Oh My, Oh My, It's Omicron

The Covid epidemic is ramping up again. Cases were up 21 percent over the past week, according to the NY Times. Even more important, so were hospitalizations and deaths: hospitalizations rose by 16 percent; and more than 1200 people are dying of Covid daily, which is not as bad as the peak levels of over 3000 in the winter of 2021 but represents a 9 percent increase over the course of a week. It’s dramatically more than this past July, when the count was around 250 deaths per day.

But no one is saying much about older people in nursing homes and assisted living facilities. This is the group that was hit hard and early when the pandemic first struck the U.S. in February, 2020. Because those who are old and frail, like most residents of long-term care facilities, are particularly vulnerable to this disease, their death rate was the highest of any subgroup in the country. And the toll on the elderly continued, with the Times reporting earlier this month that 75 percent of all Covid deaths have been in those over 65.

To date, one percent of the entire elderly population have died. Several nursing homes have reported small outbreaks, including at six senior living facilities in Oregon, but few, if any, deaths. So are nursing homes getting infection control right this time around or is it just too early for problems to have developed? The CDC reports data on vaccination rates, both with and without boosters, in nursing homes and the correlation with infections is impressive. Cases have been steadily rising among unvaccinated nursing home residents, they’ve been rising but to a lesser degree among the vaccinated, and they’ve been essentially flat in all those who have had boosters.

But all this data reflects principally the delta variant, which is currently the dominant strain of SARS-CoV-2 in the U.S. That’s about to change as the evidence is persuasive that omicron is going to supplant delta in the coming weeks. We still don’t know just how bad Omicron is, though preliminary evidence suggests it causes a milder illness than its predecessors. We also don’t know precisely how much protection vaccination including a booster confers, though a booster is better than no booster, and two doses of an mRNA vaccine are better than no vaccination. What we do know is that Omicron is much, much more contagious than Delta, which is much more readily transmissible than previous variants. The net effect is that long-term care residents will be at risk if just one person brings Omicron into the facility. That’s all it takes: one case. And even if most of the long-term care residents who contract Covid and who have had the vaccine, including a booster, won’t get terribly sick, some people who get Omicron under these conditions do get sick enough to be hospitalized and some will die. What that means is that when Omicron arrives in a nursing home, it will quickly spread throughout the facility, making most people sick. And if most people get sick, some of them will get very sick and die. We know that Omicron is coming; how should we prepare? A recent opinion piece in the NY Times suggests a two-pronged strategy: keep the virus out by testing staff on a regular basis and bolster the residents’ defenses in case Omicron sneaks in by making sure everyone has received a booster. This strikes me as an excellent approach. I propose a few modifications. Keeping the virus out: this is critical. Long-term care institutions are relatively closed communities. That means the virus can get inside one of two ways: either a resident goes out, say to visit family or to go shopping, and brings the virus back, or a staff member contracts the virus and spreads it within the LTC facility. The first route is best dealt with by requiring that residents wear masks when they go out and that they be tested before re-entering the facility if they have been indoors with a group of people. The second route is the most common means of spread since staff members often live with families, take public transportation, and live in areas with high prevalence of Covid. Addressing the risk of staff inadvertently carrying the virus with them when they come to work requires regular testing. The Times article proposes a rapid test before each shift, which is probably optimal given that an aide, for example, might test negative one day because she has a very low viral load but test positive the next day after the virus has had a chance to replicate further. That’s a lot of testing. During the earlier peak, public health authorities established guidelines that called for the frequency of surveillance to reflect how widespread Covid is in the surrounding community. Weighing the inconvenience and cost of frequent testing against the benefit of vigilance in the face of an organism that multiplies with extraordinary speed, a reasonable balance might be twice weekly testing. The lesson we should have learned from our earlier experience is that waiting is a very bad idea—if we wait to institute the revised policy until the first case of Omicron appears in the nursing home, we will be too late. The time to start is now.