI)
      Overall
      Vaccination and intent categories add up to 100%. Total for each of the characteristics may not add up to the overall owing to missing responses.
      2,38968.2 (63.7, 72.5)9.8 (7.6, 12.3)7.1 (5.3, 9.3)14.9 (11.1, 19.4)
      Age
       18–29 years (ref)263 (17.5)54.3 (39.7, 68.4)10.8 (6.1, 17.2)7.7 (3.7, 13.7)
      Estimates do not meet the National Center for Health Statistic's standards of reliability. https://www.cdc.gov/nchs/data/series/sr_02/sr02_175.pdf.
       30–44 years1,007 (38.9)64.6 (58.5, 70.3)11.9 (7.9, 16.9)9.0 (5.9, 13.1)14.5 (9.9, 20.1)
       45–59 years773 (29.0)71.4 (64.3, 77.8)8.6 (5.0, 13.4)6.8 (3.5, 11.8)13.2 (8.2, 19.6)
       ≥60 years345 (14.6)88.2 (81.1, 93.3)
      Estimates do not meet the National Center for Health Statistic's standards of reliability. https://www.cdc.gov/nchs/data/series/sr_02/sr02_175.pdf.
      1.7 (0.3, 4.9)
      Estimates do not meet the National Center for Health Statistic's standards of reliability. https://www.cdc.gov/nchs/data/series/sr_02/sr02_175.pdf.
      Race/ethnicity
      Race/ethnicity was self-reported. Respondents identified as Hispanic might be of any race. The other race category included Asians, American Indians/Alaska Natives, Native Hawaiians or other Pacific Islanders, and those who selected other or multiple races.
       Non-Hispanic White (ref)1,418 (61.4)75.7 (71.4, 79.7)7.3 (5.0, 10.1)6.5 (4.5, 9.2)10.5 (7.9, 13.6)
       Non-Hispanic Black315 (17.0)47.7 (33.2, 62.5)14.8 (8.3, 23.7)
      Estimates do not meet the National Center for Health Statistic's standards of reliability. https://www.cdc.gov/nchs/data/series/sr_02/sr02_175.pdf.
      25.7 (13.3, 41.8)
       Hispanic399 (14.1)55.4 (40.8, 69.4)14.5 (6.9, 25.5)
      Estimates do not meet the National Center for Health Statistic's standards of reliability. https://www.cdc.gov/nchs/data/series/sr_02/sr02_175.pdf.
      Estimates do not meet the National Center for Health Statistic's standards of reliability. https://www.cdc.gov/nchs/data/series/sr_02/sr02_175.pdf.
       Non-Hispanic other253 (7.5)77.4 (64.5, 87.3)
      Estimates do not meet the National Center for Health Statistic's standards of reliability. https://www.cdc.gov/nchs/data/series/sr_02/sr02_175.pdf.
      Estimates do not meet the National Center for Health Statistic's standards of reliability. https://www.cdc.gov/nchs/data/series/sr_02/sr02_175.pdf.
      Estimates do not meet the National Center for Health Statistic's standards of reliability. https://www.cdc.gov/nchs/data/series/sr_02/sr02_175.pdf.
      Sex
       Male (ref)794 (23.3)64.5 (52.2, 75.5)12.8 (7.5, 19.9)
      Estimates do not meet the National Center for Health Statistic's standards of reliability. https://www.cdc.gov/nchs/data/series/sr_02/sr02_175.pdf.
      Estimates do not meet the National Center for Health Statistic's standards of reliability. https://www.cdc.gov/nchs/data/series/sr_02/sr02_175.pdf.
       Female1,595 (76.7)69.3 (64.7, 73.7)8.8 (6.5, 11.6)7.8 (5.6, 10.5)14.0 (10.4, 18.3)
      Education
       Some college education or less (ref)540 (29.1)54.5 (46.3, 62.6)10.1 (6.6, 14.6)11.8 (7.3, 17.8)23.5 (16.0, 32.5)
       Associate or bachelor's degree767 (45.2)71.9 (64.4, 78.6)11.1 (7.4, 15.8)3.9 (2.6, 5.7)13.1 (7.2, 21.3)
       More than college degree1,081 (25.7)77.3 (69.8, 83.7)7.0 (3.6, 12.2)7.3 (3.7, 12.7)8.3 (4.5, 13.9)
      Occupation
      Excluding students.
       Physician (ref)283 (3.4)89.0 (82.8, 93.6)
      Estimates do not meet the National Center for Health Statistic's standards of reliability. https://www.cdc.gov/nchs/data/series/sr_02/sr02_175.pdf.
      1.1 (0.1, 4.1)
      Estimates do not meet the National Center for Health Statistic's standards of reliability. https://www.cdc.gov/nchs/data/series/sr_02/sr02_175.pdf.
       Nurse Practitioner/Physician assistant147 (1.4)
      Estimates do not meet the National Center for Health Statistic's standards of reliability. https://www.cdc.gov/nchs/data/series/sr_02/sr02_175.pdf.
      Estimates do not meet the National Center for Health Statistic's standards of reliability. https://www.cdc.gov/nchs/data/series/sr_02/sr02_175.pdf.
      Estimates do not meet the National Center for Health Statistic's standards of reliability. https://www.cdc.gov/nchs/data/series/sr_02/sr02_175.pdf.
      Estimates do not meet the National Center for Health Statistic's standards of reliability. https://www.cdc.gov/nchs/data/series/sr_02/sr02_175.pdf.
       Nurse178 (18.4)82.2 (73.6, 88.9)c1.5 (0.3, 4.6)
      Estimates do not meet the National Center for Health Statistic's standards of reliability. https://www.cdc.gov/nchs/data/series/sr_02/sr02_175.pdf.
       Pharmacist309 (1.3)86.4 (82.0, 90.0)6.0 (3.6, 9.3)3.0 (1.4, 5.7)4.6 (2.5, 7.6)
       Other clinical personnel
      Other clinical personnel include dentists, allied health professionals, technicians and technologists, emergency technicians, emergency medical technicians, and paramedics.
      561 (18.8)81.2 (72.5, 88.1)
      Estimates do not meet the National Center for Health Statistic's standards of reliability. https://www.cdc.gov/nchs/data/series/sr_02/sr02_175.pdf.
      Estimates do not meet the National Center for Health Statistic's standards of reliability. https://www.cdc.gov/nchs/data/series/sr_02/sr02_175.pdf.
      Estimates do not meet the National Center for Health Statistic's standards of reliability. https://www.cdc.gov/nchs/data/series/sr_02/sr02_175.pdf.
       Assistant/aide577 (24.2)52.3 (47.8, 56.8)13.9 (10.9, 17.4)12.6 (9.8, 15.9)21.2 (17.6, 25.2)
       Nonclinical personnel
      Nonclinical personnel include administrative support staff/manager and nonclinical support staff.
      305 (32.5)62.2 (50.5, 73.0)10.5 (5.6, 17.4)
      Estimates do not meet the National Center for Health Statistic's standards of reliability. https://www.cdc.gov/nchs/data/series/sr_02/sr02_175.pdf.
      20.9 (10.8, 34.5)
      Work setting
      Respondents could select >1 work setting. Each work setting is represented by a separate variable with 2 levels (yes/no, where reference level is no) rather than 1 variable with multiple categories corresponding to each work setting. Students were excluded from work setting variables (n=37).
       Hospital887 (38.6)75.0 (68.9, 80.5)8.3 (5.1, 12.6)3.1 (1.9, 4.7)13.6 (9.0, 19.3)
       Ambulatory care708 (22.6)73.7 (61.2, 83.9)9.0 (5.3, 14.1)3.5 (1.8, 6.1)
      Estimates do not meet the National Center for Health Statistic's standards of reliability. https://www.cdc.gov/nchs/data/series/sr_02/sr02_175.pdf.
       Long-term care facility/ Home health agency
      Nursing home, assisted living facility, other long-term care facilities, home health agency, or home health care.
      575 (41.7)61.1 (53.3, 68.5)12.6 (8.5, 17.7)10.6 (6.8, 15.7)15.7 (9.9, 23.1)
       Other settings
      Includes dentist office or dental clinic, pharmacy, emergency medical services, and other settings where clinical care or related services were provided to patients.
      618 (10.8)75.5 (67.1, 82.7)6.5 (3.3, 11.4)8.8 (4.6, 14.7)9.2 (5.4, 14.4)
      Area of primary workplace
      Rurality was defined using ZIP codes where >50% of the population resides in a nonmetropolitan county, a rural U.S. Census tract, or both, according to the Health Resources and Services Administration's definition of rural population. https://www.hrsa.gov/rural-health/about-us/definition/index.html.
       Rural (ref)308 (12.2)70.7 (61.9, 78.5)
      Estimates do not meet the National Center for Health Statistic's standards of reliability. https://www.cdc.gov/nchs/data/series/sr_02/sr02_175.pdf.
      9.8 (5.5, 15.9)15.0 (10.1, 21.1)
       Nonrural2,078 (87.8)67.9 (62.9, 72.6)10.5 (8.0, 13.5)6.7 (4.8, 9.2)14.9 (10.6, 20.1)
      Region
      Northeast: Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont. Midwest: Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin. South: Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia. West: Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming.
       Northeast (ref)455 (19.8)76.3 (68.2, 83.3)12.7 (7.3, 20.0)
      Estimates do not meet the National Center for Health Statistic's standards of reliability. https://www.cdc.gov/nchs/data/series/sr_02/sr02_175.pdf.
      5.5 (2.9, 9.2)
       Midwest398 (23.3)71.9 (62.3, 80.3)
      Estimates do not meet the National Center for Health Statistic's standards of reliability. https://www.cdc.gov/nchs/data/series/sr_02/sr02_175.pdf.
      5.8 (3.4, 9.0)15.8 (8.7, 25.4)
       South1,024 (36.1)63.4 (55.4, 70.9)9.1 (6.2, 12.7)9.5 (6.2, 13.8)18.0 (11.7, 25.9)
       West507 (20.8)64.7 (51.9, 76.1)11.9 (6.5, 19.6)
      Estimates do not meet the National Center for Health Statistic's standards of reliability. https://www.cdc.gov/nchs/data/series/sr_02/sr02_175.pdf.
      Estimates do not meet the National Center for Health Statistic's standards of reliability. https://www.cdc.gov/nchs/data/series/sr_02/sr02_175.pdf.
      Receipt of influenza vaccine in 2020‒2021
       Yes1,920 (75.9)78.7 (74.7, 82.3)9.2 (6.7, 12.1)4.3 (3.0, 5.9)7.9 (5.4, 11.1)
       No (ref)469 (24.1)35.2 (25.3, 46.0)11.7 (6.9, 18.3)16.0 (9.7, 24.3)37.1 (25.8, 49.6)
      Place of COVID-19 vaccination
       At work1,070 (64.9)NANANANA
       Doctor's office/medical clinic or health center/

        health department
      481 (23.3)NANANANA
       Other
      Other place of first or only COVID-19 vaccination includes other medically or nonmedically related places, such as drugstores, supermarkets, and pharmacies. NA, not applicable.
      229 (11.8)NANANANA
      Note: Bold text indicates statistical significance (p<0.05).
      Respondents who reported not receiving a COVID-19 vaccination were asked how likely they are to get a COVID-19 vaccine (n=609); response options included definitely will, probably will, unsure, probably will not, and definitely will not get a COVID-19 vaccine.
      a Korn-Graubard 95% CI.
      b Vaccination and intent categories add up to 100%. Total for each of the characteristics may not add up to the overall owing to missing responses.
      c Estimates do not meet the National Center for Health Statistic's standards of reliability. https://www.cdc.gov/nchs/data/series/sr_02/sr02_175.pdf.
      d Race/ethnicity was self-reported. Respondents identified as Hispanic might be of any race. The other race category included Asians, American Indians/Alaska Natives, Native Hawaiians or other Pacific Islanders, and those who selected other or multiple races.
      e Excluding students.
      f Other clinical personnel include dentists, allied health professionals, technicians and technologists, emergency technicians, emergency medical technicians, and paramedics.
      g Nonclinical personnel include administrative support staff/manager and nonclinical support staff.
      h Respondents could select >1 work setting. Each work setting is represented by a separate variable with 2 levels (yes/no, where reference level is no) rather than 1 variable with multiple categories corresponding to each work setting. Students were excluded from work setting variables (n=37).
      i Nursing home, assisted living facility, other long-term care facilities, home health agency, or home health care.
      j Includes dentist office or dental clinic, pharmacy, emergency medical services, and other settings where clinical care or related services were provided to patients.
      k Rurality was defined using ZIP codes where >50% of the population resides in a nonmetropolitan county, a rural U.S. Census tract, or both, according to the Health Resources and Services Administration's definition of rural population. https://www.hrsa.gov/rural-health/about-us/definition/index.html.
      l Northeast: Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont. Midwest: Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin. South: Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia. West: Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming.
      m Other place of first or only COVID-19 vaccination includes other medically or nonmedically related places, such as drugstores, supermarkets, and pharmacies.NA, not applicable.
      Findings from univariate and multivariable analysis to determine that factors associated with a receipt of a COVID-19 vaccination were generally consistent; however, work setting was no longer associated with a receipt of a COVID-19 vaccination in the multivariable analysis. HCP aged ≥60 years and those who received an influenza vaccination during the 2020–2021 season were more likely to have received a COVID-19 vaccination (APR=1.37, 95% CI=1.14, 1.65 and 1.92, 95% CI=1.53, 2.40, respectively) than their counterparts. Non-Hispanic Black HCP (APR=0.74, 95% CI=0.60, 0.92), nurse practitioners/physician assistants (APR=0.55, 95% CI=0.28, 1.07), assistants/aides (APR=0.73, 95% CI=0.64, 0.83), and nonclinical personnel (APR=0.79, 95% CI=0.68, 0.91) were less likely to have received a COVID-19 vaccine than their counterparts. Education was found to be significantly associated with receipt of a COVID-19 vaccine but was not adjusted for in the model owing to multicollinearity with occupation (Table 2).
      Table 2Factors Associated With a Receipt of ≥1 Dose of a COVID-19 Vaccine Among Healthcare Personnel‒U.S., April 2021
      CharacteristicsPrevalence ratio (95% CI)
      95% CI.
      p-ValueAdjusted prevalence ratio
      Logistic regression models included age, race/ethnicity, occupation, primary work setting, and receipt of an influenza vaccine in 2020–2021 season.
      (95% CI)
      p-Value
      Age
       18–29 years (ref)
       30–44 years1.19 (0.91, 1.56)0.171.02 (0.85, 1.22)0.82
       45–59 years1.31 (1.01, 1.71)0.021.16 (0.98, 1.38)0.07
       ≥60 years1.62 (1.25, 2.11)<0.00011.37 (1.14, 1.65)<0.001
      Race/ethnicity
      Race/ethnicity was self-reported. Respondents identified as Hispanic might be of any race. The Other race category included Asians, American Indians/Alaska Natives, Native Hawaiians or other Pacific Islanders, and those who selected other or multiple races.
       Non-Hispanic white (ref)
       Non-Hispanic Black0.63 (0.47, 0.85)<0.00010.74 (0.60, 0.92)<0.01
       Hispanic0.73 (0.57, 0.94)<0.010.90 (0.79, 1.03)0.1
       Non-Hispanic other1.02 (0.88, 1.19)0.781.06 (0.91, 1.24)0.49
      Occupation
      Excluding students.
       Physician (ref)
       Nurse Practitioner/Physician assistant0.59 (0.33, 1.05)<0.010.55 (0.28, 1.07)<0.01
       Nurse0.92 (0.83, 1.03)0.130.94 (0.83, 1.07)0.35
       Pharmacist0.97 (0.90, 1.04)0.430.93 (0.81, 1.07)0.32
       Other clinical personnel
      Other clinical personnel include dentists, allied health professionals, technicians and technologists, emergency technicians, emergency medical technicians, and paramedics.
      0.91 (0.82, 1.02)0.080.94 (0.83, 1.07)0.34
       Assistant/aide0.59 (0.53, 0.65)<0.00010.73 (0.64, 0.83)<0.0001
       Nonclinical personnel
      Nonclinical personnel include administrative support staff/manager and nonclinical support staff.
      0.70 (0.58, 0.84)<0.00010.79 (0.68, 0.91)<0.01
      Primary work setting
      Work setting presented in Table 2 is created differently from the work setting variable presented in Table 1. The work setting variable presented in this table represents healthcare personnel's primary work setting created as 1 variable with 4 categories that are mutually exclusive, which is different from the work setting variable presented in Table 1, where each subgroup was a separate variable that was not mutually exclusive. Primary work settings for students were excluded (n=37).
       Hospital (ref)
       Ambulatory care0.95 (0.80, 1.12)0.521.07 (0.95, 1.21)0.28
       Long-term care facility or home health agency/care
      Nursing home, assisted living facility, other long-term care facilities, home health agency, or home health care.
      0.82 (0.70, 0.95)<0.011.08 (0.95, 1.24)0.25
       Other settings
      Includes dentist office or dental clinic, pharmacy, emergency medical services, and other settings where clinical care or related services were provided to patients.
      1.07 (0.92, 1.26)0.421.23 (1.02, 1.49)0.07
      Receipt of influenza vaccine in 2020‒2021
       Yes2.24 (1.68, 2.98)<0.00011.92 (1.53, 2.40)<0.0001
       No (ref)
      SexNot selected
       Male (ref)Not selected
       Female1.08 (0.89, 1.29)0.42Not selected
      Education
       Some college education or less (ref)Not selected
       Associate or bachelor's degree1.32 (1.10, 1.58)<0.01Not selected
       More than college degree1.42 (1.21, 1.66)<0.0001Not selected
      Area of primary workplace
      Rurality was defined using ZIP codes where >50% of the population resides in a nonmetropolitan county, a rural U.S. Census tract, or both, according to the Health Resources and Services Administration's definition of rural population. https://www.hrsa.gov/rural-health/about-us/definition/index.html.
       Rural (ref)Not selected
       Nonrural0.96 (0.84, 1.10)0.56Not selected
      Region
      Northeast: Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont. Midwest: Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin. South: Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia. West: Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming.
       Northeast (ref)Not selected
       Midwest0.94 (0.80, 1.12)0.49Not selected
       South0.83 (0.71, 0.97)0.02Not selected
       West0.85 (0.69, 1.04)0.09Not selected
      Note: Boldface indicates statistical significance (p<0.05).
      CIs for the model-adjusted prevalence ratios were obtained using a survey design–based estimate of the variance–covariance matrix of average marginal predictions and may not correspond to p-values on the basis of the Wald chi-square test of regression coefficients.
      a 95% CI.
      b Logistic regression models included age, race/ethnicity, occupation, primary work setting, and receipt of an influenza vaccine in 2020–2021 season.
      c Race/ethnicity was self-reported. Respondents identified as Hispanic might be of any race. The Other race category included Asians, American Indians/Alaska Natives, Native Hawaiians or other Pacific Islanders, and those who selected other or multiple races.
      d Excluding students.
      e Other clinical personnel include dentists, allied health professionals, technicians and technologists, emergency technicians, emergency medical technicians, and paramedics.
      f Nonclinical personnel include administrative support staff/manager and nonclinical support staff.
      g Work setting presented in Table 2 is created differently from the work setting variable presented in Table 1. The work setting variable presented in this table represents healthcare personnel's primary work setting created as 1 variable with 4 categories that are mutually exclusive, which is different from the work setting variable presented in Table 1, where each subgroup was a separate variable that was not mutually exclusive. Primary work settings for students were excluded (n=37).
      h Nursing home, assisted living facility, other long-term care facilities, home health agency, or home health care.
      i Includes dentist office or dental clinic, pharmacy, emergency medical services, and other settings where clinical care or related services were provided to patients.
      j Rurality was defined using ZIP codes where >50% of the population resides in a nonmetropolitan county, a rural U.S. Census tract, or both, according to the Health Resources and Services Administration's definition of rural population. https://www.hrsa.gov/rural-health/about-us/definition/index.html.
      k Northeast: Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont. Midwest: Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin. South: Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia. West: Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming.
      The most common reasons for receipt of a COVID-19 vaccine among HCP included protecting self (88.1%) as well as protecting friends and family (86.3%) and patients (69.2%) from COVID-19 illness. The most common reasons for not receiving a COVID-19 vaccine among unvaccinated HCP included concerns about the side effects and safety of the COVID-19 vaccine (59.7%), desire to wait and see whether vaccines are safe (51.2%), and concerns about fast development (50.0%) and approval (50.4%) of COVID-19 vaccines (Table 3).
      Table 3Reasons for Receipt and Nonreceipt of COVID-19 Vaccine Among Healthcare Personnel‒U.S., April 2021
      ReasonsnWeighted % (95% CI)
      Korn-Graubard 95% CI.
      Reasons for nonreceipt of a COVID-19 vaccination
      More than 1 reason could be selected for reasons for a vaccination with a COVID-19 vaccine.
      ,
      Other reasons for vaccination are not presented owing to proportions not meeting the National Center for Health Statistic's standards of reliability. https://www.cdc.gov/nchs/data/series/sr_02/sr02_175.pdf.
      ,
      More than 1 reason could be selected.
       Concerned about the side effects and safety of the COVID-19 vaccine34559.7 (50.6, 68.3)
       Plan to wait and see whether it is safe and may get it later30351.2 (42.0, 60.3)
       Concerned that the COVID-19 vaccine was developed too fast29050.0 (40.9, 59.1)
       Concerned that the COVID-19 vaccine was approved too fast28850.4 (41.8, 59.0)
       Plan to use masks and other precautions instead20137.1 (28.3, 46.5)
       Concerned about having an allergic reaction to COVID-19 vaccine16029.2 (20.8, 38.8)
       Not a member of any group that is at high risk from COVID-1914523.2 (15.1, 33.1)
       Do not trust the government12716.3 (10.4, 23.9)
       Do not think that the vaccine will prevent COVID-1912218.1 (11.7, 26.1)
       Do not think that the vaccination is effective in preventing COVID-1911818.2 (11.7, 26.3)
       Not in one of the groups recommended to get the initial doses of COVID-19 vaccine85
      Estimates do not meet the National Center for Health Statistic's standards of reliability. https://www.cdc.gov/nchs/data/series/sr_02/sr02_175.pdf.
       The vaccine was/is not available83
      Estimates do not meet the National Center for Health Statistic's standards of reliability. https://www.cdc.gov/nchs/data/series/sr_02/sr02_175.pdf.
       Already had COVID-19 and should be immune6714.3 (6.8, 25.3)
      Reasons for receipt of a COVID-19 vaccination
      Other reasons for vaccination are not presented owing to proportions not meeting the National Center for Health Statistic's standards of reliability. https://www.cdc.gov/nchs/data/series/sr_02/sr02_175.pdf.
      ,
      More than 1 reason could be selected.
       To protect myself from COVID-191,58188.1 (84.2, 91.3)
       To protect my friends or family from COVID-191,51086.3 (83.1, 89.1)
       To protect patients from getting COVID-191,31769.2 (64.0, 74.0)
       Because COVID-19 was/is bad1,25867.3 (62.4, 71.9)
       COVID-19 vaccine was offered free of charge at work95657.0 (51.9, 61.9)
       It is easy or convenient to get COVID-19 vaccination at work76946.6 (41.6, 51.7)
       To avoid missing work62931.9 (27.7, 36.4)
       A doctor, nurse, or other medical professional recommended COVID-19 vaccination to me47530.2 (25.7, 35.0)
       I have a health condition (for example, diabetes, asthma, pregnancy, age)35219.9 (15.9, 24.5)
       Because it was mandatory, or I had to for work123
      Estimates do not meet the National Center for Health Statistic's standards of reliability. https://www.cdc.gov/nchs/data/series/sr_02/sr02_175.pdf.
       Because I had to for school20
      Estimates do not meet the National Center for Health Statistic's standards of reliability. https://www.cdc.gov/nchs/data/series/sr_02/sr02_175.pdf.
      a Korn-Graubard 95% CI.
      b More than 1 reason could be selected for reasons for a vaccination with a COVID-19 vaccine.
      c Other reasons for vaccination are not presented owing to proportions not meeting the National Center for Health Statistic's standards of reliability. https://www.cdc.gov/nchs/data/series/sr_02/sr02_175.pdf.
      d More than 1 reason could be selected.
      e Estimates do not meet the National Center for Health Statistic's standards of reliability. https://www.cdc.gov/nchs/data/series/sr_02/sr02_175.pdf.
      When examining the attitudes, beliefs, and perceptions about COVID-19 illness and vaccines, most HCP agreed/strongly agreed that COVID-19 was a serious threat to the health of people around them (88.0%) and that people around them were at-risk of getting COVID-19 (86.0%). In addition, 78.2% of HCP agreed/strongly agreed that COVID-19 vaccines are safe. Smaller proportions of HCP agreed/strongly agreed that HCP should be rewarded for getting vaccinated against COVID-19 (67.8%) or that HCP should be required to be vaccinated (58.2%) (Figure 1A). Vaccination coverage was highest, ranging from 72.4% to 84.5%, among HCP who agreed or strongly agreed with statements such as believing that COVID-19 vaccines are safe, that the vaccines could protect them from getting COVID-19, and that HCP should be required to be vaccinated . Among HCP who would probably/definitely not get vaccinated, a larger proportion disagreed/strongly disagreed that getting vaccinated against COVID-19 was worth the time and expense (59.2%); that if they got a COVID-19 vaccine, people around them would be better protected from COVID-19 (57.5%); that COVID-19 is a serious threat to the health of people around them (57.3%); and that the COVID-19 vaccine is safe (53.6%) (Figure 1B).
      Figure 1
      Figure 1(A) Attitudes toward COVID-19 illness and vaccination among healthcare personnel‒U.S., April 2021. (B) Healthcare providers reporting a receipt of ≥1 dose of COVID-19 vaccine and those reporting intenta for vaccination, by attitude—U.S., April 2021.
      aRespondents who reported not receiving a COVID-19 vaccination were asked how likely they are to get a COVID-19 vaccine (n=609); response options included definitely will, probably will, unsure, probably will not, and definitely will not get a COVID-19 vaccine.

      DISCUSSION

      Although HCP were among the first group to be offered COVID-19 vaccines in the initial phase of the vaccination program,
      • Dooling K
      • McClung N
      • Chamberland M
      • et al.
      The Advisory Committee on Immunization Practices’ interim recommendation for allocating initial supplies of COVID-19 vaccine - United States, 2020.
      only 68% of HCP in the U.S. reported having received ≥1 dose of a COVID-19 vaccine as of April 2021. In a survey conducted in early March 2021 by the Kaiser Family Foundation, 52% of 1,327 frontline healthcare workers who had direct contact with patients and their bodily fluids reported having received ≥1 dose of a COVID-19 vaccine.
      Kaiser Family Foundation
      KFF/post survey of frontline health care workers finds nearly half remain unvaccinated.
      Estimated vaccination coverage was higher in the current analyses, which may be owing to the later timing of this survey as well as the inclusion of all HCP regardless of direct patient contact. A study assessing vaccination intent among HCP conducted in September 2020 estimated that only 35% of HCP were very likely/absolutely certain about receiving a COVID-19 vaccine and that >38% were very not likely to receive a vaccine.
      • Nguyen KH
      • Kahn KE
      • Hoehner J
      • et al.
      COVID-19 vaccination intent, perceptions, and reasons for not vaccinating among groups prioritized for early vaccination, United States, September 2020.
      A later study assessed COVID-19 vaccination intent among HCP in November 2020 and estimated that a lower percentage (8%) of HCP would not take a COVID-19 vaccine, whereas 56% would wait for additional review before receiving a vaccine, which may have been because of the availability of additional information on COVID-19 vaccines.
      • Shekhar R
      • Sheikh AB
      • Upadhyay S
      • et al.
      COVID-19 vaccine acceptance among health care workers in the United States.
      Although COVID-19 vaccines have been authorized and available to HCP since December 2020 and 78% of HCP have received or will definitely receive a COVID-19 vaccine, approximately twice as many HCP in this study indicated that they would not receive a COVID-19 vaccine compared with most estimates from earlier studies.
      • Shekhar R
      • Sheikh AB
      • Upadhyay S
      • et al.
      COVID-19 vaccine acceptance among health care workers in the United States.
      This increase is likely owing to concerns with side effects and safety of COVID-19 vaccines as well as the perceived fast development and approval of these vaccines, as indicated in this study. Despite the increase in the percentage of HCP who would probably/definitely not get a COVID-19 vaccine, COVID-19 vaccination uptake could likely be increased among unvaccinated HCP by addressing barriers to vaccination and ensuring that findings from studies and data on COVID-19 vaccine safety are accessible and easily understood. Finally, expanding and reinforcing strategies such as promoting free vaccinations and making them easily accessible at the workplace during work hours may increase vaccination uptake because these were identified as motivating factors for vaccinated respondents.
      Similar to the demographic characteristics of people receiving ≥1 dose of a COVID-19 vaccination in the U.S., the authors observed lower COVID-19 vaccination coverage among younger, Hispanic, and non-Hispanic Black HCP.
      Demographic characteristics of people receiving COVID-19 vaccinations in the United States.
      Given that a larger proportion of recent COVID-19 cases has been reported among younger adults and those of Hispanic and non-Hispanic Black race where vaccination coverage is also low, it is important to address the potential barriers to vaccination and improve vaccination uptake in this population.
      COVID-19 Weekly cases and deaths per 100,000 population by age, race/ethnicity, and sex.
      Current analyses show that the main reasons for nonvaccination include concerns with side effects and safety of COVID-19 vaccines as well as fast development and approval of the vaccines. Providing additional information and addressing the concerns on the safety and effectiveness of COVID-19 vaccines as well as the U.S. Food and Drug Administration's approval of the vaccines may contribute to an increase in vaccination uptake among unvaccinated HCP.
      FDA approves first COVID-19 vaccine [news release].
      This analysis also found that COVID-19 vaccination coverage was highest among physicians, pharmacists, and nurses and lowest among assistants/aides. Similar results have been observed previously for influenza vaccination as well as for COVID-19 vaccination.
      Kaiser Family Foundation
      KFF/post survey of frontline health care workers finds nearly half remain unvaccinated.
      ,
      Influenza vaccination coverage among health care personnel—United States; 2019–20 influenza season.
      Not only are HCP at increased risk of contracting and transmitting COVID-19, but they can also play a critical role in influencing patients’ vaccination decisions and acting as vaccine champions for coworkers. Previous studies have concluded that vaccinated HCP are more likely to recommend vaccination to others and that HCP recommendation is one of the strongest predictors of vaccination.
      • Paterson P
      • Meurice F
      • Stanberry LR
      • Glismann S
      • Rosenthal SL
      • Larson HJ.
      Vaccine hesitancy and healthcare providers.
      ,
      • Razzaghi H
      • Kahn KE
      • Black CL
      • et al.
      Influenza and Tdap vaccination coverage among pregnant women - United States, April 2020.
      Thus, it is important to empower HCP by promoting confidence in their decision to get vaccinated and to recommend vaccination to their patients as vaccines become more widely available in settings such as doctor's offices and clinics. In addition, it has been well documented that HCP are a trusted source of information; therefore, educating HCP regarding the importance of talking to their patients about COVID-19 vaccination is essential for increasing general COVID-19 vaccination uptake.
      • Katzman JG
      • Katzman JW.
      Primary care clinicians as COVID-19 vaccine ambassadors.
      ,
      CDC COVID-19 Response Team
      COVID-19 Vaccine Conversations Tool for Healthcare Professionals.
      A set of strategies, including engagement with local and national professional associations, cultivating a culture that builds confidence in COVID-19 vaccination, and strengthening the capacity of HCP to have vaccine conversations and provide tailored information to patients, could empower HCP and promote confidence in vaccination.
      CDC COVID-19 Response Team
      COVID-19 Vaccine Conversations Tool for Healthcare Professionals.
      Finally, the lowest vaccination coverage among HCP was observed in settings such as long-term care facilities and home healthcare agencies where the population served are at increased risk of infection and severe illness from COVID-19.

      People who live in a nursing home or long-term care facility. Centers for Disease Control and Prevention.https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-in-nursing-homes.html. Updated September 11, 2020. Accessed July 12, 2021.

      A recent study assessing COVID-19 vaccination coverage among HCP from 300 long-term care facilities estimated that only 56.8% of HCP in these settings were fully vaccinated as of April 4 and that 25.9% had declined COVID-19 vaccination.
      • Lee JT
      • Althomsons SP
      • Wu H
      • et al.
      Disparities in COVID-19 vaccination coverage among health care personnel working in long-term care facilities, by job category, National Healthcare Safety Network - United States, March 2021.
      Data from CDC's National Healthcare Safety Network estimate that approximately 60% of staff in long-term care facilities have received ≥1 dose of a COVID-19 vaccine.

      Nursing home COVID-19 vaccination data dashboard. Centers for Disease Control and Prevention. https://www.cdc.gov/nhsn/covid19/ltc-vaccination-dashboard.html. Updated December 15, 2021. Accessed July 1, 2021.

      Lower COVID-19 vaccination coverage in these settings is most likely attributable to other factors such as age, race/ethnicity, and occupation of HCP and not work setting because staff at long-term care facilities were among the first to have been offered a COVID-19 vaccination on-site.
      • Dooling K
      • McClung N
      • Chamberland M
      • et al.
      The Advisory Committee on Immunization Practices’ interim recommendation for allocating initial supplies of COVID-19 vaccine - United States, 2020.
      ,
      • 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.
      Furthermore, influenza vaccination coverage among HCP in these settings is similarly low.
      Influenza vaccination coverage among health care personnel—United States; 2019–20 influenza season.
      Long-term care facilities and home healthcare agencies can use CDC's long-term care web-based toolkit, which provides access to resources, strategies, and educational materials for increasing COVID-19 vaccination among HCP and reducing COVID-19–associated morbidity and mortality among residents in long-term care settings.

      Long-term care facility toolkit: preparing for COVID-19 vaccination at your facility. Centers for Disease Control and Prevention.https://www.cdc.gov/vaccines/covid-19/toolkits/long-term-care/index.html. Updated December 15, 2021. Accessed July 1, 2021.

      Finally, mandatory employer influenza programs as well as workplace incentives have been associated with high vaccination rates, decreased HCP absenteeism, and decreased healthcare-associated infections among hospitalized patients.
      • Perl TM
      • Talbot TR.
      Universal influenza vaccination among healthcare personnel: yes we should.
      Similar mandates could increase COVID-19 vaccination uptake among HCP and prevent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission in all healthcare settings.

      Limitations

      This analysis is among the first to estimate COVID-19 vaccination among HCP in the U.S.; however, the following limitations should be considered in interpreting the findings. First, although quota sampling and raking approaches to weighting result in adjusted point estimates that are demographically representative of the U.S. HCP population, the SEs calculated with these data assumed that a probability sample had been used. However, there is no probability of selection for each respondent owing to the opt-in nature of this survey.

      American Association for Public Opinion Research. AAPOR guidance on reporting precision for nonprobability samples. Hollywood, FL: AAPOR. https://www.aapor.org/getattachment/Education-Resources/For-Researchers/AAPOR_Guidance_Nonprob_Precision_042216.pdf.aspx. Published 2016. Accessed November 11, 2021.

      Second, a potential for nonresponse and noncoverage bias may exist in the parameter estimates because of the self-selection process for entry into the panel and participation in the survey. Previous literature suggests that the respondents of panel surveys may be more frequent Internet users than the general population and may have attitudinal and behavioral differences that may result in different vaccination coverage.
      • Rainer S
      • Marcel N
      • Sabrina T.
      Differences in general health of internet users and non-users and implications for the use of web surveys.
      ,
      • Thapa DK
      • Visentin DC
      • Kornhaber R
      • West S
      • Cleary M.
      The influence of online health information on health decisions: a systematic review.
      However, in sensitivity analyses, the investigators did not find any statistically significant trend or association between COVID-19 vaccination coverage and frequency of Internet use or type of device utilized to complete the survey. Although the point estimates may be biased, the measure of association may be less affected by nonprobability sampling.
      • Kohler U
      • Kreuter F
      • Stuart EA.
      Nonprobability sampling and causal analysis.
      ,
      • Pasek J.
      When will nonprobability surveys mirror probability surveys? Considering types of inference and weighting strategies as criteria for correspondence.
      Third, vaccination status was self-reported and not validated by medical record review and might be subject to recall or social desirability bias. Fourth, some subgroups had small sample sizes, and the authors were not able to assess vaccination coverage in those groups, such as individuals of non-Hispanic Asian race/ethnicity. Finally, the survey was only administered in English, and HCP with limited English proficiency may be under-represented. Despite these limitations, Internet panel surveys are considered a useful assessment tool for timely evaluation of vaccination coverage among HCP given the limited availability of such data from other data sources.

      CONCLUSIONS

      This study is among the first to examine vaccination coverage, vaccination intent, and reasons for nonvaccination among U.S. HCP overall and by occupation and work setting. Understanding vaccination status and intent is important for addressing barriers to vaccination, especially among occupations and work settings where HCP vaccination is lowest. Implementing interventions that can mitigate barriers to vaccination, such as flexible scheduling, paid time off for vaccination, on-site vaccination, or incentives, may improve vaccination coverage among HCP. These efforts can help to curb COVID-19 transmission, especially with the surge of new variants,

      Variants and genomic surveillance for SARS-CoV-2. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/variants/index.html. Updated August 11, 2021. Accessed July 29, 2021.

      and protect the health of HCP and others, such as long-term care facility residents, who may be at increased risk for COVID-19 illness.

      ACKNOWLEDGMENTS

      The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.
      No financial disclosures were reported by the authors of this paper.

      CRediT AUTHOR STATEMENT

      Hilda Razzaghi: Conceptualization; Investigation; Methodology; Project administration; Resources; Supervision; Visualization; Writing - original draft. Svetlana Masalovich: Conceptualization; Formal analyses; Methodology; Software; Writing - original draft. Anup Srivastav: Conceptualization; Formal analyses; Methodology; Software; Validation; Writing - original draft. Carla L. Black: Conceptualization; Investigation; Methodology; Visualization; Writing - review and editing. Kimberly H. Nguyen: Conceptualization; Methodology; Visualization; Writing - review and editing. Marie A. de Perio: Conceptualization; Methodology; Visualization; Writing - review and editing. A. Scott Laney: Conceptualization; Methodology; Visualization; Writing - review and editing. James A. Singleton: Conceptualization; Methodology; Visualization; Writing - review and editing.

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