When the coronavirus began spreading through a Washington State nursing home in mid-February, ultimately killing 37 people associated with the facility, the outbreak set off alarms among infectious-disease experts, who worried that long-term care facilities for the aged would struggle to deal with the disease. Their warnings proved accurate. In New York State, more than 1,000 residents of nursing homes have been infected by the coronavirus, and 15 percent of deaths in the state have occurred in these facilities. As the virus spreads, facilities in other states, like Connecticut, are reporting similar outbreaks. Last week, the federal Centers for Medicare and Medicaid Services (CMS) called nursing homes “an accelerator” for Covid-19 because of how quickly the virus jumps from resident to resident, and the agency warned that many such homes were still not following basic infection-control procedures.
None of this is surprising. Residents of homes for the aged are the most vulnerable to infectious diseases, and America has never done a good job of protecting them from outbreaks, even of illnesses like the flu, which we have more weapons against than the coronavirus. Every year sees tens of thousands of deaths from infectious diseases without any public demand, for instance, that workers in these facilities be vaccinated. Many homes for the elderly, studies show, don’t practice adequate prevention techniques or meet minimum staffing recommendations. The question is whether the light that the coronavirus outbreak is casting on the problem will bring change.
Like the coronavirus, infectious diseases such as pneumonia and flu create by far the most damage among the elderly. Every year, from 75 percent to 90 percent of all flu deaths occur in those age 65 and older. In the 2017–2018 flu season, nearly 51,000 of the 61,099 total deaths from influenza in America occurred among people in that age category. The death rate is particularly high among those over 75, who form the core population of the 2 million or so nursing-home residents in the U.S. Nearly two-thirds of those residents are 75 or over.
Despite these figures, half of all states don’t require that workers in nursing homes be vaccinated against the flu, according to a CDC survey, even though studies have shown that workers are often the principal means by which infections make their way into a home. One impediment: worker opposition. In 2009, for instance, New York State officials, facing a swine flu epidemic and a bad flu season, decreed that all health-care workers, including nursing aids, be vaccinated, over objections from the 1199 S.E.I.U. United Healthcare union, whose president called the rule “unprecedented.” Several months later, facing lawsuits against the order, New York revoked it, claiming that there was not enough vaccine available.
One result of the lack of mandates is that only about two-thirds of nursing-home workers throughout America get flu shots, with vaccination levels even lower in states without a requirement. Though many of these states advise workers to get shots, voluntary efforts almost invariably fall well below the 80 percent to 90 percent level of vaccinations that experts say would prevent outbreaks, even as studies show that vaccination does reduce infection rates in these facilities.
Many nursing homes also don’t do a good job of training staff in infection prevention, including basic procedures like identifying patients with emerging symptoms and isolating them, wearing protective gear around those infected, and getting the proper anti-viral treatments started. Studies reveal that up to 40 percent of nursing homes receive deficiency citations on their infection-control procedures, including the Washington State facility that was the site of the coronavirus outbreak in Seattle, which now faces up to $600,000 in fines. Though each facility is supposed to have an infection-control staffer, 60 percent of these staffers at homes studied by researchers hadn’t received specialized training, according to a 2018 survey. Staffers at only 3 percent of the facilities were fully certified in controlling infections.
These inadequacies have carried over into the coronavirus epidemic. After federal officials warned nursing homes last month that the virus would likely create outbreaks among residents, the CMS began conducting inspections. The agency found that more than one-third of homes it visited were not following procedures as fundamental as frequent and proper handwashing; one-quarter weren’t using protective gear properly.
Nursing homes have also been less than frank about their preparations. A 2018 study by Kaiser Health of nursing-home payroll records gathered by Medicare found that 70 percent of the facilities had fewer workers on duty than they were reporting to the government. Though the CMS doesn’t set required staffing levels, it makes recommendations, which many homes don’t observe. “The majority of days, nursing home staffing levels are below what the CMS expects,” one author of the Kaiser study said. “That is when quality-of-care problems are going to emerge.”
In the wake of coronavirus’s emergence, the Centers for Disease Control advised nursing homes to initiate strict controls, including restricting outside visitors, examining all residents for early signs of respiratory distress, and isolating where possible those who test positive for Covid-19. The CMS followed up with more instructions, including beginning symptom screenings such as temperature checks for all residents. And the federal government instructed states to make nursing homes a priority for receiving medical supplies. But some of the shortcomings at these facilities have clearly been obstacles to controlling outbreaks. Nursing homes, for instance, complain that they’ve had trouble obtaining protective gear for their workers as shortages have emerged. Part of the problem is that many don’t use this gear during flu season and thus have little of it on hand, even in the midst of a flu season that, apart from coronavirus, may kill as many as 40,000 Americans this year.
The larger question is whether the coronavirus will lead to added measures to protect residents of nursing homes. Some signs of change are emerging. New Jersey has enacted legislation to require nursing-home workers to get annual flu shots—becoming the 25th state with that mandate. The homes themselves are now demanding the protective gear that they once ignored or rarely used—and many are finally understanding the price of failing to train staff in infectious-disease protocols. Let’s hope that the coronavirus outbreak will bring more such changes.