Jay Meyerowitz, a geriatrician in private practice who serves as the medical director of two New Jersey nursing homes, thought he was done getting phone calls about coronavirus infections in the facilities. The early months of the pandemic had been brutal. Many of the nursing-home residents had died of COVID-19; Meyerowitz, his partner, his daughter, and his medical-practice partner and best friend were sick with the disease last spring. But, in the past six months, Meyerowitz had seen no cases in either of the two facilities he oversees. Under the state’s reopening plan, the homes were in Phase 3: they had restored visitation, communal dining, and group activities. In January, when the vaccine became available to long-term-care facilities, every one of the residents and a majority of the staff in the two homes opted to be vaccinated. Then, on April 12th, Meyerowitz learned that a nursing assistant had tested positive.
The result came from a routine test conducted the previous Friday. Now the facility retested everyone. On April 13th, the results came back: three residents, all of them elderly men, were positive, although all were asymptomatic. On the 14th, a nurse developed mild symptoms and tested positive. Two days later, another resident tested positive. Two days after that, another nurse—the partner of the first person to test positive—developed symptoms, also mild, and tested positive. All of the positive results came from a single unit of the nursing home. The first and last person to test positive—the couple—had not been vaccinated. But the others had been.
Meyerowitz was shocked. “I should have known” that infections after vaccination were possible, he told me when I visited him at his house in Fort Lee. “But I just didn’t imagine it. I was lulled into a false sense of security.” His regular infectious-diseases consultant, Benjamin De La Rosa, told Meyerowitz that the breakthrough infections shouldn’t surprise him. “It’s a perfect setup for this to happen,” De La Rosa told me on the phone. “You have vulnerable residents, older, often recovering from a hospitalization, living in congregate settings, many of them in semi-private rooms. Many of the buildings are older, with poor ventilation.” In other words, all the conditions that made long-term-care facilities particularly vulnerable to the coronavirus a year ago are still in place.
The difference is the vaccine: at many assisted-living facilities in the state, all or almost all residents have been vaccinated. Numbers at shorter-term facilities, such as rehabilitation centers, are lower, ranging from zero to about seventy per cent of residents. But the most striking gap is between rates of vaccination among staff and those among residents. At many facilities where every single resident has received the vaccine, fewer than half of the staff have. “One of the obstacles to herd immunity is hesitancy on behalf of the staff,” De La Rosa said. As long as the virus is circulating in the community, an unvaccinated staff member can pick it up and bring it to the nursing home, where conditions may make the otherwise rare breakthrough infections more likely.
The Centers for Disease Control has been tracking reported breakthrough infections in the United States. As of April 20th, fewer than seventy-two hundred had occurred among the more than eighty-seven million people who were considered fully vaccinated. Most of these infections had been asymptomatic, but eighty-eight people had died. These numbers indicate that breakthrough infections are extremely rare, but De La Rosa suggested that they may be a low estimate. Asymptomatic vaccinated people are unlikely to find out that they are infected unless they live or work in a place, like a long-term-care facility, where such tests are performed routinely.
On Wednesday, the C.D.C. published a report of an outbreak of COVID-19 at a nursing home in Kentucky, where more than ninety per cent of the residents but just under fifty-three per cent of the staff had been fully vaccinated. Just as in New Jersey, the outbreak began with an unvaccinated staff member. In the Kentucky home, forty-six people—twenty-two of them fully vaccinated—ended up becoming infected, and three residents died, including one vaccinated person. Still, in the final analysis, the vaccine appeared to be more than eighty-five-per-cent effective against symptomatic disease and more than ninety-four-per-cent effective against hospitalization.
“Jay seemed mortified when he called me,” De La Rosa said, of the New Jersey outbreak. “But I reassured him. The vaccine is working. If they are not severe, or are asymptomatic, I don’t know that it’s so bad.”
An outbreak at a long-term-care facility, however small, triggers a set of quarantine measures. In New Jersey, visitation is suspended, as are all community activities. Residents have to eat in their rooms, using paper plates and disposable utensils. Bingo, music, discussions of current affairs, and other socializing in the common room and on the grounds cease. Residents who have tested positive are confined to their rooms for two weeks. Every new positive test result starts the clock anew. Isolation, in turn, leads to depression and heightened levels of anxiety. Residents who suffer from mild dementia, Meyerowitz said, had a particularly difficult time coping with the restrictions. All of these measures are particularly painful more than a year into a pandemic that has killed nearly eight thousand residents and staff of long-term-care facilities in New Jersey, accounting for more than a third of the state’s total COVID-19 deaths.
“I’m traumatized,” Meyerowitz told me. He and his family members had mild cases of COVID last spring, but his medical partner, Joseph Rizzo, who is fifty-nine and has diabetes, became very ill. “He was admitted to the hospital, the one we work at, with double pneumonia,” Meyerowitz said. “They told me he’d be intubated.” It fell to Meyerowitz, who could physically be in the room with Rizzo, to help his friend FaceTime his loved ones before the planned intubation. “I held the phone and he said goodbye,” Meyerowitz said. “And then he starts crying, and then I start crying, and we had to do it five times”—with Rizzo’s wife, his two children, and his two brothers. “He was in full cytokine storm,” Meyerowitz said, referring to the state of immune-system overdrive that can make COVID-19 deadly.
Then, however, the hospital obtained tocilizumab, a rare and expensive drug used to treat rheumatoid arthritis, and Rizzo made what looked like a miraculous recovery. He didn’t end up needing intubation and was discharged from the hospital three days later. Rizzo told me on the phone, however, that he was bedridden for a month after being discharged, and continues to suffer from “brain fog” and short-term-memory loss; he assumes that these are the aftereffects of low oxygen supply to the brain. He has stopped practicing medicine.
Meyerowitz, who is sixty-two and has been practicing medicine for half of his life, gets excited when he talks about what he calls the “great state of medical technology”—the drug that saved Rizzo’s life and the technology behind the mRNA vaccines. When residents and staff of long-term-care facilities became eligible for the vaccine, in January, Meyerowitz urged everyone to take it. All the residents did, but a third of the staff refused. “There was not one religious concern that I heard,” Meyerowitz told me. “All of it was based on believing disinformation about vaccines: ‘I haven’t been sick yet so I won’t get sick’; ‘I have O-positive blood’; ‘It’s too new.’ And these are people with bachelor of science, or bachelor of science in nursing, degrees!”
Two hundred and thirty-three long-term-care facilities in New Jersey currently have active outbreaks of COVID. A spokesperson for the state department of health pointed out in an e-mail to me that a year ago the state had more than twice as many active outbreaks, and many more deaths. Still, months after every resident and staff member at a long-term-care facility had the opportunity to receive the vaccine, hundreds of people are sick and several people a day continue to die from COVID at such facilities in the state. Thousands of people are experiencing isolation because their facilities have imposed restrictions on visitation and social activities. (New Jersey makes these figures readily available—most of the information is on Web sites accessible to the public, and I obtained details by contacting the department of health. My requests for similar breakdowns for long-term-care facilities in New York went unanswered, but available vaccination data tell a similar story: while vaccination rates for residents of long-term-care facilities in New York are well above eighty per cent, rates among staff hover below seventy.)
