I believe that many of our staff and families are hoping this is true. We are now living in the post-pandemic era and have seen the benefits of natural and vaccine immunity with people still acquiring COVID, but for the most part not getting as sick, with most self-managing their illness and often not reporting it, or not even testing. We know that both are transmitted by the aerosolized modality and that new cases occur without an obvious source. The vaccine for both flu and COVID has waning illness prevention protection after about 6 months. The protection of both vaccines from infection in elders is imperfect and may only be in the 40-70% range. Flu has been most prevalent in the winter months in part due to people living in more crowded indoor conditions at that time of the year, but this is not true for COVID. Outbreaks have occurred in the Spring, Summer, and Fall and seem to correlate with the prevalence of a new variant of concern. The mortality this past flu season has also been quite different with COVID having almost 10 times the mortality of influenza with most of the mortality occurring in those aged over 60 or in younger persons who are high-risk for serious illness. 

Last Fall, we were anticipating the triple threat and another significant surge of COVID complications, but fortunately, both threats proved much less than anticipated.  In my county, we have improved from highly prevalent status to low prevalence of COVID.  Our hospital and ICU cases with COVID have also significantly improved.  This good news is tempered by the reality that in the USA we still have about 7,000-8,000 deaths each month attributed to COVID.  Nine out of 10 of those dying are > 60 y/o and some of these are up to date on their COVID vaccine.  

We are now 3 years into the COVID-19 Pandemic. We have lived through unprecedented times where millions of people have become infected with the SARS-CoV-2 virus and, sadly, over 1.1 million people in the USA, and 6.86 million in the world, have died from this infection.  We have found that some of the initial recommendations for prevention of COVID-19 acquisition and transmission have changed. This has fostered some distrust and skepticism in the general public. In my opinion, Public Health experts have been building this COVID-19 prevention plane as they were flying it. In other words, we all have been learning as we go.

At a recent town hall meeting for a local Continuing Care Retirement Community (CCRC), I updated our residents on the state of the COVID pandemic in our community.  Compared to the prior 2 years, we are experiencing much less serious medical illness and the deaths in 2022 were about one-tenth of what we experienced in the prior 2 years.  However, the risk of dying from COVID is still about 10 times higher than that for influenza and nearly 9 in 10 COVID deaths have occurred in those over 65 years of age.   The uptake of the new bivalent booster has been disappointingly slow with only 15.4% of the eligible USA population vaccinated.  As of January 9, this booster uptake in CA has been 22.7%, which is higher in elders, but is still low.  In Sonoma County, of those over 65,  53% are boosted, but this drops to 29% of the 50-64 y/o and further drops to 8-11% for those in the 6-34 y/o age ranges.  

The FDA, CDC, & Western States Scientific Safety Review Workgroup have approved the EAU for the new Pfizer and Moderna mRNA bivalent vaccines.  These vaccines target the COVID-19 spike protein, which has rapidly mutated over the course of the pandemic.  These vaccines target the original Wuhan spike protein (monovalent vaccines) and the Omicron BA.4 & BA.5 subvariants.  BA .5 has proved very contagious and still accounts for over 88% of the infections in California.  Though the numbers of COVID cases, hospitalizations, and deaths have slowly improved since the end of July, the rates are still substantial.  On 9/8/22, a large 250-hospital network study of COVID-19 hospitalizations in the USA from January 2021-April 2022 was published in JAMA IM (https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2796235).  They found the rate of hospitalization was 10.5 times greater for unvaccinated and 2.5 times higher for vaccinated, but not boosted.  We anticipate an even greater benefit of the new bivalent vaccines which better target BA .5.  This vaccine roll-out is well timed to combine with our efforts to provide the usual Flu vaccines before winter arrives.  As of 9/10, over 50 million doses have been delivered to states for distribution. 

Once it dawned on us that a pandemic was underway, those of us involved in geriatric care knew that long-term care facilities were going to be in trouble.  And yes, we knew that the usual racial and socioeconomic disparities in outcomes would appear.  But we didn’t know exactly how much trouble, nor did we know exactly how the disparities would play out.  At least for my county of Alameda, for the pre-vaccination phase of the pandemic, we now have answers.

We are in our fifth COVID surge, and my head is spinning with the rapidly evolving federal, state, and local guidance.  Wouldn’t it be nice to visit a platform that tracks all the guidance in a convenient location?  

During the current Omicron surge, COVID-19 vaccines (primary series and boosters) are an essential way for our communities to stay healthy. We would like to share COVID-19 vaccine resources for long-term care facilities (LTCFs) and your members. 

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.  

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?

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.

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.  

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.  

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.

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:

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.  

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.  

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.  

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.  

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.