Social Opportunities and COVID-19 Mitigation in LTC

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.  

In addition, the new predominant omicron sub-variants are as contagious as measles and more immune evasive, but fortunately don’t appear more likely to produce serious illness.  The threat to those living in senior living homes is compounded by the known 2-3 days of pre-symptomatic disease when COVID can be spread without them or those around them perceiving the threat.   At the meeting, I stressed that this was a compelling reason for encouraging everyone entering indoor public settings to wear an effective well fitted mask like a KN95 or N95 mask.  

In this CCRC, the community has recently allowed public gatherings of community members without masks and small unmasked vocal performances from the outside the community.   Given the current suspected high prevalence of COVID, should these performances be canceled or attendees and performers mandated to mask?  The potential answer to these questions needs to be balanced with an awareness of the value of social opportunities.  Many seniors are hard of hearing and rely on facial expressions to relate well to others.  In addition, vocal performances through masks compromise facial communication, reduce comprehension of consonants, and adversely impact the rich tones of vocal music.  Considering these options, this community decided to allow performances without masks, but encourage mask use by attendees, but not mandate it.  This decision was made in the context of a community that has had very few cases of COVID over the course of the pandemic and has achieved a high vaccination and booster rate among its residents and staff.  

We can further protect our residents and staff by promoting COVID mitigation messaging to families and potential visitors.  Messaging for those under 45 y/o where the known risk of COVID related serious illness is low, should emphasize the value of protecting the elders in their lives by emphasizing that they could be spreading COVID to their vulnerable loved ones and other frail residents of the facility, in the 2-3 days when they are pre-symptomatic.  Now their main reason for being up to date on the COVID vaccine and bivalent booster would not be to protect themselves, but to allow them to socialize with their elders indoors with much lower risk of exposing them to COVID.  The same rationale could be used for deciding to wear effective masks while indoors in public spaces.  

Another important message for this younger population is the known fact that the vaccines are much more effective in them than in their elders, and the data after 2 years supports their long term safety.  Though the bivalent booster is new, on January 9, a large study from a health plan in Israel reported a 1/5th reduction in the risk of hospitalization from COVID compared to person > 65 y/o who were booster eligible, but hadn’t yet received it (Omicron COVID booster cuts hospitalization in over 65s, Israeli study finds | Reuters ). 

Younger persons are busy with work, family life, and school, so accessing vaccines must be easy and efficient.  In my county, we have a vaccine and testing clinic that efficiently serves walk-in clients and their families.  In addition, these vaccines are available through community physicians/NPs/PAs via patient portal/phone scheduling or community pharmacies via walk-in or the state sponsored scheduling system of [email protected].  In Sonoma County, we are also partnering with the public schools to provide COVID vaccine in the school setting.  

Unfortunately, even with implementation of measures to reduce the risk of acquiring COVID, the widespread prevalence of COVID in our communities means that the development of COVID is still a risk of elder social engagement.  However, we do have proven safe and effective medications that significantly lower the risk of serious illness.  In fact these medicines are so safe and effective, that they are now recommended for all patients over 50 and younger people with known risk factors for becoming seriously ill.  Because COVID early on may seem just like a simple cold, but a week later rapidly progresses to serious illness, experts now recommend early diagnosis and rapid access to these effective medicines.  All 3 of those approved for this purpose are most effective when given early and in fact are only recommended within 5 days of symptom onset for the 2 oral meds (Paxlovid & Molnupiravir) and 7 days for IV Remdesivir.  To date, none of the variants have developed resistance to these meds.  

The most readily available and effective medicine of the three therapeutic agents  is Paxlovid, which unfortunately has many potential drug interactions and is not recommended for those with advanced CKD (eGFR < 30) or advanced liver disease.   Despite these concerns, Paxlovid can still be safely prescribed for most of our elders.  AMDA (The Society for Post-Acute and Long-Term Care Medicine), has developed a helpful toolkit available for free to members and non-members.  It’s called, “Vax and Pax” and is available at this link:

ASPR (Administration for Strategic Preparedness and Response) has also developed targeted messaging for LTC that you may find of value at:  COVID-19 Treatments: Key Messages for Long-Term Care Facilities (

After the first year of the great Flu Pandemic of 1918, the mortality increased in 1919, but for reasons not well understood, significantly improved in 1920 and subsequent years.  I hope that a similar regression occurs with our COVID-19 pandemic.  Speaking of Flu, the vaccines approved for seniors have proven to be a good match for this year’s strains.  It’s not too late to benefit from this vaccine.  While our elders are likely vaccinated, what about their visitors, families, and your staff’s family and friends?  This vaccine is safe, effective, and recommended for everyone > 6 month old.  Early diagnosis is important for our residents with the Flu, since treatments like Tamiflu and Xofluza are effective when given within the first 48 hrs, and early facility mitigation measures for protecting other residents are of paramount importance.  

Until then, we now have good reasons and guidance to properly balance the potential benefits of social opportunities for our elders with the potential threat of this deadly virus.  Please make sure your residents, families, visitors, and staff are aware of the many reasons for being up to date on their COVID vaccine, bivalent booster, and use of effective masks when indoors in public spaces.

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Comments on "Social Opportunities and COVID-19 Mitigation in LTC"

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Ian Light - Monday, January 16, 2023

Rapid Initiation of the antivirals is critical A study in Victoria ,Australia in a Cohort of 32,000 patients in winter 2022 ( June onwards - Southern Hemisphere ) found best benefit for reducing administration to as early as possible within Twenty Four Hours - Benjamin Cowe et Al in the Conversation November 29 2022 and in Nursing Homes Molnupiravir(Lagverio)Is predeployed. There are drug interaction charts such as the National Institute USA Paxlovid Drug Interaction guide in which withholding non essential medications or reducing the dose with observation make it feasible to prescribe Paxlovid . There is also Infusion Remdesivir but dedicated Units need to be set up surely possible . From China a paper in the NEJM compared an oral version of Remdesivir (VV116)with Paxlovid with Non -Inferiority . Zhun Cao et Al NEJM 28 December 2022

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