Opinion Piece: To test our way out of the COVID-19 nightmare, focus on nursing homes

Less than 1% of Americans live in nursing homes, yet these facilities account for between 15% and 25% of Covid-19 cases and half of all deaths from the disease in some states; in Minnesota, nursing home residents and workers account for 81% of all Covid-19 deaths.

If we hope to contain SARS-CoV-2, the virus that causes Covid-19, until we have better treatments or a vaccine, we need a concerted national testing effort focused on nursing homes. From a public health perspective, they are not only areas of focused harm but are also wells of infection that may keep the pandemic rolling unless we take drastic steps.

The transmission rate for the virus was as high as five in February and March, meaning each person infected with it spread it to five others. The transmission rate is now probably down to two, with some local variation, so we have made progress. More is needed: to contain the spread of the virus we must drive the transmission rate below one.

Nursing homes offer a potential opportunity to contain the virus in a targeted way that benefits those who live in them, those who work in them, and everyone else. If we focus our efforts on testing all nursing home residents and workers, we may be able to drive down transmission rates in ways that have eluded us so far.

Workers in nursing homes care for the most vulnerable members of society in intimate ways, helping them dress, bathe, eat, and go to the toilet. They are vital to the care system of the elderly in our nation, though they are not paid that way and most are not given enough personal protective equipment and do not receive paid sick time.

This reality is likely behind the initial outbreak at the Life Care Center of Kirkland, a nursing home near Seattle.

Workers in these facilities are at great risk of occupational exposure to the coronavirus, but they also pose a risk of transmitting it more widely — bringing it into nursing homes from the community and spreading it to the community from nursing homes. This transmission risk is heightened by the fact that many individuals work in more than one facility. Another source of infection entering nursing homes is elderly people who have been discharged from the hospital to nursing homes after things like hip fractures or heart procedures for short rehabilitation stays. In many nursing homes, long-term patients live just down the hall from those who will be there for a few days or weeks only, and this mixing helps spread SARS-CoV-2.

The nation must mobilize so every state has the capacity to test all patients and workers in every nursing home across the country. We need to do this in a way that generates solid scientific evidence about how testing should be undertaken in nursing homes. That effort should answer a series of critical questions, including what tests should be deployed, how often asymptomatic workers and residents should be tested, and how long sick workers must be quarantined before they can return to work. We should also investigate how to most effectively isolate infected patients within nursing facilities, and whether a testing program can safely enable family members to visit their loved ones.

There are numerous details to be ironed out, and this work will be hard and expensive. But there are experts who have given their life’s work to these topics, and we need to empower them to work out the details about how to implement testing programs in nursing homes while ensuring that a focused national effort provides the needed resources to support this effort.

It will take federal money to do this — testing all residents and nursing home staff nationally just once would cost $440 million, and repetitive testing will be needed for some time to control the spread of SARS-CoV-2 in nursing homes. The cost of widespread testing will be enormous, but so too is the cost of the quiet default that we seem to be settling for that normalizes infection, death, and isolation of elderly nursing home residents and continues to put the workers who care for them at risk.

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