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The Delta Variant Surge and the New COVID-19 Vaccine Mandate

On July 30, the MMWR (Morbidity and Mortality Weekly Report) released an early report (A) on a series of BT (breakthrough) COVID infections in fully vaccinated persons.  These cases occurred at large public summer gatherings on Cape Cod, Massachusetts.  The Delta variant was sequenced in 89% of the cases that were sequenced.  Of the 469 cases linked to these events, 74% were BT cases.  Real-time PCR cycle times (Ct) of 127 fully vaccinated persons were similar to those of 82 unvaccinated persons, suggesting the high viral load in the nose was similar and meant that fully vaccinated persons can not only acquire the Delta variant, but also can transmit it to others.  Recognizing this reality, the CDC has now again recommended universal masking in indoor public places.  

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Is Your Community COVID Safe?

I am part of Sonoma County’s Public Health COVID-19 learning collaborative in partnership with providers in the PA/LCT (Post Acute and Long Term Care).  We have achieved a high vaccination rate for those living in our facilities, but still have vaccine holdouts in about 10-25% of our staff.  With our state doing away with the restrictive tiers this month, the public can again go into most indoor establishments without a mask, if they are fully vaccinated.  With the increasing prevalence of Delta COVID variant (appears to be twice as transmissible as the original SARS-CoV2), is it safe for your unvaccinated staff, family, and friends to follow the new CDC guidance for public gatherings?

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Setting Expectations for Unvaccinated Healthcare Personnel

On May 28, the CDC updated its guidance for fully vaccinated people in non-healthcare settings.  While this is good news for healthy independent living seniors and for our staff and their families, this guidance assumes that the prevalence of COVID in your communities is low and that people with compromised immune systems are continuing to minimize their risk of COVID exposure.  The high risk settings remain indoors with poor ventilation and large gatherings of people some of whom may not be vaccinated.  Indoor activities that increase COVID transmission risk include close gatherings with:  singing, shouting, and aerobic exercise.  

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Hospice in the Year of COVID-19

Every part of medicine has seen disruption in this past year and we have all had change forced upon us. In hospice we have struggled with our patients dying alone, the family frustrations of not being able to see their loved ones at end of life which is complicating their grief process. Many of our team members have been very removed from their ability to reach patients and this has added to the Hospice Team’s stress.

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Are Our COVID-19 Vaccines Safe and Effective?

Yesterday, the CDC’s HAN (Health Alert Network) issued a detailed report regarding their recommendation to pause administration of the Janssen (J&J) vaccine (see link to this report).  The CDC has now received VAERS reports from 6 women ages 18-48 of serious clotting events after the administration of 6.85 million doses of this vaccine (as of 4/12/21).  These events appear to have been triggered by the development of platelet-activating antibodies against platelet factor 4 (PF4), which is also known as heparin-PF4 antibody.  This may trigger Vaccine-induced Immune Thrombotic Thrombocytopenia (VITTP) which can have serious CNS consequences (1 death so far).  This association is quite rare at ~ 1 case per million vaccinations.  A similar problem has been seen with the AstraZeneca vaccine, which is also a viral vector vaccine (AD26), but hasn’t been seen in the USA or internationally with the Pfizer or Moderna mRNA vaccines.  The key issue for the CDC and ACIP at this point, is the possible under-reporting of this association.  Because these events occurred 6-13 days after vaccination, the development of this rare problem may not have been linked to the vaccine.  Hopefully this HAN report will bring in more VAERS reports to allow the CDC to provide more precise information on the real risk of this event in persons receiving the Janssen vaccine.  To put this preliminary risk in perspective, the known risk of “unvaccinated persons” aged 18-48 dying of SARS-CoV2 is 125/million, which is a vastly greater than the risk of acquiring (much less of dying) of VITTP.  

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Mandating COVID-19 Vaccination

With the remarkable efficacy of the mRNA vaccines and the newly available one shot, standard refrigeration Janssen (Johnson and Johnson) vaccine, many in long-term care are wondering if healthcare personnel (HCP) should be mandated to receive vaccines.

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Family Motivates Vaccine Acceptance

San Diego’s nursing home residents were early recipients of the coronavirus vaccine. In recent weeks, most nursing home seniors and staff eagerly lined up to be vaccinated at their facility by either CVS or Walgreens. Nursing home staff members also shared with me that some people felt hesitant about receiving the vaccine.

The Population Health team uses motivational interviewing skills that incorporate certain words, phrases, and motivators to engage and encourage patients to complete all needed care and immunizations. Recently the Public Health Communication Collaborative shared a national poll entitled “The Language of Vaccine Acceptance." The poll identifies the language most effective to improve confidence in COVID-19 vaccines.

Family is by far the most powerful motivator word for vaccine acceptance. Significantly, more Americans said they would be more willing to take the vaccine “for my family" as opposed to “for my country" or “for the economy." The wording and reasons demonstrated to be most convincing were:



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Building Vaccine Confidence

When COVID-19 exploded last March, my community went to work attempting to keep COVID out of our facilities.  We developed county-wide virtual learning collaboratives for Assisted Living (AL) communities and for SNFs, which met on a weekly basis.  By the end of June, we had done well with no outbreaks and only 4 deaths in the county.  Unfortunately, last summer’s surge in COVID prevalence shattered the myth that we had done enough to contain it.  Like the rest of our state, we pivoted to follow guidance focused more on infection control and early recognition of outbreaks.  By the end of October, we seemed to be back in the driver’s seat with much better facility COVID metrics.  However, with the winter surge, we are stretched thin on staff, resources, and again wondering when the bad news will end.  In my county, we have now have had 196 deaths, and 70% of them have occurred in senior congregate living facilities.  

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Using Monoclonal Antibodies in LTC

The FDA has given EUA (Emergency Use Authorization) for bamlanivimab (Lilly) or the “cocktail” of casirivimab and imdevimab IV infusions for mild to moderate COVID-19 patients.  These monoclonal antibodies block the binding of the spike protein to the ACE2 receptor on the human cell, which blocks viral attachment.  If given early (within 10 days of symptom onset), both medicines have been shown in high-risk adults to reduce the viral load and risk of progression to severe COVID-19, and reduce the necessity for ED visits and hospitalization.  However, they didn’t help those already hospitalized and outcomes were worse in those receiving high-flow oxygen or mechanical ventilation.  Experts suspect that infusions given within the first 3 days of symptoms will be more effective than when given later.  This is similar to what we have experienced with the use of oseltamivir (Tamiflu) in Influenza or antivirals with shingles.  

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COVID-19 Vaccines are Arriving!

Since the SARS CoV-2 virus arrived in the USA last winter, our lives have been disrupted in many ways.  We are currently in a Winter Surge that has locked down most of the state.  The latest statistics on COVID activity show a doubling or tripling of cases in most of California in the month of December, which greatly increases the risk of outbreaks in our post-acute and long-term care settings.  As of 12/10, the USA had 15.6 million confirmed cases and 294,000 deaths.  Though only 6% of the cases have been in post-acute and long-term care (PALTC), including skilled nursing facilities (SNFs) and assisted living communities (AL), our residents have had a hugely disproportionate 34% of the deaths.  As of Friday, December 11, over 100,000 persons with COVID in the USA were hospitalized and 21,000 were in ICU beds. In California, we had 33.500 new cases reported over the preceding day.  

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Local Interventions to Address Workforce Shortage

Prior to the pandemic, most of the SNFs in Sonoma County had applied for waivers, because they weren’t able to staff CNAs at the required 2.4 FTE state standard.  I heard one administrator comment that the website “Indeed.com” had become a main source for attracting CNAs from other SNFs.  In our area, we do have a training program for CNAs through partnerships of facilities with the Red Cross and the local community college, but the number of CNAs attracted to this track has been small.  Since the COVID pandemic, our CNA shortage has been aggravated by concern for personal safety, complicated sick leave policies, inconsistent work hours, and the realization that those working in multiple facilities had a much higher risk of transmitting COVID.  

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To Mask or Not to Mask: A Matter of Opinion

On October 19, 2020, an article in the Wall Street Journal was written observing that some governors in States with surges of COVID are still insisting that masking in public settings should be a personal decision.  This conflicts with the public health guidance of CDC, CDPH, and our Governor, but is still an issue in the public domain in our state where it’s common to observe people in public without a face mask, or wearing the mask under the nose or mouth.  This may not only increase the risk of our health care providers (HCP) acquiring COVID, but data are emerging to suggest that those who acquire COVID while not wearing a mask have a greater dose exposure to COVID, and are likely to become sicker.  

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Call for Non-Inferiority Test of Abbott Labs’ POC (Point of Care) Ag BinaxNOW

As a retired internist and gerontologist, I have closely followed our government’s efforts to help us identify HCP (Health Care Personnel) with SARS-CoV-2 with the goal of reducing the risk of its transmission to residents in our homes.   Early on, we had significant difficulties obtaining the materials for molecular (RT-PCR) testing and later had difficulties obtaining the results within the desired 48-hour TAT (Turn Around Time).  However, in the past several months many facilities in our state have been able to obtain at least this TAT on their mandatory weekly screening of their HCP.

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Advance Care Planning & Palliative Care Important During Pandemic: CDPH

On September 22, 2020, the California Department of Public Health posted this all-facilities letter (AFL 20-73), available at https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/AFL-20-78.aspx.  This letter provides guidance to nursing homes about the importance of person-centered advance care planning, including ensuring that current treatment preferences in light of COVID-19 are reflected in up-to-date treatment orders.  

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Influenza Immunization During the COVID Pandemic

This year, we must improve our vaccination program and IPC (Infection Prevention and Control) for influenza prevention.  In recognition of this necessity, CALTCM provided a free webinar on this subject on September 21, the slide handout and recording are available on CALTCM's COVID-19 Webinar Series webpage.  In that webinar, Dr. Lily Horng, CDPH Public Health Medical Officer, noted that the CDC recommends that persons with COVID should not receive the influenza vaccination until they are out of quarantine (10 days from diagnosis and 24 hrs afebrile), so as to reduce the transmission risk to HCP and other residents.  This statement can be found in the August 21 CDC Influenza Vaccination Guidance for Professionals.  If available, our seniors should receive the enhanced vaccines, which have been shown to be more effective and durable.  Immunization should start now so that our seniors and HCP are immunized prior to onset of influenza.  You should know that San Francisco has already had cases of influenza A.  The above CDC web site has a link to current influenza activity.  My county is considering an order for mandatory vaccination of all HCP unless there is an identified contraindication.  We now know that the masking rules at work do not prevent employees who have refused a flu shot from acquiring COVID outside of the facility and then spreading it within our facilities.  On a recent AMDA podcast, Dr. Barbara Resnick shared great ways to encourage your residents, families and HCP to receive flu shots.  She and AMDA were parts of work groups which created four helpful one-page fact sheets that will enhance your flu immunization program.  Please go to this free AMDA ON-THE-GO podcast where you can hear this superb educator and also download these helpful fact sheets.  

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Are California Nursing Homes “Death Traps”?

In Sonoma County since the surge of COVID-19 cases in late June, our senior congregate living homes have consistently had about 82% of the fatalities in our county.  This fact is consistently reported in our media on a weekly basis.  Early on in this outbreak, the term “die offs” was commonly used in facilities in recognition of how quickly some of our residents died after onset of COVID.  As in many other areas in our country, the initial bad outcomes were associated with the lack of PPE and timely testing, as well as staff shortages, and the need to learn and practice optimal IPC (Infection Prevention and Control).   However, with the in-facility assistance of specialists from CDPH HAI (Health Associated Infection) program, HSAG QIO (Health Services Advisory Group), and our public health department, most of our facilities have extinguished their initial outbreaks and have minimized the impact of new cases.  

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Important CDPH AFL of Sept 12 that Updates COVID Testing/Response Guidelines

The 9 page (AFL-20-53 ) update should be studied by management in the SNF and hospital setting since it sets expectations for testing during care transitions, dialysis care, and outbreaks.  In addition, it creates a new expectation that all HCP will be tested weekly, even when in surveillance mode.  The guidance allows for routine use of Antigen testing rather than exclusive use of RT-PCR testing.  This should allow facilities to have immediate test results.  The tracking and reporting requirements for testing results in symptomatic and asymptomatic persons are also addressed.  

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#CALTCMProud: CALTCM President Report

On March 9, CALTCM produced our first webinar on COVID-19.  On August 31st we produced our 21stwebinar.  It truly has taken a village of volunteers.  Some of the webinars attracted a thousand-plus attendees.  Over 200 people participated in our most recent webinar, which is a remarkable achievement in view of the abundance of information that is available online.

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Two High School Sisters Put Feet to Compassion

Please click on the link to the ABC news video and report on the letter writing project that these sisters operationalized not only for their loved one, but also for those who need loving through pandemic spawned isolation.  Then click on their web site and take action.

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Hope for the COVID Pandemic From the SPRINT Study

July has been a discouraging time for the SNF community in Sonoma County.  Like the rest of California, we have experienced a surge of COVID-19 cases.  We now have had COVID resident cases in 10 or our 20 SNFs and have experienced a “die-off” with 30 deaths in July.  Our county experienced a 5-fold increase in deaths in July, and 67% of those deaths were in the SNF setting.  16% were in RCFE settings, including assisted living communities and dedicated dementia or “memory care” facilities, for a total of 83% of the deaths occurring in senior congregate living settings.

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