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The nearly 3 million Americans who reside in nursing homes, assisted living centers and other group care communities constitute an almost invisible population.
This week, however, they were selected for high priority access to a most valuable resource: some of the first doses of COVID-19 vaccine available in the United States.
It’s a distinction they will share with the country’s 21 million healthcare workers, thanks to a vote from the Advisory Committee on Immunization Practices, a group of experts that advises the Centers for Disease Control and Prevention.
In some eight months of debate among the 14 members of ACIP, as the advisory group is known, the idea of putting healthcare workers first has never been in doubt. The ability of these doctors, nurses, pharmacists, paramedics, hospital staff, medical technicians and home health aides to report to work is critical to weathering the pandemic.
They are widely hailed as heroes, running into danger while those who can protect themselves do so by staying at home. Their work to care for the sick has led to disproportionate infection rates and serious illnesses among their ranks – although they represent around 6% of the nation’s population, they account for 12% of COVID-19 cases in the United States. United.
This is a totally different profile from that of patients who live in long-term care facilities. Withdrawn from active life, they receive medical care. Indeed, they are so medically fragile that some fear that the vaccine itself will precipitate their demise.
While vaccines for diseases like the flu are a guide, newer COVID-19 vaccines may not be particularly effective in nursing home residents. The aging immune system is notoriously difficult to wake up with vaccines.
None of the first two COVID-19 vaccines likely to obtain emergency use clearance from the Food and Drug Administration – one from pharmaceutical giant Pfizer and the other from a start-up named Moderna – has been studied in the very old, very frail patients who inhabit long-term care facilities. (In clinical trials largely involving thousands of younger, healthier adults, they have been shown to be over 90% effective.)
Yet if states choose to follow ACIP’s advice, this group will get the rare vaccine before teachers, before workers deemed essential to the economy, and before young seniors and those with underlying illnesses.
Why?
Simply put, they have paid for the privilege with their life.
More than 100,000 long-term care residents have died from COVID-19 in the United States and although patients at these facilities represent less than 1% of the United States population, they represent 7% of the number of coronavirus cases in the country and 40% of its COVID -19 deaths.
This death toll is likely to increase in the coming weeks. As of mid-November, more than 16,000 coronavirus infections had been reported in nursing homes and assisted living centers, according to a report by the American Health Care Assn. and the National Center for Assisted Living. Nursing homes are now experiencing the worst outbreak of new cases since the spring, with more than 2,000 residents succumbing to the virus every week, said Mark Parkinson, who heads the combined group.
“The death rate is very different” from that of the general population, said Dr. Helen “Keipp” Talbot of Vanderbilt University, who studies the vaccine’s effectiveness in the elderly. “It’s not a little different. It’s completely different. That’s what pushed these residents ahead of everyone else, ”she said.
In Tuesday’s ACIP 13-1 vote, Talbot was the only one to oppose prioritizing long-term care residents. She objected, she said, to sending a message that the oldest and most vulnerable people should not be an afterthought in the development and testing of vaccines they are likely to experience. need.
“I had to take a bit of a stand,” said Talbot.
“It’s not because I hate grandma – I love grandma!” she added. “But we have to think about this population, plan for it and protect it.”
Virtually the definition of a vulnerable population, people residing in long-term care facilities require basic assistance and skilled medical care to survive. To keep it safe, they are often sequestered in group settings that make social distancing – one of the few protections against coronavirus infection – nearly impossible.
They may seem cut off from the world, but they are far from being protected. Their facilities are staffed with armies of low-wage workers who are among the most likely to fall seriously ill with COVID-19. Black Americans and Latin Americans – the populations in which the disease has disproportionately taken its toll – make up 40% of their ranks.
In 2018, half of nursing assistants – who help residents bathe, feed and take care of themselves – earned less than $ 13.38 an hour. Paid sick days are rare, and many are returning home to crowded, multigenerational living conditions where coronavirus infections have seen intense levels of spread.
The socio-economic circumstances of these workers also mean that they are more likely to suffer from many underlying conditions that increase the risk of severe COVID-19, including asthma, obesity and diabetes.
For medically fragile residents of long-term care facilities, the implications are striking.
“Long-term care facilities are powerless to completely prevent [the coronavirus] to enter due to its asymptomatic and pre-symptomatic spread, ”Parkinson said. As the virus rages through the general population, “our worst fears have come true.”
Residents are suffering the most, although they are clearly not to blame, Talbot said.
“If you are in an establishment and cannot leave, you are not introducing a virus into that establishment,” she said. “It’s only the people who work there who bring these viruses with them – from church, home, restaurants, grocery stores.”
This has made immunization of those working in long-term care facilities a key goal. Not only will it protect a key segment of healthcare workers, but it will also indirectly protect the people they care for.
Doesn’t it make sense to vaccinate residents at the same time, even though data on its safety and effectiveness are scarce?
Several members of the ACIP committee said yes.
“You come in and vaccinate the staff and you have people who can benefit from that,” said Dr. Paul Hunter, a family medicine specialist at the University of Wisconsin. People living in nursing homes and residential care facilities might not have another practical chance to get vaccinated.
“It’s an efficiency” to vaccinate both at the same time, he said.
However, this will result in the obligation to explain to residents, their families and their doctors that vaccines carry considerable uncertainty for the elderly and frail, who have not been included in clinical trials.
The vaccine may not work. On the other hand, it could cause a strong immune response that leaves patients feeling lousy for days.
“We don’t know all of this information and ideally we wouldn’t make recommendations without it, ”said Dr Robert Atmar, infectious disease specialist at Baylor College of Medicine and ACIP Fellow. “But we are not in an ideal situation. We are in the midst of a raging epidemic and many of us have been moved by the suffering we have seen in long term care facilities over the past eight months.
Atmar said he was not so concerned that the vaccine itself would prove dangerous, but that mild reactions from some nursing home residents could lead to risky and unnecessary medical examinations, hospitalizations and treatment.
CDC assured ACIP members that it would write fact sheets to help residents and their caregivers make their decisions. But with so many unknowns, that might not be enough, Talbot said.
If a loved one dies after receiving a vaccine, will families feel responsible? Will they blame the vaccine and refuse to take it themselves?
Additionally, will the inevitable reports of post-vaccination deaths – many of which will be due to unrelated causes – undermine fragile public confidence in the safety of the vaccine, as some experts fear?
With little science to answer the last question, experts said they have little choice but to bring this hard-hit population to the fore and hope the COVID-19 vaccine will help, at least a little. .
“It won’t necessarily be the circuit we want,” said Talbot. “But it will probably be a good, solid baseline shot.”
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