Why do patients in a nursing home receive COVID-19 for the first time?


The roughly 3 million Americans living in nursing homes, assisted living, and other group care communities are an almost invisible population.

However, they were highlighted this week for their primary access to the most valuable resource: the first doses of COVID-19 vaccine available in the United States.

Discrimination shared with the country’s 21 million health workers thanks to the vote of the Advisory Committee on Immunization Practices. This panel of experts advises the Federal Centers for Disease Prevention and Control.

During an approximately eight-month discussion among 14 members of ACIP, as the advisory group is known, there was never any doubt about the idea of ​​prioritizing health workers. Surviving a pandemic is an essential condition for these doctors, nurses, pharmacists, paramedics, hospital staff, medical technicians, and home health aids to come to work.

They are widely hailed as heroes who run towards danger, while those who can defend themselves remain at home. Because of their work caring for patients, the rate of infections and serious illnesses is too high – although they make up about 6% of the country’s population, they make up 12% of COVID-19 cases in the United States.

This profile is completely different from the profile of patients living in long-term care facilities. They are withdrawn from active life at the end of medical care. In fact, they are so medically fragile that some fear that the vaccine itself could speed up their deaths.

If vaccines against diseases such as the flu provide guidance, the new COVID-19 recordings may not be particularly effective among nursing home residents. The aging immune system is notoriously difficult to arouse with vaccines.

None of the first two COVID-19 vaccines, one from the pharmaceutical giant Pfizer and the other from a start-up called Moderna, are likely to have been studied by the Food and Drug Administration for emergency use in very elderly, very fragile patients living in long-term care facilities. . (Clinical trials involving mostly younger, healthier adults have shown that they are more than 90% effective.)

Yet, if states choose to follow ACIP’s advice, this group will receive the scarce vaccination in front of teachers, workers deemed essential to the economy, and younger seniors and those with the underlying disease.

Why?

Put simply, they paid for the privilege with their lives.

More than 100,000 residents in long-term care died in the U.S. in COVID-19 -19 deaths.

This number of victims is likely to increase in the coming weeks. By mid-November, more than 16,000 coronavirus infections had been reported in nursing homes and assisted living centers, according to the American Health Care Assn. and the National Center for Assisted Living. Nursing homes are now experiencing the worst outbreak of new cases since spring, with more than 2,000 residents submitting to the virus each week, said Mark Parkinson, the leader of the united group.

“The mortality rate is significantly different from its population,” said Dr. Helen “Keipp” Talbot of Vanderbilt University, who studies the effectiveness of vaccinations in the elderly. – It’s a little different. Completely different. It drove these residents in front of everyone, ”to gain access to scarce doses of vaccine,” he said.

In Tuesday’s 13-1 ACIP vote, Talbot was the only one to object to the ranking of long-term care recipients. He said he disagreed with sending a message that the oldest and most vulnerable should not have after-thoughts in developing and testing vaccines they are likely to need.

“I had to take a little job,” Talbot said.

“Not because I hate Grandma – I love Grandma!” he added. “But we need to think about this population, plan and protect them.”

In practice, the definition of a vulnerable population means that people living in long-term care facilities need basic help and skilled medical care just to live. To ensure this, they are often segregated into groups that make it almost impossible to stay socially apart – one of the few defenses against coronavirus infection.

They may seem closed to the world, but they are by no means protected. Their facilities consist of an army of low-paid workers who are most likely to become seriously ill in COVID-19. Black and Latin American Americans — the populations in which the disease caused disproportionate damage — make up 40% of their ranks.

In 2018, half of the nursing assistants — who help residents bathe, feed, and take care of themselves — earned less than $ 13.38 an hour. Paid patient days are a rarity, and many go home to crowded, multi-generational living conditions where coronavirus infections have shown an intense spread.

The socio-economic conditions of these workers also mean that they are more likely to suffer from a number of underlying diseases that increase the risk of severe COVID-19, including asthma, obesity, and diabetes.

For medically fragile residents of long-term care facilities, the consequences are obvious.

“Long-term care facilities are powerless for complete prevention [the coronavirus] it cannot enter because of its asymptomatic and pre-symptomatic spread, ”Parkinson said. As the virus spreads among the general population, “our worst fears have come true”.

Residents suffer the most, although obviously they are not to blame, Talbot said.

“If you’re in a facility and can’t leave, you won’t bring a virus into the facility,” he said. “Only the people who work there bring these viruses with them – from church, home, restaurants, grocery stores.”

This has made vaccination key to those who employ long-term care facilities. It not only protects a key segment of healthcare workers, but also indirectly protects the people they care for.

Does it not make sense to vaccinate residents at the same time, even if data on safety and efficacy are scarce?

Several members of the ACIP committee said he thought this was the case.

“You come over and vaccinate the staff, and you have people who can benefit,” said Dr. Paul Hunter, a family physician at the University of Wisconsin. Recipients of nursing homes and residential care may not receive another adequate opportunity for vaccination.

“Efficiency” is to vaccinate both at the same time, he said.

However, in doing so, it has a duty to explain to residents, family members, and physicians that vaccinations present significant uncertainty to elderly and fragile people who have not participated in clinical trials.

The vaccine may not work. On the other hand, it can elicit a strong immune response that is felt by patients for days.

We don’t know all that information, and ideally we wouldn’t make recommendations without it, ”said Dr. Robert Atmar, a specialist in infectious diseases at Baylor College of Medicine and a member of ACIP. – But we’re not in ideal conditions. We are in the midst of a raging epidemic, and many of us have been affected by the suffering we have experienced in long-term care facilities over the past eight months. “

Atmar says he is not so worried that the vaccination itself is unsafe, but some mild residents in the nursing home need risky and unnecessary medical work, hospital care and treatment due to a mild reaction.

The CDC has assured ACIP members that it will produce briefings to help residents and their carers make their decisions. But with so many unknowns, that may not be enough, ”Talbot said.

If a loved one dies after vaccination, do families feel responsible? Are they blaming the vaccine and are they unwilling to take it themselves?

Furthermore, will the inevitable reports of post-vaccination deaths, many of which occur for independent reasons, undermine the public’s volatile confidence in the safety of the vaccine, as some experts fear?

With little science to answer the last question, experts have said they have no choice but to put this severely affected population at the top of the line and hope the COVID-19 vaccine will help at least a little bit.

“We don’t necessarily want a home race,” Talbot said. – But it will probably be a good solid basic success.