Throughout the winter, federal health agencies pushed to encourage more nursing home residents and staff to get the newest Covid booster, developing social media hashtags, funding vaccine hotlines, and flagging the worst-performing institutions to states.

However, their choice to reduce two vaccination interventions that were important in protecting residents and staff from Covid during the first vaccine rollout in late 2020 and 2021 has left the work mostly to facilities, with unsatisfactory results, according to resident advocates.

Today, slightly more than half of nursing home patients and about 23% of nursing home personnel have received the bivalent booster vaccine, a significant decrease from the more than 85% of residents and staff who received the primary vaccine.

That is still higher than the majority of Americans: Only 16% of the eligible U.S. population has received the new vaccine. When it comes to Covid, though, nursing home patients have never been like the majority of Americans. According to AARP, nursing home residents account for approximately one out of every six total Covid deaths in the United States, and hundreds of seniors continue to die each week.

The Biden administration is still working to protect the country’s most vulnerable population from SARS-CoV-2, nearly three years after the infection ravaged residents, their families, and employees. As the federal government loosens its grip on managing the pandemic in long-term care facilities, not all nursing homes are stepping up to encourage residents and staff to get boosted, raising the question of who, in a Covid-endemic America, is ultimately responsible for continuing to protect this uniquely vulnerable community from an unpredictable disease.

“There’s this tremendous mismatch between the idea that we need to be hypervigilant in protecting residents, but the underlying policy doesn’t reflect that,” said Sam Brooks, director of public policy for the National Consumer Voice for Quality Long-Term Care. “It’s kind of like things were before. That’s unfortunate. Because what happened before was the reason for this.”

The first nursing home vaccination campaign, launched by the Trump and then Biden administrations, was a bright spot in the early pandemic response: the Centers for Disease Control and Prevention collaborated with CVS and Walgreens to stage free, on-site clinics at thousands of long-term care facilities across the country, ultimately administering eight million shots.

Later, the Centers for Medicare and Medicaid Services, which oversees the more than 15,000 nursing homes that receive Medicare and Medicaid funds, mandated that its employees receive their primary Covid immunisation.

The two measures contributed to both groups’ Covid immunisation rates being significantly higher than nursing home vaccination rates for other diseases including flu and pneumococcal.

However, they were not utilised again for the bivalent injection, which protects against the Covid strain, which currently accounts for the vast majority of cases. According to the CDC, nursing home residents who are not up to date on their Covid immunisations are up to 50% more likely to be infected than their counterparts who are.

The CDC still partners with retail pharmacies to administer vaccines in tens of thousands of locations across the country, but the programme has been scaled back, putting the onus on long-term facilities to arrange most onsite vaccine clinics from pharmacies or state health departments, or administer the vaccine themselves.

Despite data suggesting that higher staff immunisation rates are related with lower rates of infection and death among residents, CMS has not revised its staff vaccine mandate to include the bivalent injection or past boosters.

“We observed an exceptional effort and extraordinary outcomes for the initial immunisation campaign in 2021. “We witnessed a routine effort and normal results for administering Covid boosters to nursing home residents,” said Ari Houser, senior methodologies advisor at the AARP Public Policy Institute. “I had thought that the lesson from that highly successful initial vaccination programme would be that we should do this more frequently… But that does not appear to have been the case.”

Everyone believes that vaccine fatigue is widespread among residents and staff alike — as it is throughout the country — but advocates say nursing facilities are doing an inconsistent job of navigating that difficulty on their own.

Administration health authorities, for their part, claim that they have approached the low booster rate from every possible angle.

Nursing home residents remain the nation’s “most vulnerable” population, according to CDC Director Rochelle Walensky, who testified before Congress on Feb. 8, adding that the current booster vaccination rate “is insufficient.”

CMS reminded nursing homes in November that they must educate residents and staff about Covid vaccinations and offer boosters. In addition, the agency increased its assistance to facilities in order to help them set up on-site clinics and distribute vaccine education materials. The agency has issued a list of nursing facility immunisation rates to states, and CMS Administrator Chiquita Brooks-LaSure wrote to the governors of Arizona, Nevada, Florida, Texas, and Mississippi last month, requesting calls about how to fix the situation. CMS has refused to say whether or not these have occurred.

A CMS spokesman said that boosters were not suggested at the time the rule was adopted in late 2021, but that the agency has “continued to encourage all eligible persons to remain up to date by receiving the most updated bivalent vaccine.”

When the booster was permitted, officials judged that vaccination demand was insufficient at this point in the pandemic to flood nursing homes with clinics again, even if only a few residents were inoculated at each session.

Instead, the CDC has concentrated its efforts on collaborating with national groups to address vaccine fatigue and hesitation, as well as to assist long-term care facilities in connecting with pharmacies, among other things. The CDC will organise a “bootcamp” later this month for long-term care facility administrators and health care clinicians to assist them find out how to enhance vaccine confidence in their institutions.

Representatives from nursing homes say the current system is doing as well as can be expected three years into the pandemic. According to facilities, there are no issues with acquiring or giving immunisations, although vaccine fatigue is frequent among residents, family members, and communities where employees live.

Residents need to be vaccinated, but not at the same rate as when the first vaccine was introduced, according to David Gifford, chief medical officer of the American Health Care Association and National Center for Assisted Living, which represents over 14,000 nursing homes and assisted living communities.

“It’s a demand issue. You can dispatch the National Guard to any care home. “You won’t see the vaccine go up,” he said. “How much do we want to bully the elderly into getting the vaccine? That’s all there is to it. Some people may not bother them as much as others.”