Attitudes towards the mixing of COVID-19 vaccinated and unvaccinated patients in multi-bed hospital rooms

COVID-19 vaccination is the most effective method of providing high protection against severe illness, hospitalisation and death from SARS-CoV2. Despite this, the issue of vaccination has been divisive.^1–3 By February 2022, it was mandatory for people working in New Zealand’s health and disability sector to be fully vaccinated (two doses of the vaccine) as they were at high risk of being infected with COVID-19 and of passing it to vulnerable people.⁴ Based on the expectation that vaccination would reduce the risk of transmitting infection, most businesses, except for hospitals and other essential services, required adults to show a “vaccine pass” before they could enter to prove they’d been vaccinated to minimise the spread of COVID-19 in the community.⁵

Most New Zealand hospitals, including Dunedin Public Hospital, have multi-bed rooms, which are likely to be shared by both vaccinated and unvaccinated patients. Inpatients do not have the right to know other patients’ vaccination status or whether they have a transmissible disease, and they are not usually given a choice over who they share a room with. Since patients spend most of the day in the same room, the risk of transmission from an unsuspected COVID-19 infection may be substantial.⁶ Previous reports describe a 21–39% risk of transmission to hospital roommates when one of the occupants has COVID-19. These studies suggest using vaccination status to determine bed or room placement, however, the population vaccination rates in these studies were unknown.^6,7

Many hospital patients have a high risk of severe illness from COVID-19 due to underlying chronic conditions, immunosuppression, or simply because of older age and frailty.⁸ It is important to assess and manage patients’ feelings and expectations about sharing hospital rooms, as failure to address potential concerns can cause anxiety or result in them being reluctant to attend hospital. This study was conducted in February 2022 at the beginning of the first Omicron wave in New Zealand when community case numbers were increasing rapidly across the country (from 202 on 8 February 2022 to 1,160 on 16 February 2022). We aimed to provide a snapshot of patients’ and healthcare professionals' views on the mixing of vaccinated and unvaccinated patients in multi-bed hospital rooms. It is hoped that the information will inform policies for future phases of this and other pandemics.

Methods

Community setting and hospital polices at the time of the study

New Zealand adopted an elimination approach during the first wave of COVID-19 in February 2020. Suppressive strategies such as travel restrictions, mandatory self-isolations for those arriving from overseas, bans on public gathering, border closures and national lockdown resulted in substantial reduction in daily cases, and ultimately in elimination of COVID-19 in New Zealand by May 2020.^9,10 While there were several small outbreaks occurring in other regions afterwards,¹⁰ the Southern District Health Board (DHB) remained free from COVID-19 until 10 February 2022 (the third day of our study), when it confirmed its first case since May 2020. In the general population, 96% of eligible people in New Zealand had had a first dose of a COVID-19 vaccine, 94% had had two doses and 57% had had a booster by 8 February 2022.

By February 2022, it was mandatory for people working in New Zealand’s health and disability sector to be fully vaccinated to reduce their risk of being infected with COVID-19 and passing it to vulnerable people. Other measures included mandatory use of surgical masks for all visitors and patients, N95 masks for staff who have patient contact and physical distancing including limiting the number of people in a room and in a lift.

On 13 February 2022, Dunedin Public Hospital announced that all patients were to undergo a COVID-19 PCR test on admission to hospital. On the same day, new visitor policies included limiting each patient to two registered visitors, only one visitor per day, reduced visiting hours from 2–6pm, door screening and no mask exemptions. There was no requirement for visitors to have vaccination passes.

Patient survey

Inclusion criteria: patients admitted to Dunedin Public Hospital in one of four wards—General Medicine, General Surgery, Orthopaedics, or Respiratory—were invited to participate in a paper-based survey from 8 February 2022 to 16 February 2022, inclusive.

Exclusion criteria: charge nurses were asked to identify patients who were too frail or ill to take part. We also excluded children (and their parents) under 16—because COVID-19 vaccination had only recently been approved for children—patients unable to provide informed consent, where there would be a substantial language barrier (the survey was only available in English), patients under isolation precautions and patient who were absent or unavailable after two attempts to reach them.

Three interviewers (JW, LP, JS)  administered the surveys. Participants were offered help interpreting questions if needed. We collected demographic data, education level, COVID-19 vaccination status, their perception of their own risk of illness from COVID-19, whether they were in a multi-bed or a single-bed room and how many roommates they had. Participants were asked to rate how comfortable they were with sharing a room with patients of different, same and unknown vaccination status on a five-point scale from 1 (very uncomfortable) to 5 (very comfortable). Patients were further asked for their opinions (yes/no/don’t know) on: whether patients of different COVID-19 vaccination status should be located in separate rooms; whether they have the right to know their roommates’ COVID-19 vaccination status; whether their roommates have the right to know their vaccination status; and whether hospital visitors should be required to be fully vaccinated for COVID-19. We also asked for suggestions for the hospital to protect patients against COVID-19 and to address other issues regarding multi-bed hospital rooms (Appendix  1).

Staff interviews

Consultant physicians, medical registrars, registered nurses and charge nurse managers involved in the care of patients on participating wards were invited to participate in a structured face-to-face interview. Interviews were approximately 10 minutes in length and followed a structured, pre-approved template of six questions centred around the staff’s views on the mixing of differing vaccination status patients, the risks involved and the current or possible future policy (Appendix 2).  All interviews were conducted by SL with LN  acting as a scribe.  

The study was approved by the University of Otago Human Ethics Committee. Ngāi Tahu Māori research consultation was undertaken via the University of Otago’s research procedure.

Analyses

Descriptive statistics of patient survey data included percentages, means, 95% confidence intervals (CI) and medians. The qualitative aspect of the patient surveys and staff interviews was analysed by LN and SA  independently using thematic analysis.¹¹

Results

Sixty-three out of 118 eligible patients (53%) agreed to participate. Most identified as NZ European (81%), with 6% identifying as Māori, 2% Cook Island Māori, and 11% other ethnicities. Most were 55 years old and above. Out of the 63 participants, only one was unvaccinated and two preferred not to say. Only three participants (5%) had been previously tested positive for COVID-19. Fifty-four of the 63 participants were in multi-bed hospital rooms (Table 1).

Overall, 37 (59%) participants thought patients of different vaccination status should be in separate rooms, while 17 (27%) opposed the idea, and 9 (14%) were unsure. Most participants felt comfortable sharing a multi-bed hospital room with patients of the same vaccination status as themselves, with a mean of 4.4 (95% CI, 4.1–4.7) and a median of 5.0 (on a 5-point scale where 5 = very comfortable, 1 = very uncomfortable). Participants felt less comfortable sharing a room with patients of different vaccination status and patients of vaccination status unknown to them (mean 2.6 [95% CI, 2.2–3.0], median 2; mean 2.8 [95% CI, 2.4–3.2], median 2; respectively) (Table 2).

Similar proportions of participants thought that they should or should not have the right to know the COVID-19 vaccination status of other patients sharing a room with them (n=28 (45%) and 25 (40%) respectively). Thirty-four participants (55%) said that other patients sharing a room with them should have the right to know their COVID-19 vaccination status; 23 (37%) opposed. Most participants (n=46 [73%]) thought that hospital visitors should be required to be fully vaccinated for COVID-19, whereas 10 (16%) opposed (Table 2).

Participants who opposed (17 out of 63) separating patients based on their vaccination status felt more comfortable sharing a room with all patients regardless of their vaccination status than participants who supported or were unsure about separation (Table 3). Participants who self-identified as having a higher risk of severe illness from COVID-19 supported the separation of patients based on vaccination status more strongly than those without self-identified high risk (not shown). All participants who were unvaccinated or preferred not to say (3 out of 63) chose “no” for the ideas of separating patients based on their vaccination status, having the right to know each other’s vaccination status or making it mandatory for hospital visitors to be fully vaccinated.

Qualitative responses

Table 4 is a summary of patients’ free-text responses on the separation of multi-bed hospital rooms based on vaccination status and suggestions for protecting patients from COVID-19. In particular, most patients who favoured the separation of patients by vaccination status commented on minimising the risk to individuals, however, many also acknowledged the practical limitations around maintaining such separation. Resource limitation was a common argument raised against separation by vaccination status, along with ethical considerations such as patient rights and discrimination. Some patient responses were polarised and highly emotive on both sides. One patient commented on the need to “stop the drama” while another stated that “we need to stop this rot in society”.

Staff interviews

Fifteen staff (of 49 invited to participate) were interviewed. This included six senior medical officers, a registrar, four charge nurse managers, three registered nurses and one director of nursing. A summary of staff attitudes towards the separation of multi-bed rooms by vaccination status is outlined in Table 5.

Protecting the unvaccinated and vulnerable patients and fairness for vaccinated patients were raised by staff in favour of separation. Similar to patient views, practical limitations and ethical issues were some of the arguments against separation. Discrimination and the need for equitable healthcare was a concern raised by staff, particularly regarding ethnic discrepancies:

“There are ethnic groups in NZ with lower vaccination rates, particularly Māori. Even if this wasn’t the intention, it could give the appearance of an ethnicity-based policy. It would be unintended but it would still occur—and we don’t do that in the healthcare system.”

Other arguments raised against separating patients by vaccination status include vaccination status as a poor indicator of true infection and the increased risk of infection outside the hospital generally. Regardless of viewpoint on separating patients, the right to healthcare and/or the health practitioners’ obligation to provide care was universally acknowledged by staff.

A few participants questioned the efficacy of policies and protocols, and a few stated that COVID-19 is a constantly changing situation as new information emerges.

“The current hospital policies seem to change quite quickly, and quite regularly, the response in the first wave was different to the requirements in the Delta wave… And I think that it’s difficult to set firm rules and boundaries because the whole knowledge of various mutations of COVID is such that it’s a fluid situation and you have to adjust accordingly.”

Discussion

To our knowledge, this is the first study to explore hospital patient and staff perspectives on the mixing of patients of different vaccination status in shared hospital rooms either in New Zealand or internationally. We found that more than half the patients were in favour of separating patients by vaccination status and that most patients felt comfortable sharing a multi-bed hospital room with patients of the same vaccination status as themselves.

Patients and staff who favoured the separation of patients into rooms by vaccination status believed that it would help to reduce the risk of COVID-19 transmission. In contrast, patients and staff who opposed separation thought that doing so would provide insignificant benefit, given the potential for transmission between vaccinated and unvaccinated people due to breakthrough infections.

Vaccination reduces the risk of COVID-19 transmission, infection and severity of infection in people of the same household,^12,13 and the transmission rate between roommates and between household members may be comparable.^6,7,14,15 There is little published information on nosocomial transmission in New Zealand, although several hospital outbreaks have occurred with an estimated 30–50% of contacts in multi-bed rooms becoming infected (H McGann, personal communication). This suggests that separating patients by vaccination status may reduce the spread of an outbreak before diagnosis has taken place. A recently published New Zealand paper by Watson et al.¹⁶ found that despite a large number of breakthrough infections among the vaccinated, unvaccinated individuals are 3.3 times more likely to be infected and 20 times more likely to be hospitalised, hence they have a greater risk of bringing COVID-19 into hospital even if they are admitted for other reasons.¹⁶

In terms of the implementation of separate rooms for vaccinated and unvaccinated patients, some patients and most staff did not see it as practically and/or ethically possible and thought that current practices to reduce risk were adequate. One staff member thought that separation by vaccination status would not work unless staff were also compartmentalised, wherein small groups of staff would have no physical connection to other groups. There is evidence that doing this reduces the risk of transmission,¹⁷ however, this may not be practical given the workforce constraints. Other international studies have described patients and staffs’ experiences with social isolation, loneliness and stigma because of physical separation, including having their own room and restricted visitation due to COVID-19 policies.¹⁸ This highlights the balance that needs to be made between theoretical interventions to potentially reduce the risk of infection and the practicalities of running the hospital and looking after patients’ wellbeing.

Some patients and staff appeared to consider being unvaccinated as equivalent to being COVID-positive, even though vaccines are not 100% effective and breakthrough infections can still occur.^16,19 It may be that conceptualising preventive measures designed to reduce spread at a population level (i.e., vaccinating the entire population) and the alternative (not being vaccinated) does not translate well to the perceived risk at an individual level.²⁰

There was no consensus on whether a patient has the right to know their roommates’ vaccination status, reflecting the dilemma of weighing up the right to information that might have direct health consequences on oneself versus the right to health information privacy. If patients had no choice but to disclose their vaccination status in order to be admitted, some may choose to not seek healthcare to keep that information private. Patients have a right to keep their health information private and also have the right to healthcare regardless of vaccination status.

Most patients (73%) thought that visitors should be fully vaccinated. Many argued that visitors are, technically, not essential personnel in providing healthcare; thus, they are not included within the “right to healthcare”. By contrast, some staff members argued that visitors played critical roles in patient care and should not be excluded. Three days after the first Omicron COVID-19 case in Dunedin (13 February 2022), Dunedin Public Hospital introduced new policies limiting patients to two registered visitors per patient with only one visitor per day, reducing visiting hours, screening visitors at the door and not allowing face-mask exemptions. Similar policies are widely practiced in other countries, but their impact on COVID-19 control has been unclear.^21,22 In New Zealand there has been no requirement for hospital visitors to have vaccination passes and introducing such a policy would likely present practical and ethical challenges.

None of the staff we interviewed knew of any ward policies that were in place to reduce the mixing of patients with different vaccination statuses. The main additional measure suggested by the staff was better screening on admission, particularly using more efficient and comprehensive testing. During the conduct of this study (on 13 February 2022), the hospital announced that all patients admitted to wards would undergo a COVID-19 test on admission. This aimed to reduce the risk of transmission by identifying both symptomatic and asymptomatic patients.²³ However, limitations such as false negatives, particularly during the incubation period, and transmission from staff and visitors may still lead to outbreaks in hospitals.²³

Our study provides a snapshot of patient opinions on COVID-19 vaccination status in the middle of the controversy over the government-mandated vaccination in a changing COVID climate and at a time when few people had direct experience of COVID-19 disease. COVID-19 infections have since become widespread and the government mandates for vaccination have been dropped, but transmission of COVID-19 within healthcare settings remains an ongoing concern. At the time of writing, New Zealand is experiencing another uptick of COVID-19 in the community, and it seems likely that we will experience further waves of infection for some time. The likelihood of sharing a hospital room with someone with COVID-19 will reflect the prevalence in the community and we need to better understand the measures that can be taken to minimise nosocomial spread.

Our study, while novel and giving a unique snapshot, had some limitations. Although care was taken to maintain confidentiality of patient’s responses, some patients may have discussed the survey with their roommates, which may have influenced their responses. Many patients were excluded (50%) due to the nature of their illness: most of these were too frail/ill, or were under contact precautions. It is likely that these groups have somewhat different attitudes to those included. Given that 93% of patients had received at least two doses of the COVID-19 vaccine, the results are also unlikely to reflect the views of unvaccinated people. Reflecting the demographic composition of Dunedin, there was limited representation of Māori in our sample, with only 6% of participants identified as Māori compared to 16.7% of the New Zealand population. To recruit staff, we emailed every consultant responsible for the four wards and approached nurses, charge nurses and resident medical officers in-person on the wards opportunistically. A low response rate from consultants to our emails is likely to reflect their very high workload at the time. However, we were able to recruit and interview sufficient numbers in-person to reach data saturation.

Priorities for future research include assessing the risk of transmission of SARS-CoV2 in shared hospital rooms and the extent to which this can be minimised by screening patients on admission. Further exploration around the attitudes about COVID-19 isolation and the feasibility of separation of patients is also required. Since the study was conducted, there have been many changes to government policies around COVID-19, such as the removal of vaccine mandates. Many people now have personal experience of COVID-19 infection. These are likely to have also resulted in changes in public opinion with regard to sharing hospital rooms with unvaccinated people, but similar concerns may arise with other vaccine-preventable infections, such as influenza, that could be transmitted in shared rooms.

Conclusion

In summary, both staff and vaccinated patients would prefer to separate patients by COVID-19 vaccination status but are aware of the practical and ethical problems this would cause. There were mixed views on the actual risks involved in mixing unvaccinated and vaccinated patients among patients and staff members, and a key issue was whether vaccination status gives an accurate prediction of the true risk of COVID-19 transmission. While many patients are concerned about the risk of infection, most staff viewed current precautionary measures as adequate. However, both patients and staff agreed that faster and more efficient screening of patients and visitors would reduce these risks.

View Tables 1–5.

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View Appendices.