It was a battle many thought we had already won. Residents of nursing homes, the people most at risk of dying in the COVID-19 pandemic, were among the first to get vaccinated last winter, leading to a dramatic decline in new infections.
But now, just two months after the ambitious nursing home vaccination program wrapped up, there are worrisome signs that the danger remains and may even be growing again. The percentage of nursing home residents who are vaccinated has declined since March, amid complaints from senior care leaders of difficulty getting shots for newly admitted residents.
Perhaps more concerning, a sizable share of Massachusetts nursing home staff continue to go unvaccinated for COVID-19, despite aggressive initiatives to convince the hesitant. Just 59 percent of nursing home staff are fully vaccinated, according to state data. Now, nursing home leaders who witnessed the explosion of COVID infections and deaths a year ago are wary that their own nurses, aides, and other employees could risk the health of their residents.
“It’s a topic of conversation among every provider,” said Elissa Sherman, president of LeadingAge, a trade association that represents nonprofit nursing homes and assisted-living centers. “We have to do whatever we can to try to get as many vaccinated as possible.”
One of the largest senior care operators in the state, Hebrew SeniorLife, has already said its 1,125 nursing home staffers must get vaccinated, but has stopped short of enforcing the mandate. Others, fearing they’ll have difficulty filling positions, have so far relied on a softer approach.
Underscoring the anxiety is news of a recent deadly cluster in Kentucky. An unvaccinated employee ignited a COVID-19 outbreak at a nursing home where most residents — but only about half the staff — had been vaccinated. In all, 26 residents were infected, including 18 who had been vaccinated, and 20 workers were infected, including four who had been vaccinated, according to a review by the Centers for Disease Control and Prevention. Three residents died, including two who were unvaccinated.
The significant number of infections among vaccinated residents underscores the special risk of these homes, with their close quarters and largely indoor life and the often weakened immune systems of the residents. Nationally, less than 0.01 percent of people who have been vaccinated have been infected with the coronavirus, according to CDC data.
In Massachusetts, state data show total nursing home COVID-19 cases have plummeted from several hundred a week in late January to roughly 30 a week recently. But senior leaders know that number can spike quickly if clusters of cases break out.
A much-heralded federal program sent pharmacy chains CVS and Walgreens into nursing homes and other long-term-care facilities nationwide from late December through early March to administer vaccines to staff and residents. When it concluded, 84 percent of Massachusetts nursing home residents at that time were fully vaccinated, state data show.
But since then, as residents were discharged or died and others who are unvaccinated entered care, that figure has declined. Today, roughly 81 percent of nursing home residents in Massachusetts are fully vaccinated, the data show.
“It seems they are creating a new type of petri dish where we could have a resurgence if we don’t get a [vaccination] program consistently implemented,” said Daryl Cameron Every, a Milton elder law attorney who is encountering different COVID vaccination policies as she helps seniors transitioning between and among hospitals, geriatric psychiatric facilities, and nursing homes.
She recently battled a geriatric psychiatric facility, which said it was not responsible for obtaining a shot for a 70-year-old client with dementia and delusions who had been there for months. In late March, when the man was poised to be discharged to an Ayer nursing home, administrators there said they didn’t have the necessary refrigeration to handle vaccines themselves and were awaiting guidance from the state, Every said.
Her client was finally admitted to the nursing home April 21 -- still unvaccinated -- and had been in quarantine awaiting a vaccination, which finally came Thursday, with a one-dose Johnson & Johnson shot.
“It was kind of like banging your head against a wall,” said Julie Curcuru, the man’s daughter, about the months-long mission to get her father vaccinated. She said the nursing home initially offered to transport him outside the facility to get a shot, but the family nixed that because he became severely disoriented and agitated during an earlier move, thinking he was in an airport.
“I am still just unbelieving that this population can be overlooked,” Curcuru said. “I guess we can learn from this and get better before another pandemic.”
The Baker administration says it helps nursing homes by sending “rapid response teams” to facilities where residents have lower vaccination rates.
But the state’s process for getting shots to patients entering nursing homes leaves some waiting weeks in quarantine, unable to participate in group activities or eat in common dining areas, said Dr. Asif Merchant, medical director at four nursing homes in the Metro West area and partner of a company that runs medical services for 45 nursing homes in Massachusetts.
“It means that a person cannot have visitors in their room,” said Merchant, who has been lobbying for more state help for beleaguered facilities and families.
The problem, say nursing home administrators, is that the state’s response teams typically just provide a second dose of Pfizer vaccine to residents who already had their first Pfizer shot somewhere else. Few nursing home pharmacies have the cold storage capacity to store the Pfizer vaccine.
But for nursing homes with residents needing a first dose of Pfizer, or any dose of the other vaccines, administrators and families have been largely on their own. The state in late February directed nursing home administrators to contact their own long-term-care pharmacies to provide the shots. It also told administrators to direct their unvaccinated staff — many still hesitant to get a shot — to mass vaccination sites or other locations, rather than allow them to get a shot at their workplace.
The end result has been some new nursing home residents statewide remain unvaccinated, leaving them quarantined and vulnerable.
Meanwhile, many of the people taking care of them are not getting vaccinated either.
Recognizing the problem, the state last month permitted nursing homes to vaccinate staff right at the facility.
But the rules, focused on preventing vaccine waste, still require nursing homes to “ensure that there are sufficient residents and staff in need “ before ordering doses for any of them. That means families and nursing homes must wait until they have at least 10 unvaccinated residents or enough willing staff before ordering Moderna, which comes in 10-dose vials, or at least five for the Johnson & Johnson vials.
Vaccinations have dramatically tamped down infections, but unvaccinated nursing home staff remain a threat. On Monday, state health secretary Marylou Sudders said most of the infections were among nursing home workers.
Now, nursing homes are redoubling efforts to persuade reluctant workers to get their shots, offering staff paid time off, gift cards, raffle prizes, event tickets, giveaways, T-shirts, and more, said Tara Gregorio, president of the Massachusetts Senior Care Association, an industry trade group.
They’ve also tapped nurses aides, housekeepers, and department heads to act as “vaccine ambassadors” to encourage their peers, she said. And they’ve provided educational videos and fliers in multiple languages, including Haitian Creole, Chinese, Spanish, and Portuguese, hosted by respected physicians.
Amid the high-stakes campaign, talk of mandating shots has percolated through the industry, but nursing home administrators worry that could drive out already-scarce staff.
“I do believe mandating is on the horizon and am strongly considering it down the road,” said Lou Woolf, president of Hebrew SeniorLife.
With deep resources and stable staffing, the Harvard-affiliated organization is unusual in the industry. At least 75 percent of Hebrew SeniorLife’s nursing home workers are fully vaccinated and another 6 percent are awaiting second shots, well above the state’s average.
A year before the pandemic, Hebrew SeniorLife required flu shots for the first time for staff. Administrators achieved 100 percent compliance by imposing what seemed at the time an onerous condition: Holdouts would be required to wear masks 24/7 during flu season.
“That was totally embarrassing then, but not now,” Woolf said. “We don’t have that hammer anymore.”