Viewpoint: Nursing Home Guidance Endangers Elderly

March 11, 2021
Kevin Kavanagh, MD

The CMS update on when nursing home residents can have visitors raises grave concerns. The recommendation appears to assume that herd immunity is reached at 70%.

Our elderly in nursing homes have been at grave risk for contracting coronavirus disease 2019 (COVID-19). Yesterday the Centers for Medicare and Medicaid Services (CMS) released revised nursing home guidelines for visitation recommendations. They are designed to provide relief to the grave psychological toll COVID-19 has inflicted through long-term isolation and separation of residents from loved ones. But one has to ask, are they safe? I have grave concerns, for example:

Indoor visitation is not recommended for: “Unvaccinated residents if; 1) the COVID-19 county positivity rate is greater than 10%; and 2) less than 70% of residents in the facility are fully vaccinated….”

However, this recommendation appears to assume that herd immunity is reached at 70%. This figure appears to be even a low community estimate for obtaining herd immunity. And certainly, will not be true for spread which occurs in an indoor setting with poor ventilation and high resident contact; let alone that which is needed for to achieve herd immunity with the new variants.

For the United Kingdom (B.1.1.7) and other variants, it is estimated over 80% of the community would have to be immune. And with some of the variants (e.g. P1, Brazilian) it is feared reinfections can frequently occur, negating the protection of natural immunity. In addition, allowing visitations by setting the safe level of the COVID-19 test positivity rate at less than 10% is ludicrous and frankly unsafe. According to John Hopkins University, the United States testing positive rate did not reach above 10% during our August surge.

These recommendations also allow visitations during a facility outbreak: “While outbreaks increase the risk of COVID-19 transmission, a facility should not restrict visitation for all residents as long as there is evidence that the transmission of COVID-19 is contained to a single area (e.g., unit) of the facility.”

Again, this makes little sense and ignores the fact that this virus can aerosolize and float around the entire facility. Aerosolization takes place with loud vocalization which can be commonplace in nursing homes. Poor ventilation combined with an aerosolized virus is nothing short of a petri dish for spread and the dangers to those visiting should not be understated. A negative pressure room or facility wing with separate ventilation would be needed.

This is the reason COVID-19 only facilities were developed as a strategy to prevent spread and why New York State suspended the housing of COVID-19 patients in nursing homes. Unfortunately, these regulations could also be used to help justify this past action.

After a case of COVID-19 occurs in a nursing home, visitation can continue if: “When a new case of COVID-19 among residents or staff is identified, a facility should immediately begin outbreak testing and suspend all visitation until at least one round of facility-wide testing is completed.” And visitation can be resumed, “If the first round of outbreak testing reveals no additional COVID-19 cases in other areas (e.g., units) of the facility, then visitation can resume for residents in areas/units with no COVID-19 cases. However, the facility should suspend visitation on the affected unit until the facility meets the criteria to discontinue outbreak testing.”

This recommendation is very problematic, since new exposures will be testing negative due to the long incubation time of COVID-19. Testing did not stop a super-spreader event to take place in the Rose Garden; it will not stop one taking place in a nursing home. All need to be quarantined for 14 days and if no new cases occur, then the nursing home can resume visitation. Again, the strategy of segregating patients into an area of a facility will not defeat an airborne virus in a nursing home.

Nowhere in this news release could I find a recommendation for upgrading nursing home air exchanges or air sanitization; or that proper and ample PPE and staffing are available.

Regardless of what we deeply desire to take place, or are able to mandate or recommend, the virus will spread relentlessly. It is an uncaring soulless machine which is evolutionarily programmed to inflict a devastating toll as it efficiently spreads and evolves throughout our communities. Enacting these recommendations at this time is reckless and places nursing home residents at undue risk.Our loved ones deserve better.