Is Massachusetts ready for a second wave of COVID-19?

Cases are on the rise and the weather is starting to cool, which could signal a second wave of infections.David L. Ryan/Globe Staff

The number of confirmed coronavirus cases in Massachusetts climbed by 708 on Thursday, the highest daily number since May. Boston recently entered the “red zone" on the state’s coronavirus map, indicating a higher rate of infection. Hospitalizations have increased.

It all signals a possible second surge in the fall and winter, as cooler weather drives people indoors. Is Massachusetts ready? How well are lessons from the spring being applied?

In one high-profile area, college officials have imposed testing guidelines on students and faculty and cracked down on parties. And Mayor Martin J. Walsh has warned students to behave responsibly.

Against that backdrop, the Globe took a look at plans for protecting four of the most vulnerable populations — nursing home residents, essential workers, homeless people, and inmates. We found high awareness of the challenges, with officials pledging to protect the vulnerable. But in some cases advocates found efforts lacking.

Resident George Brackett, 77, had his temperature checked by LPN Stephanie Dupervil in his room at Rogerson House in Boston.Craig F. Walker/Globe Staff/The Boston Globe

Nursing homes

Two-thirds of the people who have died of COVID-19 in Massachusetts were residents of nursing homes. And as of Sept. 20, the state’s nursing homes still had the highest death rate in the nation and the second-highest COVID-19 infection rate, according to federal data.

No one wants to see a repeat of what happened at the Holyoke Soldiers' Home, where 76 veterans died in what were described as crowded, “deplorable” conditions.

Since then, federal and state regulators have stepped up their game with millions of dollars and new rules to control infections, improve testing, and bolster staffing.

But advocates for nursing home residents say the regulations aren’t stringent enough and question whether the state’s health department, which has a long history of weak enforcement, will aggressively monitor facilities.

“We really have to hold our breath that they did learn their lesson,” said Arlene Germain, policy director of Massachusetts Advocates for Nursing Home Reform.

In particular, advocates say, the state’s new rules for higher staffing levels give facilities too much wiggle room to circumvent those requirements, and fail to explicitly require an infection control expert at each facility. It’s also unclear how the state will ensure the new money is being spent as intended.

The nursing homes' trade group asserts the new measures will make a difference. “With guidance and financial support from federal and state government, nursing homes are much better prepared to contain and prevent future COVID outbreaks,” Tara Gregorio, president of Massachusetts Senior Care Association, said in a statement. “While staffing shortages persist, nursing facilities are actively recruiting . . . and [certified nursing assistants] and other training programs are resuming in the hopes of increasing the labor pool and the skills of our frontline staff.”

The head of the union that represents thousands of nursing home workers is also more optimistic the changes will better protect residents. Tim Foley, executive vice president of 1199SEIU United Healthcare Workers East, said the rules contain “the right elements.”

“We will make sure it’s not just words on paper,” Foley said.

The Department of Public Health said that it has already conducted hundreds of infection control surveys and other inspections and that the new rules hold nursing homes “to higher standards of care and infection control.” The state is also providing funding for nursing homes that set up spaces to isolate COVID-19 patients.

An inmate wearing protective gloves wiped down a general population room door after it was sanitized at the Worcester County House Of Corrections in West Boylston.David L. Ryan/Globe Staff

Essential workers

The lowest-paid workers have shouldered many of the highest-risk jobs during the pandemic, stocking grocery stores, keeping trains and buses running, cleaning buildings, and caring for the sick, elderly, and dying. State data indicate thousands of them have been infected.

Safety standards issued in the spring require employers to provide worker training on safe distancing and hygiene, adequate space, a process for regular disinfection, and a plan for handling sick employees. But it exempted a wide swath of industries and workers including those in grocery stores, child care, prisons, homeless shelters, and health care facilities, among others.

Advocates say the rules don’t address the primary way coronavirus is believed to be transmitted — through tiny droplets in the air.

Without directives to improve ventilation systems and provide face coverings for employees, essential workers remain vulnerable to a second surge, said Jodi Sugerman-Brozan, executive director of the Massachusetts Coalition for Occupational Safety & Health.

The rules also allow employers to “self-certify” that they’re meeting standards, “and the only way they get inspected is if someone complains,” Sugerman-Brozan said.

The state attorney general’s office created a hot line for workers to file anonymous complaints and received more than 1,700 about coronavirus-related concerns at work sites from mid-May until late summer. Then, the Department of Labor Standards launched its own online complaint form, but it requires workers to identify themselves — a likely deterrent for those who fear retaliation, Sugerman-Brozan said.

The Baker administration said that its multi-agency team works closely with communities hit hardest by the virus and meets with local leaders to scrutinize residential and business activities that might be contributing to rising infections.

Officer Josh DeLisle, left, of the Boston Police Department Street Outreach Unit offered a fresh mask to a man sitting outside a "comfort station" run by the Boston Public Health Commission.Craig F. Walker/Globe Staff/The Boston Globe

Homeless people

From the beginning of the pandemic, government officials and advocates worried about the virus running rampant among people with no place to live, no option to obey stay-at-home orders.

To make room for physical distancing in shelters, the city found hundreds of beds for homeless people in empty college dormitories and other buildings, said Sheila A. Dillon, Boston’s chief of housing and director of neighborhood development.

At the same time, demand for shelter beds dropped, as fear may have kept people away, including the many from outside Boston, Dillon said. But as the weather cools, Dillon expects more people to seek shelter and the city is looking for additional places for them.

The virus brought a surprise that so far no one can explain: Even though many homeless people did become infected, very few became seriously ill, and only about a dozen died (an exact count is not available).

As a result, the city’s big challenge was finding places to isolate infected people who could infect others, but weren’t sick enough to need a hospital bed, and several respite centers were established to accommodate them. City officials expect to focus on finding such respite and recovery beds, rather than adding large-scale hospital space, if there is a second wave.

"I feel like we moved mountains in terms of decongesting shelters, isolating, and quarantining,” said Dr. Jessie M. Gaeta, chief medical officer of the Boston Health Care for the Homeless Program. “I’m sure we prevented some transmission and some deaths.”

At the peak of the pandemic, a third of homeless people were found to be infected. Currently, fewer than 2 percent of the homeless population are testing positive; only seven homeless people in Boston have tested positive since July, according to the city health commission.

St. Francis House, a day shelter for homeless people, swiftly reconfigured itself, making sure all windows could open, adding HEPA air filters, limiting face-to-face interactions, requiring health screenings, and offering portable meals, among other measures. People could grab their food and eat outside. But as it gets chillier that option will vanish.

Recently Karen LaFrazia, president and CEO, noticed that 50 to 80 people had lined up outside before the 6:30 a.m. opening.

As the weather worsens, people will want to come inside and stay longer, making it difficult to maintain physical distancing. “We’re faced with a very significant ethical dilemma,” LaFrazia said. "Do you turn people away? Do you let people come in? I don’t know what we’re going to do.”

Inmates

Controlling an airborne infection like the coronavirus can be especially difficult in close quarters of a correctional facility, and stories of severe outbreaks behind bars have been reported around the country. In Massachusetts, there have been a few outbreaks, and 10 deaths.

Massachusetts correctional officials say they’re working to control the virus, but advocates want to see more people released.

A study of Massachusetts prisons and jails published in August found that the rate of infections among inmates was nearly three times that of the state’s general population and five times that of the US population.

Middlesex Sheriff Peter J. Koutoujian, president of the Massachusetts Sheriffs Association, said the 13 county jails have “done a really good job of containing this disease and keeping people healthy.” Advised by Dr. Alysse Wurcel, a Tufts Medical Center infectious disease specialist, the jails quarantine every new arrival for 14 days, test those who have symptoms, and provide correctional officers and all inmates are given masks, she said.

The incarcerated population has declined since April 1, but is starting to increase again, with 6,238 in the jails and 6,892 in the state-run prisons as of Wednesday.

The Department of Correction, which runs the prison system for those serving longer sentences, said in a statement that it is working "to maintain social distancing, proper mask use, enhanced cleaning and sanitizing (especially on touch surfaces), and screenings for visitors, staff and vendors prior to entry.”

But Elizabeth Matos, executive director of Prisoners Legal Services of Massachusetts, said inmates "are in a scary situation. Clients are still calling us very concerned for their health and safety,” she said.

Prisoners' Legal Services is pursuing litigation to get more prisoners released, such as those who are elderly, being held on technical probation violations rather than new crimes, or within three to six months of being released. “It’s not possible to socially distance inside,” Matos said.