How the numbers have changed since April 6, 2020, the last time I shared an update about the number of confirmed cases of COVID-19. Sources: Johns Hopkins COVID-19 Interactive Map and the Maine CDC. (Time: 10:45 am)

  • Number of confirmed cases of COVID-19 around the world: Was 1,362,936 and is at this moment 2,499,723.
  • Number of confirmed cases of COVID-19 in the United States: Was 368,449 and is at this moment 788,110.
  • Number of confirmed cases of COVID-19 in Maine: Was 499 and is at this moment 875.

These numbers only tell part of the story. There are other important numbers: People who have died, people who have recovered, for instance. The sources I cited above should have those other numbers. And there are so many questions to ask. What’s being done here in Maine and other states to help “flatten the curve”? How has it been working? When will things ease up? When will it be safe to resume our normal lives again? What might that normal actually look like? How are people coping? What lessons are we learning? Lots of questions and one of the people I trust for answers — insightful answers — is Dr. Dora Anne Mills. She was the director of the Maine CDC and the State’s Health Officer for 14 years. She is currently the Chief Health Improvement Officer for MaineHealth.

Dr. Mills has been sharing information about COVID-19 on her Facebook page. She calls them Not-So-Brief COVID-19 Updates. Because not everyone is on Facebook or has access to the information, with her permission, I will be sharing some of them on the Catching Health blog. This is her latest update, which she posted Monday, April 19th at 11:00 pm. Thank you, Dr. Mills.

Nursing Homes: Canaries in the coal mines?

Coal miners used to carry caged canaries with them deep into the mine tunnels. Since dangerous gases would kill the canary before the miners, the canaries provided a warning to exit immediately. Are our nursing homes like canaries in the coal mines?

As of Friday, 20% of all reported cases of COVID-19 in Maine are from recent outbreaks in five long term care facilities. 112 residents and 52 staff from these facilities – three in the Portland area and one each in Belfast and Augusta – have tested positive, and nine deaths have been recorded. The New York Times reported on Friday that nationally, about one-fifth of all deaths from COVID-19 are from long term care (LTC) facilities. That represents at least 7,000 lives. In some states, such as New Hampshire and Washington, one-half of all COVID-19 deaths are among LTC residents.

A Kirkland, Washington LTC facility served as an early warning, with an outbreak that started in February and was eventually linked to 43 deaths. By early March, the federal government (Centers for Medicare and Medicaid, CMS) issued guidance and subsequent requirements for LTCs to shut down to visitors and screen all employees each shift for fever and symptoms.

Maine’s LTC community came together very quickly to address the issues. Although I have engaged with this community intermittently for years, they are not a group I routinely work with. However, after reading what occurred in Washington state, I started attending their meetings (all online, of course) to help address the threat of COVID-19 in Maine LTCs.

The collaboration and communication among many members of this community have been remarkable. For instance, to name just a few examples: Danielle Watford from the Maine Health Care Association started issuing frequent COVID-19 updates to LTCs; the Maine CDC started a weekly call for LTCs to provide guidance and answers to questions; MaineHealth’s Senior Living Collaborative with over 40 LTC members quickly pivoted to focus on COVID-19 and opened its online meetings and resources to others; and MaineHealth’s geriatric leaders (Drs. Richard Marino and Heidi Wierman) have convened a weekly call of geriatric providers in LTCs. It seemed extraordinary how quickly the community came together, regardless of affiliation, and how easily they have shared information and resources with each other. Clearly, they have stepped up in the spirit of trying to do what is best for residents and their families in the face of a looming crisis.

As a result of these and other efforts, many Maine LTCs took additional steps to keep residents safe. This included early adoption of taking temperatures of employees as they arrived for work as well as stockpiling and learning how to properly use and extend PPE.

Although there was an early outbreak at Oceanview, a senior living community in which most residents live in separate homes, it appeared perhaps Maine’s early and aggressive steps were working. Maybe, just maybe, we might escape the widespread LTC outbreaks seen elsewhere.

That all changed about 10 days ago when an outbreak at Tall Pines in Belfast was reported. This was quickly followed by outbreaks at the Augusta Center for Health and Rehabilitation, the Maine Veterans’ Home in Scarborough, The Cedars in Portland, and Falmouth by the Sea.

Although there have been media reports about the poor ratings of one of these facilities, most are highly rated by CMS. Two leaders in this field shared with me that the facilities among these five they are most familiar with were aggressively vigilant and early adopters of new guidance to keep their residents safe. It appears no LTC facility is immune from COVID-19.

Lessons learned

What lessons can we learn from these outbreaks? Certainly, time will provide the clearest lessons. As I often say, “epidemics are lived forward and understood backward” (with deference to Kierkegaard). But even in the midst of this crisis, I think that like the coal miners, these outbreaks should make us pause to hear what the canary is trying to teach us.

A cautionary tale

First, what is most striking to me is that these outbreaks provide us a window into what would happen if social distancing stopped across our communities at this point in time since LTCs are one of the few places in which social distancing cannot fully occur. It is clear from the way the virus has snuck into these facilities across a wide swath of Maine and swept across them, that the virus is circulating in the state. It is also clear that it spreads like a brush fire when people are living or working together. The rapid spread in LTCs is certainly a cautionary tale about the need for continued social mandates for now.

Although the susceptibility of LTC residents to severe disease with COVID-19 is likely responsible for the relatively high number of fatalities seen there, the rest of us are not immune. According to preliminary US CDC data from this country, nearly one in five people with COVID-19 ages 20 – 44 is hospitalized; one in four ages 45 – 64; over one in three ages 65 – 74; and about half of those 75 and older are hospitalized. So, like the coal miners, we should pay attention to LTCs as if they are our canary warning us.

Silent transmission

Second, although Maine’s hospitalizations have started to flatten a bit the last few days, the numbers of new cases of COVID-19 and deaths have continued to increase, and likely these possible trends are related to the LTC outbreaks. When an LTC is determined to have an outbreak, defined by at least three cases among residents and/or staff, then currently, Maine CDC is recommending all residents and staff be tested. With five LTCs meeting the definition of having an outbreak, several hundred residents and staff have been tested. This has resulted in 164 new cases of COVID-19 in the last 10 days. Many if not most of these are reported to be asymptomatic. According to very preliminary data elsewhere, this means many will go on to have symptoms, though a significant proportion (~18 – 30%) may not. Because many residents in LTCs have advance directives asking not to be hospitalized, many have remained at the LTC for treatment and comfort measures. Sadly, several have passed, contributing to the increases in deaths in the last 10 days.

The LTC testing here and elsewhere has reinforced one of the biggest lessons of the last few weeks about COVID-19 – that there is quite a bit of silent (asymptomatic) transmission of this virus. This also raises the question of why all LTC residents and staff are not tested on an ongoing basis. Preliminary data from across the country at this point in time indicate that with one or two cases in an LTC, isolation and quarantine measures can work to prevent the spread. It is also uncertain what to do with negative test results and how often to repeat the test, especially given the high false-negative rates with the current tests. (High false-negative rates with the PCR test are mostly due to challenges in obtaining adequate samples since the swab must be placed deep into the nose and kept there for a relatively long time.) However, testing supplies are also very limited, making it important to adhere to some standards that also provide some sensible limits. Otherwise, testing may not be available for other patients in other settings.

But with this said, these standards could change. Remember, this is the first pandemic with a coronavirus. And this is a novel coronavirus. Data are being shared with new lessons learned every week. And new tests are being developed, so the standards for testing in LTCs could change.

A microcosm for our society

One lesson I believe the LTC outbreaks teach us as we look to the future is that LTCs are a microcosm for our society. What we need to do to contain the pandemic in our communities, in our state, and across the country, are the same overall strategies we need for LTCs. For instance, in all of these settings – LTCs and across our communities – we need adequate healthcare resources to care for those sick with COVID-19, including during unexpected outbreaks. Normally, empty beds and extra staffing are considered healthcare “fat” that needs to be cut. However, with an ongoing threat of outbreaks for the foreseeable future, we need to make sure there are sufficient staffing and beds to quickly ramp up, including assuring there are enough LTC staff to safely care for multiple patients sick with COVID-19.

Both settings need plenty of PPE as well as training on how to use it properly. For instance, how PPE should be donned, doffed (taken off), re-used, and preserved has significantly changed over the last few weeks. Because of worldwide shortages of PPE, it is critical it be re-used and preserved using safe strategies aligned with CDC guidance. But it is also critical it be donned and doffed in ways to prevent the spread of the infection. In fact, most experts recommend peer monitoring, i.e. having peers monitor how one is adhering to infection control procedures such as donning and doffing PPE when caring for patients with COVID-19. This is to make sure it is done without possible contamination and spread of the virus. Training and peer monitoring are challenging to implement in hospitals, and even more so in LTCs.

Strategies

Ongoing social distancing – to one degree or another – is also clearly going to be needed across our communities as well as in LTCs until we have herd immunity, which is likely not until there is sufficient vaccine. Social distancing in LTCs needs modified strategies because of the close proximity residents and staff must have. As challenging as it has been to limit visitors and group activities, it seems those strategies may have to be used for a while. Cohorting residents and staff is another recommended strategy in such settings. Cohorting refers to the grouping of individuals who are positive for COVID-19 in the same location (e.g. a wing or unit) in order to minimize risk of exposure and infection from others. Likewise, cohorting can be done with those who are negative for COVID-19 or with who have been exposed to the virus but who test negative.

Along with social distancing, there is the need for identifying cases early, isolating (or cohorting) them, identifying contacts, and taking steps to ensure the contacts are not spreading the infection. These strategies call for an increased public health workforce – across our communities as well as in LTCs – to work intensely with health professionals, patients, their contacts, and families, as Maine CDC staff have been doing.

Testing

Then there is testing. The largest common denominator to addressing this pandemic in LTCs and across our communities is testing. We routinely test large swaths of the population for much slower-moving infections, such as testing all pregnant women for HIV/AIDS. We routinely test someone mildly ill with a fever for influenza or someone with a sore throat for strep. But at this time, we do not have enough testing supplies across this state and country to test those with symptoms of COVID-19 or routinely test those who may be at risk for the infection, such as those in LTCs.

Without easily accessible and preferably rapid testing, we are like the coal miners descending blindly into dark tunnels. The LTCs have provided us a canary – the rapid spread of this pandemic within these facilities and the tragic resulting deaths. These outbreaks show us what can happen if we were not practicing social distancing. However, without mass testing, we cannot easily detect outbreaks in our communities and risk overwhelming surges as social distancing loosens.

Heroes

Meanwhile, it is important to recognize the many heroes in this pandemic. High on my list of heroes are the thousands of Maine women and men who work in our senior living facilities – LTCs, nursing homes, skilled nursing facilities, assisted living facilities, congregate housing, etc. They have been placed in unprecedented and what must seem like surreal situations, without the usual support of residents’ families and facing this pandemic that can slither silently. But they are carrying on – shining a light by caring for some of our most vulnerable, revered, and beloved members of our families and communities. Thank you!

Dora Anne Mills, MD, MPH, FAAP

Additional information

Podcast of Dr. Mills’ updates

Dr. Mills’ daughter started a podcast where she has been reading her mother’s updates. Here’s the link to the latest update. You’ll find the previous ones there as well.