They’re the most vulnerable to severe disease and death. They’re the most vaccinated slice of the population. Yet COVID-19 cases are ticking up nonetheless among seniors living in many California nursing homes.

California Department of Public Health

“We’ve seen a small number of skilled nursing facility outbreaks over the past few weeks,” said Dr. Matthew Zahn, deputy county health officer for Orange County. “It’s not clear at this point whether this represents a larger trend, but our experience so far indicates that these outbreaks are related to lower booster dose rates in facility residents.”

Only 41% of California nursing home residents had received a booster shot by the end of November, according to federal data. In Los Angeles County, the average was 46%, compared to 35% in Orange County, 33% in Riverside County and 23% in San Bernardino County.

Staff boosters lagged as well. In Los Angeles County, an average 23% of workers had been boosted, compared to 20% in Orange County, 16% in Riverside County and 10% in San Bernardino County.

The uptick in cases may well reflect an expected post-Thanksgiving surge in cases. “It is unlikely that this reflects an outbreak of Omicron, given the limited number of cases currently identified,” said Dr. John Swartzberg, clinical professor emeritus at UC Berkeley, by email. “Could this represent a superspreading event(s)? Overall, it’s difficult to make too much out of this other than to closely follow what happens over the next week or two.”

As nursing homes were the leading edge early in the pandemic, experts are doing exactly that.

“It’s kind of ominous, but only in the sense that it’s presaging a winter wave,” said Andrew Noymer, an epidemiologist and demographer at UC Irvine, who has been expecting a winter surge since for months. “Delta remains the dominant strain in California, so the usual rules apply in terms of how transmissible it is and how severe it is. I would definitely recommend booster shots for those who haven’t gotten one and are eligible.”

Marisela Munoz holds a photo of her mother Evangelina C. Martinez at her home in Canyon Country, Friday August 28, 2020. Martinez, died of COVID-19 at Astoria Nursing and Rehabilitation Center in Sylmar at the age of 93. (Photo by Hans Gutknecht, Los Angeles Daily News/SCNG)

‘Precautions are indicated’

The California Department of Public Health cautioned that, due to the Thanksgiving holiday, test and case reporting were low in late November. Comparing current numbers to late October instead shows that skilled nursing cases are up only slightly, officials said by email. San Bernardino County has not seen any significant rise either, spokesman David Wert said.

Nearly 71% of COVID-19 deaths have been in the 65-and-older age group, according to state data. But so far, the uptick in cases does not appear to have sparked a big uptick in deaths.

In Los Angeles County, which has a third of California’s nursing home beds, officials aren’t taking chances.

“Due to the introduction of the newly identified Omicron variant … and until more information is known about this variant’s transmissibility, its impact on vaccine effectiveness and breakthrough infections, including in individuals who have received booster doses, whether it is associated with more severe disease, and whether it is susceptible to currently available COVID-19 treatments, additional infection control precautions are indicated and necessary for Skilled Nursing Facilities because residents are at heightened risk for poor health outcomes,” said a new public health order, issued Dec. 3.

From Dec. 15 through Jan. 31, the order states, all skilled nursing facility residents, employees and contractors, regardless of vaccination status, who may encounter residents must test for COVID-19 infection once a week.

“In addition … all visitors, regardless of vaccinations status, must provide proof of either a negative PCR test taken within 72 hours prior to entry, or a negative antigen test taken within 24 hours prior to entry,” the order states.

“That’s an extraordinary step,” said Deborah Pacyna, director of public affairs for the California Association of Health Facilities, which represents the vast majority of nursing homes in the state. “The federal government is saying, ‘Open up, let people in to visit,’ and L.A. is saying, ‘Make visitors get tested every day.’ That’s not going to make a lot of people want to visit.”

Hrag Bekerian, administrator of Gem Transitional Care Center, at the Pasadena center in August 2020.   (Photo by Sarah Reingewirtz, Los Angeles Daily News/SCNG)

Early in the pandemic, San Bernardino County, like many other counties, formed a multidisciplinary task force to keep an eye on skilled nursing facilities. It has been focusing on vaccinations and making COVID treatments available to minimize the potential for outbreaks and their spread, Wert said.

“We have continuous surveillance of COVID activity in nursing homes and meet on a regular basis. This includes weekly ‘checkup’ calls to SNFs and review of the state data set. This ongoing monitoring is a detection system that allows the Task Force visibility on a real time basis so that the Task Force can deploy resources to support facilities as they respond to outbreaks from the onset.”

Vaccination key

The vaccination status of health workers in these facilities matters.

Researchers from the University of Rochester, Harvard and UCLA found that nursing homes with low staff vaccination coverage had higher numbers of cases and deaths than those with high staff vaccination coverage. “These findings show the extent to which staff vaccination protects nursing home residents, particularly in communities with high COVID-19 transmission,” said their piece in the New England Journal of Medicine.

California was the first state to mandate vaccination for health care workers, and 95% of nursing home staffers are now fully vaccinated, according to data from the Centers for Disease Control. That’s compared to 88% of nursing home residents.

Holocaust survivor Edith Frankie became one of the Los Angeles Jewish Home’s first residents to be vaccinated for COVID-19 on Dec. 30. 2020. (Photo courtesy Los Angeles Jewish Home)

That varies by county, though, according to the CDC data: In Los Angeles County, 97% of workers and more than 89% of residents were vaccinated. In Orange County, 97% of workers and more than 87% of residents were vaccinated; in Riverside County, 92% of workers and 79% of residents were vaccinated; and in San Bernardino County, 88% of workers and 79% of residents were vaccinated.

That so many workers and residents are vaccinated in California is somewhat comforting, but Dr. George Rutherford, professor of epidemiology and biostatistics at UC San Francisco, would like to see more data on how many are fully vaccinated, including boosters.

California’s vaccine requirements are surely a factor in staffing shortages, Pacyna said. In New York and Minnesota, facilities are so short on workers that National Guard members are being called in to help. Things aren’t that bad in California — yet — but it’s still a struggle.

‘A crisis situation’

“We’re definitely in a crisis situation, there’s no question,” Pacyna said. “We have a significant percentage of our providers using the nursing registry to supplement staff at least once a month — more frequently for others — and that’s a very expensive proposition. Most are using overtime extensively with people who want to take on extra shifts or work doubles. That’s a problem in itself — it creates a lot of stress and burnout.”

That translates into a lack of access for patients. If facilities don’t have enough workers to satisfy worker-to-patient staffing ratios, they simply accept fewer patients, Pacyna said. “Instead of 99, they have 70. That makes it harder to find a place to stay.”

Executive Director Patricia Gustin greets residents at the dining room at Emerald Court in Anaheim in  March. Residents were able to come to the dining room for the first time since social distancing restrictions were put into place. (Photo by Paul Bersebach, Orange County Register/SCNG)

As experts continue to pore over the numbers, UCI’s Noymer cautions against writing off the potential threat of Omicron — there’s not enough evidence yet to support the ‘it’s-more-contagious-but-milder’ claims being bandied about — and is intrigued by growing evidence that mixing and matching booster shots may pack more punch than sticking with a single brand alone.

In the nation’s nursing homes, booster clinics are ongoing, and even if cases rise, we’re in a much better place now than we were last year, Pacyna said.

“The silver lining is that we’re not seeing the number of deaths we were experiencing before the vaccines.”

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