When COVID-19 vaccines began rolling out in Colorado nursing homes at the start of the year, many people thought residents would soon be able to return to their pre-pandemic lives — but reality has turned out to be a bit messier.
As evidence mounts that the delta variant of the virus may be more likely to cause “breakthrough” cases in fully vaccinated people, especially senior citizens and those with compromised immune systems, the state and nursing home operators are putting renewed emphasis on wrapping the most vulnerable in multiple layers of protection.
Last week, the Colorado Department of Public Health and Environment announced it was tightening rules meant to keep the virus out, and two organizations that run a combined nine nursing homes in the state said employees will have to get the vaccine or find other work. The state has not mandated vaccines for nursing home staff.
Denver took even more aggressive action, requiring anyone working in long-term care facilities or other high-risk locations to get vaccinated by Sept. 30.
Efforts to get Colorado nursing home residents vaccinated were largely successful: about 88% of residents statewide have gotten the shots, and COVID-19 numbers have plummeted. In December, more than 2,152 residents tested positive, and 537 died; in July, the state saw 58 cases in nursing homes and 10 deaths, according to data from the Centers for Disease Control and Prevention.
Still, the picture isn’t entirely positive. Cases in Colorado nursing homes increased slightly from June to July, and nationwide, they more than doubled, according to The New York Times.
In late June, a team from the CDC visited Mesa County to investigate an outbreak of breakthrough cases in nursing home residents, possibly sparked when an unvaccinated staff member unknowingly brought the virus to work.
And the percentage of breakthrough cases in Colorado nursing home residents has increased. In April, none of the people who tested positive in nursing homes were fully vaccinated; in June, almost half were; and in July, 70% of nursing-home cases were breakthroughs.
Some growth in the percentage of cases caused by breakthroughs is expected, as the pool of unvaccinated people shrinks. Still, it’s notable that the increase happened as the delta variant increased its foothold in Colorado. In the week of April 18, about 0.4% of the COVID-19 tests chosen at random from around the state for genetic sequencing contained delta. Three months later, 100% of the samples in the week of July 18 did.
Taking a stand
Randy FitzGerald, regional executive director for the Good Samaritan Society, said a slight rebound in cases in July showed it was time to require all staff to get vaccinated. The organization owns nursing homes in Fort Collins, Greeley and Simla.
About 60% of staff providing care nationwide have gotten the shot, but with the delta variant spreading, it was clear education alone wouldn’t convince the rest fast enough, FitzGerald said.
“It was time for our organization to take a stand,” he said.
Genesis Healthcare, which owns six long-term care facilities in Colorado, also announced this week that its workers would have to get vaccinated. Nationwide, the company employs about 70,000 people.
In the same week, the state reinstated an order requiring even vaccinated people to wear masks anywhere inside a long-term care facility. Vaccinated staff of assisted living facilities had been able to go maskless since early June. Nursing homes still had to follow a stricter federal requirement that all staff wear masks around residents, so the only change was extending that to other areas on nursing home property, like offices, said Doug Farmer, president and CEO of the Colorado Health Care Association.
The state also increased testing requirements. In recent months, all staff had to be tested weekly, but now, unvaccinated staff also have to take a daily rapid test.
State epidemiologist Dr. Rachel Herlihy estimated the vaccines are currently providing about 80% protection against any COVID-19 infection, with higher effectiveness in preventing severe illness and death. It’s still unclear how common it is for vaccinated people to spread the virus.
“We know that the vaccines are highly effective, but they are not 100% effective, and so vaccine breakthrough cases are going to be expected,” she said.
Vaccines work by training the immune system to recognize a specific virus, essentially allowing the body to build up forces to attack that virus. People whose immune systems are weakened by age or health conditions have a harder time responding, so they’re at a higher risk of getting sick after vaccination than healthy people — though still better off than they would be without the shot.
A study of 50 people employed by Oregon Health and Science University found vaccinated participants who were older than 70 produced only about 15% as many antibodies as those in their 20s. The antibodies they looked at bind to the virus, to stop it from entering cells. While that’s only one part of the body’s defenses, it’s an important one, and lower levels could be a sign that a person isn’t as well-protected as others, said Fikadu Tafesse, an assistant professor of microbiology and immunology at OHSU.
“The younger the person, the more antibodies they produce,” he said.
It’s not yet clear what level of antibodies is necessary to fend off the virus, so knowing your individual levels won’t tell you much, Tafesse said. There is evidence that older people are more susceptible to breakthrough infections, however, which suggests their less-robust response to the vaccine may be significant, he said.
“They need to be more careful, especially with the delta variant,” he said.
Since older people’s immune systems may not be as effective in fighting the virus, the focus is starting to shift toward preventing them from being exposed in the first place.
Most nursing homes would support a vaccine mandate if it also applied to other health care settings, to prevent employees who don’t want to get the vaccine from leaving for a hospital or doctor’s office, Farmer said. He estimated about 71% of nursing home employees statewide are already vaccinated.
“If you mandate it for one sector and not another, you’re going to have employees move,” he said.
Denver’s mandate covers most settings where nurses or aides could work, including long-term care, hospitals, clinics, emergency medical services and home health agencies. Without a statewide mandate or action in the surrounding counties, it’s possible that staff who don’t want the vaccine will just find work outside the city, though.
When asked why Colorado wasn’t mandating the inoculation of nursing home staff, the state health department said in a statement that it is committed to making the vaccine “accessible” for staff and residents of long-term care facilities. It also said additional measures to control the virus could become necessary as the situation evolves.
“Our experts will continue to monitor virus data so we can make mitigation decisions that best fit Colorado’s residential care facilities,” the statement said. “When instituting more stringent measures, we must give consideration to stopping the spread of COVID, and also the quality of life for both staff and residents.”
FitzGerald said the Good Samaritan Society homes are making staffing plans in case some employees leave, but it’s possible a mandate also will attract people who want to work in the safest environment possible. If they can keep the virus out, residents can safely continue eating together and doing group activities with distancing, he said.
“We still feel the virus is a very real threat,” he said.
The overall community’s vaccination rate may be even more important than the rate among staff, though, Farmer said. If the virus is spreading widely in a community, the odds that a handful of unvaccinated employees or visitors will bring it in are much higher than they would be if the area had a higher rate of protection, he said.
“If we have any hope of keeping this out of nursing homes in the long run, it’s got to be at the community level,” he said.