How vaccine hesitancy is the cause of breakthrough infections in nursing homes

Jay Meyerowitz, a geriatrician in private practice who is the medical director of two New Jersey nursing homes, believed he was done receiving phone calls about coronavirus infections at the facilities. The first months of the pandemic were brutal. Many nursing home residents had died COVID-19; Meyerowitz, her partner, her daughter, and her medical practice partner and best friend were diagnosed with the disease last spring. But, in the past six months, Meyerowitz had not seen any cases at any of the two facilities he oversees. As part of the plan to reopen the state, the houses were in phase 3: they had restored visits, communal meals and group activities. In January, when the vaccine became available in long-term care facilities, each of the residents and a majority of staff at both homes chose to be vaccinated. Then, on April 12, Meyerowitz learned that a nursing assistant had tested positive.

The result came from a routine test carried out the previous Friday. Now the establishment has retested everyone. On April 13, the results returned: three residents, all elderly, were positive, although all asymptomatic. On the 14th, a nurse developed mild symptoms and tested positive. Two days later, another resident tested positive. Two days later, another nurse – the partner of the first person who tested positive – developed symptoms, also mild, and tested positive. All positive results came from a single unit in the nursing home. The first and last person to test positive – the couple – had not been vaccinated. But the others had been.

Meyerowitz was shocked. “I should have known” that post-vaccination infections were possible, he told me when I visited him at his home in Fort Lee. “But I just couldn’t imagine it. I was lulled into a false sense of security. His regular infectious disease consultant, Benjamin De La Rosa, told Meyerowitz that breakthrough infections shouldn’t surprise him. “It’s a perfect setup for that to happen,” De La Rosa told me over the phone. “You have vulnerable, older residents, often recovering from hospitalization, living in collective premises, many in semi-private rooms. Many buildings are older and poorly ventilated. In other words, all of the conditions that made long-term care facilities particularly vulnerable to the coronavirus a year ago are still in place.

The difference is the vaccine: in many assisted living centers across the state, all or almost residents were vaccinated. The number of short-term facilities, such as rehabilitation centers, is lower, ranging from zero to around seventy percent of residents. But the most striking gap is between the vaccination rates of staff and those of residents. In many facilities where every resident has received the vaccine, less than half of the staff have received it. “One of the obstacles to collective immunity is reluctance on the part of the staff,” said De La Rosa. As long as the virus is circulating in the community, an unvaccinated staff member can pick it up and bring it to the nursing home, where conditions can make breakthrough infections, otherwise rare, more likely.

The Centers for Disease Control followed reported breakthrough infections in the United States. As of April 20, less than seventy-two hundred were among the more than eighty-seven million people considered to be fully vaccinated. Most of these infections were asymptomatic, but eighty-eight people died. These numbers indicate that rupture infections are extremely rare, but De La Rosa suggested they could be a low estimate. Asymptomatic vaccinated people are unlikely to find out they are infected unless they live or work in a place, such as a long-term care facility, where such tests are performed regularly.

On Wednesday, the CDC released a report an epidemic of COVID-19 in a Kentucky nursing home, where more than ninety percent of the residents but just under fifty-three percent of the staff had been fully immunized. Much like in New Jersey, the outbreak started with an unvaccinated staff member. In the Kentucky home, forty-six people – including twenty-two fully vaccinated – were eventually infected, and three residents died, including one vaccinated. Yet, in the final analysis, the vaccine appears to be over eighty-five percent effective against symptomatic illnesses and over ninety-four percent against hospitalization.

“Jay looked mortified when he called me,” De La Rosa said of the New Jersey outbreak. “But I reassured him. The vaccine works. If they’re not serious or asymptomatic, I don’t know if it’s that serious.

An outbreak in a long-term care facility, no matter how small, triggers a set of quarantine measures. In New Jersey, tours are suspended, as are all community activities. Residents should eat in their room, using paper plates and disposable utensils. The bingo, music, current affairs discussions and other gatherings in the common room and on the field cease. Residents who have tested positive are confined to their rooms for two weeks. Each new positive test result restarts the clock. Isolation, in turn, leads to depression and increased levels of anxiety. Residents who suffer from mild dementia, Meyerowitz said, have had a particularly difficult time dealing with the restrictions. All these measures are particularly painful more than a year after the start of a pandemic which killed nearly eight thousand residents and staff of long-term care facilities in New Jersey, representing more than a third of total COVID-19 deaths.

“I’m traumatized,” Meyerowitz told me. He and his family have had mild cases of COVID last spring, but her medical partner, Joseph Rizzo, 59, with diabetes, fell seriously ill. “He was admitted to the hospital, the one where we work, with double pneumonia,” Meyerowitz said. “They told me he would be intubated. It was up to Meyerowitz, who could be physically in the room with Rizzo, to help his friend FaceTime his loved ones before the planned intubation. “I held the phone and he said goodbye,” Meyerowitz said. “And then he starts to cry, then I start to cry, and we must have done it five times” – with Rizzo’s wife, two children and two brothers. “He was in the middle of a cytokine storm,” Meyerowitz said, referring to the overdrive state of the immune system that can make COVID-19 fatal.

Then, however, the hospital got tocilizumab, a rare and expensive drug used to treat rheumatoid arthritis, and Rizzo did what looked like a miraculous cure. He did not need an intubation and was discharged from the hospital three days later. Rizzo told me over the phone, however, that he was bedridden for a month after being released and continues to suffer from “brain fog” and short-term memory loss; he speculates that these are the consequences of a poor supply of oxygen to the brain. He stopped practicing medicine.

Meyerowitz, who is sixty-two years old and has practiced medicine for half of his life, gets excited when he talks about what he calls the “great state of medical technology” – the drug that saved his life. Rizzo and the technology behind mRNA vaccines. When residents and staff of long-term care facilities became eligible for the vaccine in January, Meyerowitz urged everyone to take it. All residents did, but a third of the staff refused. “I didn’t hear any religious concerns,” Meyerowitz told me. “It was all based on the belief in vaccine misinformation: ‘I haven’t been sick yet, so I won’t get sick’; “I have O-positive blood”; “It’s too new. And these are people who have a Bachelor of Science or a Bachelor of Science in Nursing! “

Two hundred and thirty-three long-term care facilities in New Jersey currently have active outbreaks of COVID. A spokesperson for the State Department of Health pointed out to me in an email that a year ago, the state had more than twice as many active outbreaks and many more deaths. Yet months after every resident and staff of a long-term care facility has had the opportunity to receive the vaccine, hundreds of people are sick and many people continue to die every day COVID in these state facilities. Thousands of people live in isolation because their facilities have placed restrictions on tours and social activities. (New Jersey makes these numbers readily available – most of the information is on publicly available websites, and I got details by contacting the Department of Health. My requests for similar outages for health care facilities long term in New York went unanswered, but immunization data available tell a similar story: While vaccination rates for residents of long-term care facilities in New York City are well over eighty percent, rates among staff are below seventy.)

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