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A New York State Department of Health (NYSDOH) report says the coronavirus outbreak that has afflicted nursing homes throughout the state may have resulted from staff and visitors unknowingly infecting residents early in the pandemic.
“Unfortunately, we did not understand the disease early on, we did not realize how widespread it was within our community, and therefore, it was able to be introduced into a vulnerable population,” said Dr. Howard Zucker, New York State commissioner of health, in a NYSDOH press release.
According to data submitted to NYSDOH by New York nursing homes, approximately 37,500 nursing home staff members, or one in four of the state’s approximately 158,000 nursing home workers, were infected with COVID-19 between March and early June 2020.
During the same period, more than a third of the state’s nursing home facilities had residents that were sick with the virus, the report said. Of the infected nursing home staff members, nearly 7,000 were working in facilities in the month of March.
Other studies suggest even higher numbers. A May 2020 serological study, conducted by the lab BioReference, of roughly 3,500 nursing home employees in New York state found that 29% of the nursing home staff tested positive for the COVID-19 antibodies. This means up to 45,820 nursing home staff were infected by May, or nearly one in three workers.
“It is likely that thousands of employees who were infected in mid-March transmitted the virus unknowingly—through no fault of their own—while working, which then led to resident infection,” the NYSDOH report stated.
There had been speculation that the high infection rate at New York state nursing homes was due to the facilities admitting COVID-positive residents, however, the report said that is unlikely as state law requires that a nursing home only accept a COVID-positive patient if the facility can provide adequate care. In this instance, that specifically speaks to a nursing home’s ability to properly isolate patients and follow protective procedures, according to the report.
In cases where nursing homes cannot provide adequate care and protective measures for COVID-positive patients, various alternative facilities are available throughout the state, the report added.
“There was no need for nursing homes to accept COVID-positive patients if they could not provide adequate care in a safe environment, as required by state law, as there were alternatives available facilities for such patients,” the report said.
The report instead suggested the viral outbreak in nursing homes was likely due to a lack of knowledge early on about how the virus is spread through nursing home employees and visitors.
In March, the federal government’s Centers for Disease Control and Prevention (CDC) did not suspect asymptomatic people were likely to spread the infection, the report explained. With this in mind, the CDC issued guidance on March 7 stating certain asymptomatic healthcare employees exposed to others with the virus were “not restricted from work.”
“This early, and ultimately erroneous, understanding of viral spread allowed many nursing home COVID-positive employees to continue working,” the NYSDOH report stated. “It was not until much later, as the true number of asymptomatic cases became clear, that evidence based upon contact tracing established definitively that asymptomatic people were in fact capable of spreading the virus.”
Additionally, the CDC issued March 16 guidance stating nursing home employees who were symptomatic but not tested should wait only three days after the symptoms had passed to return to work and only seven days after the COVID-19-like symptoms first appeared.
As more was learned about the virus, the CDC issued updated guidance on April 13 for asymptomatic workers and April 30 for symptomatic workers. The guidance increased isolation to 10 days, however, data show the disease was already at its peak in New York nursing homes by that point, the report stated.
“It is likely that a significant percentage of both mildly symptomatic and asymptomatic employees were advised to continue working during March and April and thus unknowingly spread the disease within the facility,” the report said. “The entire situation was further compounded by the lack of testing nationwide capacity in March, making it impossible to have an accurate assessment of which nursing home staff were COVID positive.”
Beyond the risk posed by COVID-positive employees was the risk from COVID-positive nursing home visitors. The report explained that prior to nursing home visitation being suspended in New York state on March 13, there was no tracking or testing of family and friends within nursing homes. At that point, any asymptomatic or symptomatic visitor could have been granted access, the report contended.
“Given what we now know about how widespread the virus was in New York prior to testing availability in February and early March, there is a high likelihood that COVID-positive visitors entered nursing homes, although there is no specific data to support this assumption,” the report added.
NYSDOH later issued updated guidance to nursing homes asking them to examine their supply of personal protective equipment (PPE) and mandating staff temperature checks at the beginning of each shift and staff use of face masks. The guidance also mandated that nursing homes cancel all congregate activities.
Additionally, New York Governor Andrew Cuomo issued an executive order banning all nursing home visitation statewide, expanding on an order issued days earlier on March 7 in New York’s first known hot spot, New Rochelle.
On May 10, New York state mandated twice-weekly testing of staff for nursing homes in regions of the state in phases I and II of reopening, and once-weekly testing for all nursing homes in phase III and beyond.
NYSDOH surveyors and epidemiologists conducted calls, video assessments, and in-person assessments to determine compliance, and nursing homes found to be in non-compliance had the potential to lose their operating license, the report stated.
“Our analysis brings to the forefront the possibility of transmission from staff as an important mode of transmission,” the report said. “If states had accurate information about COVID transmission at an earlier time and had the testing capacity to detect asymptomatic but infected individuals, other procedures might have been taken.”
New York state has approximately 100,000 nursing home residents in 613 nursing home facilities statewide. Although an analysis conducted by the Kaiser Family Foundation in 2017 found that New York state has more nursing home residents than any state in the U.S. despite being the nation’s fourth most populous state, New York’s nursing homes fatalities are not disproportionate to the rest of the country, the report said.
Indeed, the report pointed to a New York Times analysis which found that New York state ranked 46th in the nation in terms of its percentage of total deaths in nursing homes. This means 45 U.S. states have had a greater percentage of COVID fatalities within nursing homes so far, the report stated.
“These are national issues that must be addressed (e.g. better training of staff, enhanced and rapid testing, and better coordination with other healthcare facilities) as nursing homes and other congregate settings will pose a continued risk for the coronavirus or another public health threat in the future that attacks older adults,” according to the report.
New York state identified its first case of COVID-19 in an international traveler on March 1. Since then, congregate settings such as nursing homes have been particularly vulnerable to the virus. In New York, the first known introduction of COVID-19 within a nursing home occurred on March 5 when a nursing home staff member tested positive, and the first confirmed case of COVID-19 in a nursing home resident occurred on March 11.
“When we saw the rise in deaths in the nursing homes, the public health leader, scientist, the doctor in me, and most importantly, the son with his own recent memories, kept asking himself, ‘What happened?'” Zucker said. “It is important to know why, because it matters. It matters for New York, it matters for the nation, it matters to prevent repeating behaviors, and it matters to bring closure for families.”