When coronavirus cases began to spike again, experts outlined the worst-case scenario: that those spikes, initially concentrated among younger people who were more cavalier once businesses reopened, would eventually migrate to older people — particularly long-term care facilities, where so many seniors have already died from Covid-19.
And now, according to a new data analysis from the Kaiser Family Foundation, it seems those fears are being realized. The question is how bad it will get.
Over a two-week period from late June to July 10, in 23 states that KFF characterized as “hot spots,” the number of cases in long-term care facilities increased by 18 percent. That was lower than the overall increase in cases over the same period in those states, which was 49 percent, but it was still substantially higher than the increase in long-term care cases in the not-hot spot states (about 4 percent; overall cases in those states rose by 11 percent).
That disparity strongly suggests the more dramatic increase in long-term care cases in the hot-spot states is the result of broader community spread. It also indicates that the precautions nursing homes are taking to keep the virus out can only do so much good if the coronavirus is spreading rapidly in the outside world.
Texas and Florida, for example, saw the largest increases in overall cases during the time period studied — and they experienced the biggest spikes in long-term care cases. Overall cases in both states have doubled; infections in nursing homes jumped by 50 percent.
“These increases are particularly troubling given that they have happened amidst the strict measures that facilities have put in place,” Priya Chidambaram, the policy analyst at KFF who wrote the analysis, told me.
You could be tempted to take heart that the number of cases among long-term care patients has not increased as much as cases for the general population in US hot spots. But considering how much more adverse their outcomes are likely to be, that is actually little solace.
Long-term care patients account for less than 4 percent of all confirmed US Covid-19 cases, but more than 25 percent of the nearly 150,000 deaths. The disease is extremely deadly for older people: more than 10 percent of people older than 80 who contracted the coronavirus in Spain, Italy, and South Korea have died. According to the New York Times, the overall US case fatality rate is about 4 percent, but in nursing homes it is closer to 20 percent.
The same trends are playing out in the states currently enduring surges. Chidambaram told me that long-term care deaths in the new hot spots had increased at six times the rate of the states with more contained spread over a recent two-week period. In Texas, deaths in nursing homes leapt by more than 60 percent in that time; Florida also saw a 20 percent increase.
“We are more likely to see severe illness and death among those in long-term care facilities, so any rise in cases is concerning,” she said.
As I covered previously, the US had set itself up for failure in containing a pandemic within long-term care settings. For too long, those facilities have been poorly funded and they had not been adequately prepared for a major infectious disease outbreak. Early shortages in providing adequate Covid-19 testing for patients and protective gear for staff compounded the preexisting problems.
But the US is now months into the pandemic and this new data shows the country hasn’t been able to fully insulate nursing homes and assisted-living facilities when the virus is spreading in the broader community. Long-term care facilities have taken precautions — mandated testing, restrictions on visitors, isolating sick residents — but it still hasn’t been enough to suppress the virus’s spread.
“There is so far not much evidence that we know how to shield the most vulnerable when there is widespread community transmission,” Marc Lipsitch, a Harvard epidemiologist, told me recently.
And nursing homes are still enduring shortages in staffing or protective equipment or both; about 1 in 3 facilities have reported those problems, per KFF. Lags and gaps in reporting make it difficult to ascertain the exact toll of the virus on long-term care workers, but even a cursory attempt to reconcile the federal data on residents specifically with the Times’s count of all cases and deaths in nursing homes, including workers, suggests tens of thousands of workers have gotten sick and hundreds if not thousands of them have died in the pandemic.
So mitigation measures focused on nursing homes can’t totally prevent the coronavirus from finding its ways to vulnerable populations. Instead, the best way to protect nursing home residents and other older people is to contain the virus altogether. Several experts have pointed out to me that the countries that have seen the best results in long-term care settings are the ones that have, on the whole, kept their outbreaks under control.
As William Hanage at Harvard put it to me, both Massachusetts and Norway have seen about 60 percent of their coronavirus deaths occur in nursing homes. But for Massachusetts, that amounts to nearly 5,000 deaths, while in Norway, it is less than 200.
“The best way to keep these people safe is to keep community transmission low,” he said.
Instead, the recent spikes have led to record highs in new daily cases. Hospitalizations matched their spring peak. Cases have started to plateau in the past few days, but they aren’t dropping yet.
If the goal is to suppress spread overall to protect the elderly, as experts say it should be, then the US still has a long way to go.
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