ANNAPOLIS, MD—Governor Larry Hogan today directed the Maryland Department of Health (MDH) to take the necessary steps to publish data related to COVID-19 cases and fatalities associated with nursing homes, assisted living facilities, and other facilities providing congregate living for residents.
This week, the state’scoronavirus resource page,coronavirus.maryland.gov, will begin displaying available data for individual facilities, including cases and fatalities.
“As we plan our recovery, we are taking additional steps to protect our most vulnerable citizens, including older Marylanders,” said Governor Hogan. “Keeping Marylanders informed and being transparent with the facts continues to be at the heart of our response to COVID-19. We are grateful to the staff in our nursing homes working around the clock to save lives.”
In New York state, 19 nursing homes have each reported20 or more deathsfrom COVID-19. A nursing home in New Jersey reported70 deathsout of its 500 residents. In the words of New YorkGov. Andrew Cuomo, these homes have become a “feeding frenzy” for the virus and “the single biggest fear.”
With the clustering of people who are frail and have multiple other illnesses like heart disease, stroke, chronic lung disease and diabetes, therisk of severe illness and deathfrom COVID-19 is much higher in nursing homes.
Yet, the United States does not know how many people are dying from COVID-19 in part because the government isonly just now requiring nursing homesto start reporting numbers of presumed and confirmed cases and deaths to the federal Centers for Disease Control and Prevention.
The missing cases could dramatically skew the national death count. When France started reporting death data from some of its nursing homes, the daily COVID-19fatality numbers almost doubled.
The Associated Pressconducted its own survey in the U.S. and found there had been nearly 11,000 COVID-related nursing home deaths across the country as of April 24. However,just 23 stateshave been publicly reporting nursing home deaths. States also vary in how and where they areperforming tests, and some count only proven cases and not also presumptive ones, leading to significant underestimates of the death toll.
As a geriatrician atBoston Medical CenterandresearcheratBoston University School of Medicine, I have watched in dismay as COVID-19 has become a deadly flash flood among the very old people I care for and study. I would not be surprised if the deaths in nursing homes at least double the U.S. COVID-19 death count.
In Massachusetts, 77% of nursing homes affected
Hints of whatnursing homesand their residents and staff are going through have emerged from the states that have started publicly sharing data about them.
With MassachusettsGov. Charlie Bakerleading the charge,the Massachusetts Department of Public Healthis providing a daily update on nursing homes where residents or staff have either tested positive or are presumed to be infected with COVID-19.
As of April 25,about 77% of Massachusetts nursing homes– 299 of 389 – had at least one case of COVID-19. That percentage will no doubt climb as the state carries out its mandated testing at nursing homes. About one-third of Massachusetts nursing homes reported more than 30 COVID-19 cases each among residents and staff.
Nursing homes are required to maintaininfection prevention protocolsto prevent the spread of infectious diseases into and within their facilities. But COVID-19, which ismuch more contagious than the flu, has punched holes in even the most careful and diligent facilities. Some nursing homes have also beenin troublefor past problems with infection control.
It was initially estimated that on average, a person infected with COVID-19 led to an additional 2.5 people becoming infected. This basicreproductive numberis called R0. ALos Alamos National Laboratory studyreleased April 7 indicates that this earlier estimate is woefully low and that the R0 is more like 5.7. For comparison, the R0 for flu is around 2.
Among nursing home residents, the reproductive number is likely even higher than the average of 5.7. Many of the brave and caringstaffin these nursing homes become infected, likely because of the intensity of this higher R0 and their exposure time with residents. By onereport, nearly half of surveyed nursing homes reported staff staying home and not working because they had signs of or were proven to have COVID-19. The exposure to COVID-19 underscores how critical it is fornursing homesto get the adequate supplies ofpersonal protective equipmentthey have been crying out for.
I believe it is likely that the majority of nursing homes throughout the U.S. and beyond have or will soon have multiple residents and staff who are COVID-19 positive. One large nursing home operator in Britain estimates thattwo-thirds of its homes have outbreaks.
We haven’t heard about most deaths yet
By the Centers for Disease Control and Prevention’s latest estimate, the U.S. has about15,600 nursing homeswith some 1.3 million residents. One quarter of those residents, about 425,000, are over the age of 80. In Massachusetts, theaverage age of deathin confirmed COVID-19 cases is 82.
As of April 26,56% of Massachusetts’ COVID-19 deathsoccurred in nursing homes. TheWorld Health Organizationsimilarly estimates that half of COVID-19 deaths in Europe and the Baltics are among their4.1 millionnursing home residents. A minimum of 50% of the COVID-19 deaths occurring in nursing homes also agrees with theKaiser Family Foundation’sreview of data from the 23 states that are publicly reporting nursing home deaths.
The limited scope of counting people who have died from COVID-19 is not just a U.S. problem. A representative of British nursing homes,Care England, says that 7,500 people in nursing homes there have died due to COVID-19 – five times the U.K. government’s estimate of 1,600.
One indication of the high death toll from nursing homes comes fromBelgium. The countryhas the highest per capita rateof COVID-19 deaths in the world – 57 per 100,000 people – primarily becauseofficials there include nursing homes’ COVID-19 deathsin the national count and they are including both presumed and proven cases. Like Massachusetts, more than half of COVID-19 deaths in Belgium occuroutside of hospitals.
The current U.S. rate, according toJohns Hopkins University, is 16 per 100,000, but its reports are only as reliable as itsdata sources, which include the CDC and state departments of health.This rate is likely lowerthan Belgium and 11 other countries because of the great variation across the U.S. in which data are not included, such as people who die outside of hospitals, and the data missing due to limited testing.
On April 19, theCenters for Medicare Servicesannounced it would begin requiring U.S. nursing homes to report all confirmed or presumed COVID-19 cases to the CDC. I hope this will include past cases and deaths.
To get an accurate count, veterans’ homes, assisted living centers, group homes and other senior housing facilities must be required to report their past and current COVID-19 cases and deaths, as well.
There is plenty we still do not know about for why nursing home residents have borne the brunt of this pandemic. As Gov. Baker has indicated, “This is a topic that will get a lot of appropriate analysis after the fact.”