Covid-19 infections and deaths in nursing homes plummeted after the omicron variant receded and efforts were undertaken to ensure staff and residents were vaccinated, boosted and masked. Yet as fall fades into winter, many operators are bracing for the likelihood of a tripledemic: Covid-19, Respiratory Syncytial Virus (RSV) and influenza all at once. 

Mandatory masking and visitation limits, which were in some cases at the expense of resident comfort, helped reduce the infection rate of all three viruses in previous years.

As many of those measures have eased or gone away in facilities across the country, in an effort to return to some semblance of normal and as Covid-19 has become endemic, some operators and funding providers fear for the worst without the extra precautions.

“COVID, RSV and the flu all at once – what’s that going to do to our industry and admission bans,” LTC Properties CEO Wendy Simpson said during the company’s earnings call. “We’re hoping that [admission bans] won’t be instituted again, because those were very harmful for both assisted living and SNFs, but if occupancy does not continue to increase or it decreases because of a surge in the fall, that could delay margin recovery.”

A study conducted by the Commonwealth Fund last month found that if vaccination continued at its current pace, the country faced a potential winter surge of Covid infections that could result in 16,000 hospitalizations and 1,200 deaths per day by March 2023.

The booster protects against the newest variants; a CDC analysis published at the end of September showed that getting a second booster dose proved to be 74% effective at 60 days against severe Covid-related outcomes, like hospitalization or death. The second booster was 90% effective against death alone, in comparison to one booster, according to the analysis.

The population included nursing home residents from 196 nursing homes in 19 states operated by Genesis HealthCare.

But only 42.2% of residents and 24.7% of staff are considered up to date on vaccines, according to data released by the Centers for Medicare & Medicaid Services (CMS) as of Oct. 30.

Operators still believe they are in a much better position to handle Covid infections than in previous years, and the majority of providers are well-versed in the precautions necessary to navigate the yearly flu and RSV season.

Chubb said keeping residents and staff up-to-date on the latest information is vitally important, through visual aids, newsletter education, and regular updates on regional transmission rates.

“We’re very well equipped to deal with infections at this point,” Brickyard Healthcare Chief Clinical Officer Lisa Chubb said. “So having the universal and the individual source control mechanisms, if those things are in place, then we’re able to manage really any infection that’s thrown at us.”

A growing concern

Dr. Swati Guar, the medical director of New Horizons Nursing Facilities with the Northeast Georgia Health System, has been closely monitoring infections in the state, which currently has very high influenza activity and a recent uptick in Covid cases, according to CDC data.

“There are a lot of areas where the community transmission had dropped down to a medium level or low,” Dr. Gaur told Skilled Nursing News. “We are seeing that it jumped back up so, you know, facilities that were in a community transmission where it was not high but substantial, have seen this week some of those areas going back up to a high transmission.”

Dr. Guar added that the emergence of the BQ.1 and BQ.1.1 Covid variants continue to crop up with higher frequency in the Southeast and Southwest and in nursing homes in those concentrated areas. For nursing homes in high transmission areas, masking is still mandated by the CDC. For lower transmission areas, it is a decision operators have to make.

Chubb said that as the holiday season begins, nursing home operators should take steps to educate staff and patients about RSV transmission.

“RSV might be able to come in through a visitation, you know, with children that visit at the holidays coming,” she told Skilled Nursing News. “So, offering that education to everyone on those infection control and prevention practices is going to be imperative as we move into the season.”

Nationally, RSV cases are monitored by surveillance testing in hospitals. Although RSV is most common in infants and young children, older adults are also at risk.

“The surveillance activity is showing that we have already reached the 2019-2020 peak, which typically happens in the December/January timeframe, and we are here in the early part of November, already seeing that we have surpassed the peak,” Dr. Gaur said.

Steps to mitigate risk

While nursing home residents and staff are more prepared than the general public, there are still huge disparities between the percentage of vaccinated and boosted individuals — especially as large swaths of the nation are experiencing vaccine fatigue.

“Right now is the time that the facilities should be talking to the staff, talking to the family members, talking to the residents, and saying, ‘We understand that you are tired of vaccines, however, take the time for administration,’” Dr. Guar said.

Dr. Guar said that New Horizons facilitated co-administration of Covid boosters and flu shots.

“95 plus percent of all our residents are fully vaccinated,” she said. “That is going to get the severity of illness down even if they get exposed to the flu.”

David Gifford, AHCA/NCAL’s chief medical officer, urged public health officials and policymakers to continue to prioritize long-term care residents to get boosted.

“We are very concerned about these viruses impacting our long term care residents and staff this upcoming winter. We continue to strongly encourage our residents, staff, and the general public to stay up to date with their vaccinations to ensure everyone has the highest protection,” Gifford said.

Gifford urged providers to adhere to the following guidelines:

• Encourage residents and staff to get vaccinated with the COVID and flu booster to help significantly reduce risk of getting very sick.

• If infection is detected, take antivirals early on, as they also reduce the risk of getting seriously ill.

• Encourage anyone to stay home or away from others if sick with either runny nose, sore throat, cough, or fever.

• Ensure good airflow and check that your HVAC system is working, and filters are clean to reduce viral spread.

Dr. Guar added that when residents come up with illnesses, it is important to test them for both Covid and the flu.

She also urged facilities to employ Paxlovid where appropriate and to try to educate residents and staff about the drug to dispel misconceptions – especially around rebound cases with the drug.

Although only under 5% of people who take Paxlovid experience rebound, there is a misconception that Paxlovid causes a rebound of symptoms, which creates hesitancy around the drug, she said.

“Education is a big piece of it, you know, people, it’s somewhat of a newer medication, but we don’t have the luxury of many years to kind of slowly diffuse into our community,” she added.

Ultimately, masking may be one of the most helpful tools in combating a tripledemic this winter.

“What we are doing is we are taking this success that we have had with masking and use of PPE and extending it to any respiratory illness,” she said. “Why would I have success with one respiratory illness and not want to, you know, take it and translate it into preventing the flu and RSV as well.”