Direct and indirect effectiveness of mRNA vaccination against SARS-CoV-2 infection in long-term care facilities in Spain

Objectives To estimate indirect and total (direct plus indirect) effects of COVID-19 vaccination in residents in long-term care facilities (LTCF). Design Registries-based cohort study including all residents in LTCF ≥65 years offered vaccination between 27 December 2020 and 10 March 2021. Risk of SARS-CoV-2 infection following vaccination was compared with the risk in the same individuals in a period before vaccination. Risk in non-vaccinated was also compared to a period before the vaccination programme to estimate indirect protection. Standardized cumulative risk was computed adjusted by previous documented infection (before the start of follow-up) and daily-varying SARS-CoV-2 incidence and reproductive number. Participants 573,533 records of 299,209 individuals in the National vaccination registry were selected; 99.0% had ≥1 vaccine-dose, 99.8% was Pfizer/BioNTech (BNT162b2). Residents mean age was 85.9, 70.9% were females. A previous SARS-CoV-2 infection was found in around 25% and 13% of participants, respectively, at the time of vaccine offer and in the reference period. Main outcome measures Documented SARS-CoV-2 infection identified in the National COVID-19 laboratory registry. Results Total VE was 57.2% (95% Confidence Interval: 56.1%-58.3%), and was highest ≥28 days after the first vaccine-dose ( proxy of ≥7 days after the second dose) and for individuals naïve to SARS-CoV-2 [81.8% (81.0%-82.7%)] compared to those with previous infection [56.8% (47.1%-67.7%)]. Vaccination prevented up to 9.6 (9.3-9.9) cases per 10.000 vaccinated per day; 11.6 (11.3-11.9) if naïve vs. 0.8 (0.5-1.0) if previous infection. Indirect protection in the non-vaccinated could only be estimated for naïve individuals, at 81.4% (73.3%-90.3%) and up to 12.8 (9.4-16.2) infections prevented per 10.000 indirectly protected per day. Conclusions Our results confirm the effectiveness of mRNA vaccination in institutionalized elderly population, endorse the policy of universal vaccination in this setting, including in people with previous infection, and suggest that even non-vaccinated individuals benefit from indirect protection. Key messages COIVD-19 vaccination reduced the risk of documented SARS-CoV-2 infection in institutionalized elderly by 57.2% (56.1% to 58.3%), which increased to 81.2% (80.2% to 82%) for the fully vaccinated. In individuals naïve to SARS-CoV-2 vaccination reduced the risk by up to 81.8% and averted up to 11.6 cases per 10,000 vaccinated persons per day. Those with previous infection also benefited from a risk reduction of 57%, which translated in less than 1 infection averted per 10,000 vaccinated persons per day. Non-vaccinated individuals living in facilities where the majority (residents and staff) had been vaccinated showed a risk reduction similar to those actually vaccinated.