Rising cases of COVID-19 have driven up hospitalizations across the country — and experts expect higher mortality to follow, particularly in nursing homes, where the risk of adverse outcomes remains high.
Even with available treatments and high vaccination rates, boosters remain a key way to stave off serious cases. Yet uptake lags in many states. In nursing homes, the surprising number of employees and residents who remain without booster shots could have serious consequences as COVID-19 cases continue to spike.
In 2019, nursing homes employed over 1.6 million people. Even with staffing shortages since then, more than one million remaining employees have yet to receive a booster, according to a study in the New England Journal of Medicine. That number is worrying many experts, particularly given that nursing home staff were considered a major source of infection for the very vulnerable residents.
Dr. McGarry, who specializes in long-term care at the University of Rochester, asserted that having a highly-vaccinated staff not only protects employees themselves but also the residents they care for. McGarry's research previously demonstrated this critical link with a full vaccination series.
"Low booster rates among direct care staff will place vulnerable nursing residents at increased risk of COVID infection and, unfortunately, a number of these infections will result in adverse outcomes, including death," Professor Brian McGarry told Salon.
As vaccine efficacy against new variants continues to wane, it would not be unreasonable to assume a similar susceptibility would put geriatric patients at extremely high risk from unboosted staff.
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"While vaccines dramatically lower absolute risk, vaccinated nursing home residents are at the much higher relative risk of hospitalization or death if infected compared to the general population," McGarry explained.
Old age and having multiple chronic conditions are leading risk factors for adverse outcomes from COVID-19, even in the vaccinated. That puts nursing home residents at extreme risks for contracting COVID-19. A recent CDC report did find however that an additional primary series vaccination or a booster dose provided significantly more protection against infection during omicron's peak.
Though the Supreme Court upheld a Centers for Medicare & Medicaid Services (CMS) federal vaccine mandate for healthcare workers, it does not extend to booster shots. In a separate ruling, the Supreme Court struck down a more sweeping Occupational Safety and Health Administration mandate that applied to workers outside of healthcare.
CMS now mandates reports from nursing homes on vaccination and testing among staff. Those reports show that only one in nine employees remain unvaccinated, yet an abysmal 25% have received a booster, reported AARP, calling for support for booster administration.
Following the largest wave of the pandemic this past winter, experts stressed the critical importance of boosters. As the omicron variant spread initially, health officials warned that another surge posed an imminent threat to residents of nursing homes.
"We can't afford another COVID-19 surge in nursing homes," Health and Human Services Secretary Xavier Becerra said in a live stream. "You know that. I know that. Higher numbers of COVID cases would likely once again have a devastating impact on our loved ones ... and we know we just have to work doubly hard to keep them safe."
Early in the pandemic, the mortality rate in the US was well over 1,000 per week in nursing homes alone. In mid-April, for the first time since the pandemic began nursing homes saw fewer than 60 deaths all stemming from complications of a COVID-19 infection.
The highest weekly death toll was recorded over a year and a half earlier. During a single week in mid-December, over 6,000 residents of nursing homes lost their lives to the virus. It was during that spate of deadly outbreaks that vaccinations first became available to older Americans.
COVID-related deaths in nursing homes hit an all-pandemic low when the rate of new cases returned to manageable levels. Shortly after, mitigation strategies began to unravel. When a federal court struck down CDC mask mandates on public transportation and travel hubs, few social distancing and masking mandates remained on a federal level.
Soon thereafter, their loved ones were once again able to visit as restrictions eased. In most nursing homes, visitor restrictions have been relaxed (and rightfully so given the importance of caregivers for quality of life and support for nursing home residents), meaning that there are more chances for COVID to enter the nursing home. Hence, the frequency of staff COVID testing may start to decline during this new phase pandemic.
One out of seven US COVID-19 deaths has been residents in nursing homes. Yet nursing homes house less than 1% of the population.
"With cases increasing, it is important that all people have the protection they need, which is why, today, CDC has also strengthened another booster recommendation. Those 50 and older and those who are 12 and older and immunocompromised should get a second booster dose," Dr. Rochelle P. Walensky stated in a press release.
Just over a week ago, the United States passed another grim milestone of the pandemic: COVID-19 had claimed over one million American lives. In a speech, President Joe Biden responded to the news of one million deaths, encouraging vigilance among Americans. Emphasizing testing, vaccination, and treatments, to "do everything we can to save as many lives as possible," he notably omitted masking and social distancing.
McGarry suggested that boosters are even more urgent as a result of the relaxed social distancing standards. As he explained, if we drop "active" control strategies like masking and distancing, we have to in turn double-down on "passive" approaches, like vaccinations and boosters.
COVID-19 cases began rise steadily recently with the emergence of the BA.2 subvariant of omicron, also known as the "stealth" variant. That variant is incredibly contagious, and overtook its predecessor to constitute the majority of cases.
Now another highly infectious omicron subvariant, BA.2.12.1, is estimated to account for nearly half of all US cases, though "stealth" omicron lingers.
Nursing home residents are already more susceptible to severe COVID-19 symptoms, and live in a space that simply contains more transmission vectors on account of being a long-term care facility. During the course of the pandemic, one out of seven US COVID-19 deaths has been residents in nursing homes. Yet nursing homes house less than 1% of the population.
"I believe mandates may be the only viable policy option to increase uptake," McGarry added, acknowledging that mandated boosters might be more difficult to enforce although he was unable to explain what he called an "entrenched resistance to the booster."
He went on to suggest that a middle-ground approach may suffice. Unboosted staff would simply have to take a more proactive approach to reduce transmission risk.
"But ultimately, the long-term solution is to make nursing homes better places to work ... so that staff are incentivized to stay in their position even in the face of a mandate or that there is a pool of replacement workers willing to fill the slots vacated by individuals unwilling to get boosted," he concluded. "This long-standing issue, which COVID has only magnified, is to make nursing home jobs more attractive to high-quality CNAs, LPNs, and RNs through better pay, benefits, and working conditions. This in turn requires greater financial investment at the state and federal level."
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