In line for vaccination, and not getting younger

Ruth Ann Platt, watching the news on television about effective vaccines for the coronavirus, couldn’t wait for them to reach her nursing home in Gainesville, Georgia. “I thought it was a great thing from the get-go,” she said.

When Platt, 88, moved into New Horizons Lanier Park last year after surgery for a fractured femur, the facility had already instituted harsh restrictions to contain COVID-19 outbreaks. “I’ve lived in this room for seven months,” she said.

She has yet to share a meal with another resident, attend a concert or take an art class. The hair salon has remained closed, she said, so “pretty soon I’ll be Rapunzel.” She is tiring of video chats as a substitute for visits with her children, grandchildren and eight great-grandchildren.

Happily, she received her second dose of the Moderna vaccine last month. New Horizons, part of the nonprofit Northeast Georgia Health System, opted out of a federal partnership that relies on CVS and Walgreens to serve long-term-care facilities. Using its own pharmacy and nurses, it began vaccinating residents quickly, starting Dec 29.

Now, Platt said, “I would love to find someone who plays a good game of pinochle.”

The report card for vaccination in long-term-care facilities, whose residents supposedly stood at the front of the line, shows a mixed performance.

Nationally, almost 3.4 million long-term-care residents and staff members have received at least one shot, the Centres for Disease Control and Prevention reported on Thursday; close to 800,000 had gotten two.

By mid-January, Medicare data showed that cases in long-term-care facilities had dropped by almost 46% compared with four weeks earlier, reflecting the decline in cases across the country but probably also the impact of vaccination.

But experts and advocates, noting that an estimated 5 million people live or work in long-term care, have expressed intense frustration at the slow initial rollout. “There’s been nothing warp speed about long-term care,” said David Grabowski, a health policy researcher at Harvard Medical School.

They also worry about the even more sluggish rate at assisted-living facilities and about workers who are suspicious of vaccination.

Last fall, the Trump administration contracted with the two big pharmacy chains, which agreed to hold three clinics at each facility: first dose, second dose and one to catch any stragglers missed earlier.

The pace of vaccination has picked up substantially. Walgreens increased the number of doses it was administering, from 165,000 in December to 1.3 million last month. It has completed the first doses at all 5,529 of the nursing homes it contracted with and expects to deliver the second doses by Feb. 25 and to complete third visits by mid- to late March.

Similarly, CVS, which has the larger program, has delivered first doses to all of the 7,822 nursing homes it is serving and about 77% of the second doses.

Company executives emphasised that while the Centres for Disease Control and Prevention prioritised long-term care for vaccination, individual states determined when programmes began.

“We were actually planning for a national rollout on the same date,” said Chris Cox, senior vice president for pharmacy business at CVS. “We were ready to go.” But while nearly all states activated nursing home clinics on Dec 21 or 28, most didn’t launch assisted living clinics until January, often weeks later.

The virus didn’t wait. Infections in long-term care reached a peak in December, according to a Kaiser Family Foundation analysis; so did deaths, in many states. Although long-term-care residents and staff members account for just 5% of the nation’s COVID-19 cases, they represent 37% of the deaths.

With a swifter response, “we could have had more nursing home residents vaccinated more effectively four to six weeks earlier,” said Dr Michael Wasserman, a geriatrician and past president of the California Association of Long Term Care Medicine. “That’s a lot of deaths that could have been prevented.”

Future business students may scrutinise this plan for years. “This was never going to be easy, with 30,000-plus facilities and millions of residents and staff,” Grabowski said. “States and the federal government were happy to push this over to the private sector.”

Early on, facility administrators grappled with cumbersome consent forms, a problem that has since been resolved. CVS and Walgreens executives also report having to contact some facilities multiple times simply to schedule clinics.

Administrators, for their part, questioned the three-visit plan. How would these clinics reach staff members who worked night and weekend shifts? Or newly admitted residents, those returning from hospitals and those who were discharged after only one dose? The CDC is reportedly working on a transition plan.

Moreover, although the chains post updated numbers daily, “we don’t have the level of information we’d like, even now,” said Tricia Neuman, executive director of the Program on Medicare Policy at Kaiser Family Foundation. The aggregate numbers don’t show which facilities the companies visited or the proportions of residents and staff members they vaccinated.

Residents have responded enthusiastically. The CDC has estimated that during the programme’s first month, in nursing homes with clinics, a median 77.8% of residents received their first doses.

“People who live in nursing homes would do just about anything to reconnect with the outside world and the people they love,” said Dr Kathleen Unroe, a geriatrician at the Indiana University School of Medicine who also practices at Northwest Manor, a nursing home in Indianapolis.

One of her patients initially had doubts. “I didn’t want to be a guinea pig,” said Norma Ware, 86. “I’m not crazy about shots, anyway.” But after conversations with her family and “a very friendly nurse,” she received both doses and became a believer.

The bigger problem: a reluctant staff. The CDC reported that at nursing homes with clinics, only a median 37.5% of staff members were vaccinated in the first month.

Other health care workers have also shown hesitance. But in nursing homes, particularly, many workers are women of colour, familiar with longstanding inequities in health care and mistrustful of the medical establishment.

“They were poorly paid and overworked before the pandemic,” Grabowski said, noting that the workers had also faced shortages of personal protective equipment and adding: “They didn’t get paid sick leave or hazard pay. So now we’re saying, ‘You need to get vaccinated.’ I’m not surprised that many are saying, ‘Wait a minute, why?’”

Yet long-term-care workers are vulnerable to COVID-19; they can also transmit the virus as they enter and leave facilities and work second jobs to make ends meet.

At the two New Horizons homes in Gainesville, the medical director, Dr Swati Gaur, has held six staff town halls, in person or online, including one at 2 am for the night shift, and offered rewards like free meals. About half of the workers have been vaccinated, Gaur said.

“As their colleagues get vaccinated, their friends and peers and co-workers, those numbers will go up,” Wasserman predicted.

The lagging pace of vaccination in assisted-living facilities, which have also experienced lethal outbreaks, has generated anxiety, too. In some states, only about half of residents have received even a first dose.

Still, by some point in March the majority of long-term-care residents and many staff members are likely to have the protection of vaccines, either Pfizer or Moderna. Then what?

For residents, the top priority is to be able to see — and hug — their families. Geriatricians fear that, for residents, the risks from extended social isolation rival those from the coronavirus.

“We absolutely need to see restrictions loosened up,” said Robyn Grant, director of public policy and advocacy at the National Consumer Voice, which promotes quality in long-term care. “Residents have been suffering. This can’t continue.”

Both Medicare and the CDC are said to be preparing guidance on how and when to resume family visits. Vaccinated residents could also regain contact with one another, gradually returning to communal meals and activities. “The goal is to get these residents out of their rooms,” Gaur said.

Platt offered some advice that could hasten that day. “This is no time for fear,” she counselled fellow residents. “Get your shot. Just get your shot and go on with your life.”

© 2021 New York Times News Service