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Federal Register / Vol. 86, No. 91 / Thursday, May 13, 2021 / Rules and Regulations
This rule presents additional difficulties in estimating both costs and benefits due primarily to the fact that an unknown but significant fraction of current LTC staff and residents have already received an explanation of the benefits of vaccination to persons who are elderly or high risk from specific health conditions or both, and the rarely serious risks associated with vaccination for example, the statistically negligible risk of severe allergic reactions to the vaccine. For a statistically average LTC resident, the average pre-COVID life expectancy if death occurs while in the facility is likely to be on the order of 3 years or fewer but taking into account those who recover and leave the facility and those enrolled for skilled nursing services we estimate overall life expectancies to be about 5 years.74 We also estimate that vaccination reduces the chance of infection by about 95 percent, and the risk of death from the virus to a fraction of 1 percent.75 In Israel, of the first 2.9
million people vaccinated with two doses there were only about 50
infections involving severe conditions resulting from the virus after the 14th day and of these so few deaths that they were not reported in statistical summaries. These data also show that vaccine effectiveness rates are very high for both older and younger recipients.
Of those receiving the second vaccine dose, after the 14th day 46 people over the age of 60 became infected and had a severe case, compared to 6 people under the age of 60. Two million nine hundred thousand 2.9 million people received a second dose; therefore both rates are near zero. 76
C. Anticipated Costs of the Interim Final Rule The previously calculated information collection costs of this rule are one of three major categories of cost. The
second large cluster of costs are for the required resident, client, and staff education. In addition, we are requiring facilities to offer COVID19 vaccines to residents, clients, and staff.
As documented subsequently in this analysis and in a research report on this issue, about 1.5 million individuals work in nursing facilities at any one time.77 These individuals are at high risk both to become infected with COVID19 and to transmit the SARS
CoV2 virus to residents or visitors. Far more than most occupations, nursing home care requires sustained close contact with multiple persons on a daily basis.
In Table 5, we present estimates of total numbers of individuals in the categories regulated under this rule, distinguishing among long-term and shorter-term nursing facility residents, residents and staff, and numbers at the beginning of a year and at any one time during the year, versus the much higher numbers when turnover is taken into account. In this table we assume that the number departing each year is the same as the number entering each year, which is a reasonable approximation to changes in just a few years, but do not take account of the aging of the population over time.
These figures are approximations, because none of the data that is routinely collected and published on resident populations or staff counts focus on numbers of individuals residing or working in the facility during the course of a year or over time.
Depending on the average length of stay that is, turnover in different facilities, an average population at any one time of, for example, 100 persons would be consistent with radically different numbers of individuals, such as 112
individuals in one facility if one person left each month and was replaced by another person, compared to 365 if one
person left each day and was replaced that same day by another person.
In Table 5, we assume it is likely that about 80 or 90 percent of LTC facility residents at the beginning of the year, and 60 or 70 percent of the LTC facility staff at the beginning of the year, were vaccinated by the end of March, due mainly to the efforts of the Partnership.
But there are many new persons in each category during the first three months one fourth of the annual number shown in the second column and likely fewer of these will have been vaccinated elsewhere. Hence, we assume that the percent of persons who were vaccinated by the end of March is only 70 percent of long-term care residents, 40 percent of skilled nursing care residents, and 60
percent of the LTC facility staff serving both types of residents. The estimated numbers for ICFsIID are lower because few residents or staff were eligible for vaccination from any source other than the Partnership in the first three months of the year. The estimated numbers of ICFIID residents and staff, and turnover rates, are particularly rough estimates since there are no published sources that we have found that contain such estimates. We assume that staff turnover is about as high as in LTC
facilities, but that resident turnover is considerably lower since resident mortality is not a major factor.
The estimate that 53 percent of these LTC facility and ICFIID populations as of the end of March were actually vaccinated is simply a weighted average of these numbers. The second and third sections of Table 5 show how these numbers are split between residents and staff, and LTC facilities and ICFsIID, respectively. This table estimates that during the first year after the issuance of this regulation, as many people will be candidates for vaccination in these facilities as during the first three months of calendar year 2021 see last column.

TABLE 5ESTIMATES OF NUMBER AND VACCINATION STATUS OF RESIDENTS AND STAFF
Thousands Beginning of year 2021
Long-Term Care Residents
Skilled Nursing Care Residents

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1,200
200

74 At age 80, the average life expectancy of a male is about 8 years and of females about 10 years, or an overall average of about 9 years. Long-term care nursing home residents, however, have shorter life expectancies because they have severe health problems or would not have been admitted to a facility. For those who die while in a facility the average life expectancy is about two years. But some recover and leave so we have used five years as a reference point. See discussion at David B.
Reuben, Medical Care for the Final Years of Life:

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New during 2021

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400
2,100

Percent vaccinated by March 31

Total for 2021

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1,600
2,300

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70
40

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When youre 83, Its not going to be 20 years,
JAMA, Dec. 23, 2009, 26862694.
75 For patients in skilled nursing facilities, average length of stay is less than a month. Hence, turnover is far higher.
76 See Dvir Aran, Estimating real-world COVID
19 vaccine effectiveness in Israel using aggregated counts, medRxiv, February 28, 2021, at https
www.medrxiv.org/content/10.1101/2021.02.
05.21251139v3.full.pdf and Noa Dagan et al.,
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Remaining vaccination candidates 2021

Number vaccinated by March 31
1,120
920

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480
1,380

New candidates 1st quarter 2022

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100
525

Total first year candidates

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580
1,905

BNT162b2 mRNA Covid19 Vaccine in a Nationwide Mass Vaccination Setting, The New England Journal of Medicine, 2/24/2021, at https
www.nejm.org/doi/full/10.1056/NEJMoa2101765.
77 Kaiser Family Foundation, COVID19 and Workers at Risk: Examining the Long-Term Care Workforce, April 23, 2020, at https www.kff.org/
coronavirus-covid-19/issue-brief/covid-19-andworkers-at-risk-examining-the-long-term-careworkforce/.

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