The early epidemiologist John Snow studied mortality data during the London cholera outbreak of 1854 and identified dramatically different mortality rates among customers of competing water companies.1 Prominent in the descriptions of Snow’s work is his use of a map showing a hot spot of deaths near what was presumed to be a contaminated well in London’s Soho.1
Unlike cholera in the mid-1800s, which predated modern germ theory, there is no controversy today regarding coronavirus being the infectious agent for COVID-19, and that the virus is very contagious. However, much is still unknown about the risks for COVID-19 disease and why some people become infected, why some infected people have mild disease and others die from it, and which protective actions against the virus are the most effective. Furthermore, the data on the disease prevalence, severity, and mortality are disappointingly weak, given our modern connectivity and the promises of high value from huge investments in electronic medical records.
Although the risk factors vary from country to country and among US states, emerging data from around the globe suggest that nursing-home residents are at exceptionally high risk for contracting COVID-19, with some areas reporting that close to half of regional deaths are either in nursing homes or in a hospital after admission from a nursing home.2
Given that less than 0.5% of Americans live in nursing homes,3 the remarkable concentration of risk in such facilities may have profound implications for how we handle the pandemic. As of June 29, 2020, data from 42 states show that 45% of COVID-19–related fatalities have occurred among residents of long-term care facilities.4 Some states, including Minnesota, Pennsylvania, and Rhode Island, have the nursing home portion of COVID-19–related deaths of more than 70%. Nursing homes are hot spots for coronavirus infection, and they need much more resources and attention than they are currently receiving.
Even if we assume that only 25% of coronavirus-related deaths are of nursing-home residents, the concentration of risk is enormous. The Table shows the extremely high relative risk faced by nursing-home residents, given that approximately 0.5% of Americans live in nursing homes and approximately 99.5% of Americans live outside nursing homes.3
To put the Table into perspective, a relative risk of 1 would mean that nursing-home residents have the same mortality risk from COVID-19 as everyone else. Male drunk drivers aged 16 to 20 years have a relative risk for a fatal crash of approximately 50.5 Patients with stage IV lung cancer under age 65 years have an age-adjusted relative risk for all-cause death of less than 100 compared with all-cause death in the total population.6 Using a rate of 33% of COVID-19–related deaths for nursing-home residents, which is lower than the reported national average of 45%, gives us a staggering relative risk of 98.4 A corollary is that the risk for death among those of us who are not in nursing homes is much lower.
The nation has taken steps to try to protect nursing-home residents from COVID-19. Most of the more than 15,000 nursing homes in the United States7 have been on lockdown since mid-March, with no visitors or communal activities, and residents are largely restricted to their rooms. Despite these steps, COVID-19 continues to spread into nursing homes, likely resulting from asymptomatic staff bringing the virus into the facility.
These actions, however, have come too late for many nursing-home residents and are largely unenforceable, as suggested by a recent report from the New Center, discussing “how we got there and why America allowed its most vulnerable people to be exposed to this deadly virus.”8 According to this report, regulatory actions from the Centers for Medicare & Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) were late to respond in a meaningful way. “Of all actions taken by CMS and CDC on nursing homes, only the new regulatory requirements for reporting nursing home cases to the CDC issued on April 19, 2020, were enforceable. All other guidance issued was not legally binding on states or nursing homes,” the report states.8
Very few nursing-home facilities currently have access to surveillance testing for COVID-19 or adequate personal protective equipment (PPE). Once in the facility, many nursing homes lack the resources to fight the coronavirus effectively. Facilities are not able to cohort residents with the coronavirus, and many staff members are unable or unwilling to work under these conditions.
Given the high COVID-19–related death rate in nursing homes and our current underinvestment in this sector, even a few dollars redirected to fighting COVID-19 in nursing homes would likely have a huge payoff. High-value public health investments may include universal testing of nursing-home staff and residents, adequate PPE for the workforce, additional pay to recruit and retain workers, and resources to segregate residents with COVID-19 safely.
Such investments for testing, PPE, funding workers, and segregating patients with COVID-19 would protect nursing-home residents, and they may also allow us to open the rest of the economy more quickly. Obviously, mortality is not the only concern here, and severe complications from COVID-19 may be more evenly spread across individuals in nursing homes and elsewhere. We clearly need more data, but protecting a large share of high-risk individuals from COVID-19 would also be an important step forward.
John Snow helped to limit the London cholera epidemic by convincing officials to remove the handle of a water pump at the contaminated well. No one is proposing closing nursing homes, but similar decisive investments in nursing homes and other long-term care facilities could be the COVID-19 equivalent “handle” that saves lives immediately.
- Tuthill K. John Snow and the Broad Street pump: on the trail of an epidemic. John Snow site. www.ph.ucla.edu/epi/snow/snowcricketarticle.html. Accessed June 29, 2020.
- Comas-Herrera A, Zalakaín J, Litwin C, et al. Mortality associated with COVID-19 outbreaks in care homes: early international evidence. International Long-Term Care Policy Network; updated May 21, 2020. https://ltccovid.org/wp-content/uploads/2020/06/Mortality-associated-with-COVID-21-May-1.pdf. Accessed June 29, 2020.
- Harris-Kojetin L, Sengupta M, Lendon JP, et al. Long-term care providers and services users in the United States, 2015–2016: data from the National Study of Long-Term Care Providers. Vital Health Stat 3. February 2019:v-78.
- Tolbert J, Hall C, Orgera K, et al; for the Kaiser Family Foundation. State data and policy actions to address coronavirus. Updated June 11, 2020. www.kff.org/health-costs/issue-brief/state-data-and-policy-actions-to-address-coronavirus/. Accessed June 29, 2020.
- Zador PL, Krawchuk SA, Voas RB. Relative risk of fatal crash involvement by BAC, age, and gender. US Department of Transportation; April 2000. www.nhtsa.gov/people/injury/research/809-050pdf.pdf. Accessed June 29, 2020.
- Goldberg SW, Mulshine JL, Hagstrom D, Pyenson BS. An actuarial approach to comparing early stage and late stage lung cancer mortality and survival. Popul Health Manag. 2010;13:33-46. https://pdfs.semanticscholar.org/677a/c75246a71040711d6f668adc961754eb8bd9.pdf?_ga=2.144174773.166456885.1593475491-886875150.1593475491. Accessed June 29, 2020.
- Centers for Disease Control and Prevention. National Center for Health Statistics. Nursing home care. March 11, 2016. www.cdc.gov/nchs/fastats/nursing-home-care.htm. Accessed June 15, 2020.
- Spranovic A. COVID-19 in nursing homes: how could we let this happen? The New Center. June 2020. https://newcenter.org/wp-content/uploads/2020/06/Nursing-Homes-1_compressed.pdf. Accessed June 15, 2020.