March 02, 2020

Save Our Seniors

            For over 100 years, scientists and infectious disease specialists have been anticipating another influenza pandemic like the 1918 “Spanish flu” which killed approximately 50 million people world-wide. In the US alone, the death toll was 675,000; the disease spread across the globe, affecting some 500 million people, aided and abetted by troop demobilization when World War I came to an end. We have never had an outbreak quite like it, but there have been years when the influenza strain was particularly virulent, principally when the genetic material of the virus “shifted” rather than “drifted”: every year, the influenza virus mutates to a lesser or greater degree, and if the change is dramatic, the general population will be especially susceptible to the illness. Over the decades, we have found new and better strategies for minimizing the impact of influenza: we have developed moderately effective vaccines, we have designed protocols to limit the spread of the disease when an outbreak occurs, and we have better ways of caring for patients who do become ill. Despite our best efforts, influenza remains a major source of morbidity and mortality every year, with the CDC reporting that so far this season, there have been 32 million cases of the flu, resulting in 310,000 hospitalizations and 18,000 deaths. Long-term care facilities (institutions providing either short-term rehabilitative care or long-term nursing care), with a total of about 1.7 million beds, are a hot spot for the spread of the flu. The patients in these facilities tend to be old, to have multiple chronic medical conditions, and weakened immune systems. They live in close quarters and have frequent contact with one another. Not surprisingly, skilled nursing facilities look as though they may also be fertile ground for the new COVID-19 virus.
            Just this weekend, an outbreak of a respiratory illness was reported at the Life Care Center of Kirkland, Washington, not far from Seattle. Among the 108 residents and 180 staff members of this skilled nursing facility, over 50 reportedly have respiratory symptoms. At the same time, the Department of Public Health of Washington State reported a cluster of 6 confirmed cases of COVID-19 at the Evergreen Hospital, of whom 4 were connected to Life Care Center of Kirkland (3 residents and one staff member). This is a rapidly evolving story: one of those residents, a man in his 70s described as having underlying chronic medical problems, has since died. Health officials in Washington State suspect the virus has been circulating for some time, probably weeks, undetected because it was not being tested for. Meanwhile, the anxiety level is mounting in the Seattle area, as well as in neighboring Oregon and California, where cases have also been reported. The good news is that we know what basic steps to take to contain the spread of the disease in skilled nursing facilities. We know because we have been developing expertise to handle another, sometimes deadly viral illness, influenza, for the past 100 years.
            The CDC just issued guidelines to long-term care facilities reminding them of what these practices are. They are really quite simple and, while they won’t eliminate the threat, they are likely to diminish it significantly. The recommendations deal with ways to prevent spread into a facility, to prevent spread within a facility, and to prevent spread between facilities.
            With regard to limiting spread into a facility, the CDC promotes posting signs telling visitors to stay away if they have respiratory symptoms. Likewise, employees should stay home if they are feverish, coughing, or sneezing. Finally, protocols should be established to evaluate every new admission for signs of respiratory illness.
            In terms of preventing spread within a facility, staff should monitor all residents for respiratory symptoms. Anyone who develops symptoms should be confined to his or her room. Standard “droplet” and “contact” precautions should be maintained by staff. Lastly, good hand hygiene should be facilitated with the widespread distribution of Purell dispensers—as well as old-fashioned soap and water. 
            Avoiding spread between facilities requires informing the receiving institution, typically a hospital, that a patient with respiratory symptoms consistent with COVID-19 is being transferred. Communication with the local department of health is also key.
            There are differences between influenza and COVID-19 that may influence how effective the strategies used against flu will prove to be in the current situation. Perhaps the most glaring difference is that we don’t have a vaccination for COVID-19—one of the best ways to minimize the impact of influenza in a long-term care facility is to vaccinate residents and staff before the beginning of the flu season.  Another key difference is that individuals infected with the new virus appear to be infectious even if they have no symptoms. We are unlikely to be able to keep long-term care residents perfectly safe, just as we cannot eliminate the risk of falls or functional decline, but there are steps we can take that will make a difference.