Skyline Happenings

With the vaccinated elderly susceptible to breakthrough infections, inoculation of workers is becoming more urgent.

Ed note: Our Health Care Committee will be discussing this issue at an upcoming meeting. Do you have an opinion on vaccine mandates for health care workers?

By Matt Richtel and Reed Abelson in the NYT

In late spring, the 142 nursing homes operated by the Good Samaritan Society hit a milestone that was unthinkable just four months earlier: Zero cases of Covid-19 across the whole company, from 900 at the peak of the pandemic.

The relief was short-lived.

The case count has ticked up again: It’s still below 100 among residents and staff, the company said, but includes many breakthrough cases of vaccinated residents testing positive. Then last week, two vaccinated residents died with Covid at the Good Samaritan Society-Deuel County nursing home in Clear Lake, South Dakota.

The company said it had pinpointed the cause of the spread there and at other of its facilities: The breakthroughs had happened in the same homes where unvaccinated staff were testing positive, seemingly carrying the virus into the home from the community.

“We fought this virus, and we were winning with the vaccine,” said Randy Bury, chief executive of the Good Samaritan Society, a nonprofit chain that operates in 24 states.

Late last month, the company became one of the largest long-term care chains in the country to order mandatory vaccines for staff, highlighting turmoil within an industry desperate to avoid a repeat of the devastation that swept through this highly vulnerable population.

After sharp drops in infections over the last several months, the number of Covid cases among U.S. nursing-home residents and staff roughly tripled from the week of July 4 to the week ending July 25, according to the Centers for Disease Control and Prevention. The agency’s data show that cases of Covid among residents had risen to 1,312, the highest figure reported since early March.

With the Delta variant, people now have to make different calculations about personal risk. The problem is that the parameters are not yet fully known.

By Benjamin Wallace-Wells July 31, 2021 the The New Yorker

So many things have gone wrong in the American response to the pandemic, but two important things have gone right: scientists have developed a vaccine, and older Americans have got it. Seventy-six per cent of Americans between the ages of fifty and sixty-four have received at least one dose, according to the Mayo Clinic’s vaccination tracker. Between the ages of sixty-five and seventy-four, it’s ninety-one per cent, and among those over the age of seventy-five it’s eighty-seven. (Slightly smaller numbers have received a full, two-dose vaccination.) Blue states have been a little more compliant, and the red states a bit less, but the regional differences among older Americans haven’t been so big. Even in deep-red South Carolina, ninety-three per cent of senior citizens have received at least one dose. In Nebraska, ninety-five per cent have, and the numbers in Idaho and Florida are ninety per cent and ninety-eight per cent, respectively. There was no mass campaign to combat disinformation among the aged, no detectable conversion of anti-vaxxer senior citizens to pro-science liberals. “They have the same worries about the vaccine, but when they did the risk-benefit it was just so clear to them that the risks were so severe,” Mollyann Brodie, who runs public-opinion surveys on the pandemic for the Kaiser Family Foundation, told me. There is a dark irony in this. For months, conservative television hosts have fulminated to a largely older audience about the madness of the vaccine campaign: Tucker Carlson has scrunched up his face and said the word “Fauci” with Old Testament menace; a renegade ex-Times reporter named Alex Berenson has rattled off statistics in a rhythm that sounds designed to perplex. Through it all, this older audience has tuned in loyally, from armchairs in Idaho and South Carolina, while already fully vaccinated—their cells displaying the telltale protein piece, antibodies formed and ready. They have taken the campaigns on television neither literally nor seriously; they have understood that it is for show.

The broadly effective vaccination of older Americans and the embarrassingly ineffective vaccination of everyone else, just as the highly contagious Delta variant has won out in the microbe wars, has given the pandemic its current uncertainty: cases are rising sharply, but deaths are not. One reason for this strange situation is how heavily the coronavirus’s risk of death is concentrated among older people––most of whom are now vaccinated. At the outset of the pandemic, the Dartmouth economist Andrew Levin had calculated the mortality risk from covid-19 by age (he originally used data from South Korea, Iceland, Sweden, and New Zealand , because it was the first available), creating tables that the Centers for Disease Control and Prevention still uses. Over the phone, just back from a congressional hearing, he read me the numbers: at the age of thirty, one in five thousand infected and unvaccinated Americans might be expected to die; at forty, one in fifteen hundred; at seventy, one in forty; at eighty, nearly one in ten, close to five hundred times the mortality risk of a thirty-year-old. Vaccinating the elderly was the essential prophylaxis—it kept the vulnerable safe and gave everyone else a little more freedom. Levin did a calculation for me and estimated that, even though just half of Americans over all have been fully vaccinated, those vaccines (concentrated among the most vulnerable) have cut the infection-fatality rate by about seventy-five per cent. William Hanage, an epidemiologist at Harvard, told me, “The relationship between cases and outcomes—be they hospitalizations or deaths—has been altered. It is no longer the same.”

This is what made everyone pretty sanguine at the beginning of the summer. As the Delta variant has spread, the relationship between the virus and the most severe illnesses is different from what it has been in the past. Since mid-June, the seven-day average of new cases in the United States has grown by five hundred and fifty per cent, from about fourteen thousand to about seventy-seven thousand. But the number of deaths is almost exactly the same. In mid-June, the national seven-day rolling average of daily deaths was about three hundred and fifty. On Friday, it was three hundred and one. (That level, according to the Kaiser Family Foundation, means that covid is now just the seventh-leading cause of death—far below heart disease and cancer and also below accidents, strokes, respiratory disease, and Alzheimer’s, and just above diabetes.) The experience of the U.K., where the Delta variant has already peaked, was similar. Michael Osterholm, an epidemiologist at the University of Minnesota who served on the Biden-Harris Transition covid-19 Advisory Board, reviewed with me data from this summer’s U.K. surge, sorted by age group, and compared it with those from that country’s previous surge. The case numbers were about the same, he pointed out. But the deaths? “Way down, way down, way down.”

New vaccine mandates are being rolled out at VA, in California, New York City, the Mayo Clinic, among other places.

Thanks to Dick Dion, MD

Dan Diamond 7:30 p.m. EDT in the Washington Post

Faced with the explosive growth of a new virusvariant, the state of California and the city of New York gave workers a choice: Get vaccinated or face weekly testing. And an array of hospitals from coast to coast, including the prestigious Mayo Clinic, declared they would require staff to get vaccinated, following a joint plea from the nation’s major medical groups.

Health-care leaders say the moves represent an escalation of the nation’s fight against the coronavirus — the first concerted effort to mandate that tens of millions of Americans get vaccinated, more than seven months after regulators authorized the shots and as new cases rip through the nation. VA’s mandate applies to more than 100,000 front-line workers, New York City’s applies to about 45,000 city employees and contractors, and California’s applies to more than 2.2 million state employees and health workers.

“You can call it a tipping point,” said Mark Ghaly, California’s health secretary, noting that millions of people have declined the shots despite public health experts’ appeals and a range of incentives. “For so many Californians and Americans, this might be the time to get vaccinated.”Residents wait in line to receive a coronavirus vaccine in January at a nursing home and rehabilitation center in New York City. (Yuki Iwamura/AP)

Ghaly noted that in California, about 900 coronavirus cases in mid-June were severe enough to require hospitalization versus nearly 3,000 now, driven by the hyper-transmissible delta variant. “As we stare down schools opening up in just a matter of a couple of weeks, as we look at the projections with delta, we felt now is the right time,” he said.

Confirmed coronavirus infections nationwide have quadrupled in July, from about 13,000 cases per day at the start of the month to more than 54,000 now, according to Washington Post tracking. Hospital leaders in states such as Alabama, Florida and Missouri have implored holdouts to get vaccinated, citing data that the shots preventthe most severe forms of the diseasethat lead to hospitalization and even death.

“We have reached a confluence where health-care workers want vaccine mandates, and government is responding,” said Ezekiel Emanuel, a bioethicist at the University of Pennsylvania who organized the joint statement from nearly 60 medical groups, including the American Medical Association and the American Nurses Association, urging every health facility to require workers to get vaccinated.

In facilities like ours, we have a number of immunocompromised individuals. Some have had no protective antibody response to the vaccine. Even so, we might feel safe and remain unmasked because we have herd immunity–virtually 100% of the residents have received the two doses of COVID-19 vaccine.

But wait! Are we really safe. 20% of our staff goes out into the community daily, unimmunized by choice, and exposed to the rapidly spreading delta COVID variant. All staff are masked to be sure. But these are not N-95 masks and the staff often works close to us in various venues. Waiting for a positive COVID test or symptoms is not a useful strategy here.

We’ve tried education and hesitancy support–but this is a continuing public health crisis! Many universities and businesses are instituting vaccine mandates. Many hospitals and nursing homes are also.

It’s time for all staff to be vaccinated unless there is a medical contraindication. This is not a political issue! Let’s value and protect our most vulnerable.