Every long-term care resident deserves to enjoy these festivities to the fullest without the risk of acquiring a respiratory virus that may land them in the hospital, or worse. As highlighted during the pandemic, what happens in the outer community is the major driver of viral spread into long-term care centers. So, it is incumbent upon all of us to ensure that our population is equipped to fight off common respiratory viruses, such as influenza, RSV and COVID-19; however, the challenge lies in convincing our nation’s seniors, healthcare workers, and the general public to roll up their sleeves and get vaccinated. 

As a geriatrician and current chief medical officer at the nation’s largest organization representing long-term and post-acute care centers, I have witnessed both the devastating impact these viruses can have and the incredible strides the global medical community has made in developing effective vaccines. We know that these vaccines may not necessarily prevent infection, but they do reduce the risk of severe illness and a potential trip to the hospital or worse — death. 

A need to double-down

Despite these major advancements and historic milestones, we are seeing a decline in the number of individuals willing to receive these vaccines. “Vaccine fatigue” and hesitancy are rampant throughout our society but especially when it comes to the COVID-19 and RSV vaccines. 

A recent KFF survey found that more than half (51%) of all adults say they “definitely” or “probably” will not get the latest COVID-19 shot and two-thirds of the general public are not worried about getting the virus. Meanwhile, only 16% of adults 60 years and older report having received the RSV vaccine. These surveys are consistent with what we’re seeing unfold. 

Recent data from the CDC shows low vaccination rates in the community. While we are seeing the same trends in long-term care settings, it is encouraging that our uptake is higher than in the community. Nonetheless, we need to double-down on our efforts to increase those numbers. 

Much has been written about challenges with vaccine availability or why we should hold more clinics to vaccinate our residents. These are not the reasons we’re seeing slow uptake. While initially the new COVID-19 vaccine was hard to access because it was first sent to commercial pharmacies serving the general public, the vaccine is now more widely available through the pharmacies serving nursing homes. National regulations require nursing homes to educate and offer every resident and staff member the COVID-19 vaccine. 

Harmful ripple effects

The primary issue is that the majority of residents or their family members who are making decisions for them either no longer believe the COVID vaccines are necessary or express fear and skepticism about getting the new shots. We are hearing similar concerns related to the RSV vaccine, despite evidence that it is most effective among the elderly, individuals with chronic diseases, and those who live in a long-term care setting. 

I’m also concerned that this vaccine fatigue and hesitancy is impacting interest in the influenza vaccine, which is lower this year than in pre-pandemic years. 

In addition, there are administrative and insurance reimbursement challenges that need to be addressed. In long-term care, we need vaccines to be readily available to order when a current resident or new admission wants the vaccine. Additionally, those orders need to come with a guarantee that we, as providers, or the pharmacy receives reimbursement from all insurance providers — not just Medicare. Cutting the red tape around reimbursement can help ensure that long-term care providers have access to the vaccine and remain focused on encouraging uptake. One way federal policymakers could take this a step further would be to offer a pool of free vaccines available to long-term care providers. This would eliminate the administrative burden and streamline access to vaccines for residents and staff. 

While free vaccines would be ideal, most importantly we need effective and consistent public health messaging, which is the major driver of the current vaccination rates. We need every provider in every healthcare setting — from the physician’s office, commercial pharmacy, adult day care, hospital and beyond — to discuss the importance of the vaccines with the elderly and their family and address each person’s concerns. 

We’ve come a long way, but … 

Unfortunately, many new admissions arrive to a nursing home or assisted living community without having been offered or received the vaccine during their encounters with clinicians in other healthcare settings. 

Using nursing homes as a stopgap to vaccinate all individuals is ineffective and insufficient. Seniors and families need to be offered the vaccine before they’re admitted to a long-term care facility — and at every subsequent interaction, especially since primary healthcare providers are seen as trusted advisors. Long-term care staff can then help pick up those missed or continue to work to convince hesitant or skeptical residents to get vaccinated. By increasing our education efforts throughout the healthcare community, we can work together to encourage more individuals — residents and staff alike — to get vaccinated.

We’ve come a long way since 2020: COVID-19 is no longer a pandemic, and the mortality rate among nursing home residents remains at record lows. Vaccines are a major reason why, but after three years of battling this virus, Americans have a hard time acknowledging vaccines are still necessary. 

Nursing home providers cannot shoulder the responsibility of combating these deeply held beliefs all on their own. As a country, we need to focus on collectively increasing vaccination rates among the general population and avoid isolating or placing blame on specific communities or individuals. 

Long-term care providers should be applauded for achieving higher vaccination rates than in other settings, but we need a collective endeavor to take this further. 

By having the entire healthcare community and public health system collaborate, we can overcome vaccine skepticism and hesitancy and achieve even better vaccination rates among our residents. In turn, we can better protect our most vulnerable community members. 

David Gifford, MD, M.PH, is the chief medical officer of the American Health Care Association and the National Center for Assisted Living (AHCA/NCAL). 

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

Have a column idea? See our submission guidelines here.

A team from Kaiser Permanente Northern California gave flu shots to more than 1.6 million patients ages 18 to 64 years. A total of 632,962 people received either the high-dose quadrivalent (four-strain) flu vaccine, while 997,366 people got one of two standard-dose vaccines. They were inoculated in the 2018-19 and 2019-20 respiratory virus seasons. The team compared how effective the shots were against infection and hospitalization.

Of the 675,252 older adults who were between the ages of  50 to 64 years, 41.4% received the recombinant vaccine, and 58.6% were given a standard-dose vaccine.

Then the team looked at flu tests. Of 16,340 tests performed, 23.4% were positive for the flu; 38.8% of cases were in people aged 50 to 64 years and 16.7% of them were hospitalized.

Among the older adults, 559 of 1,386 people in the recombinant group developed the flu compared to 925 out of 2,435 people in the standard-dose group. That means there’s a relative vaccine effectiveness of 15.3%.

The four-strain flu shot made by Sanofi is made without chicken eggs. This means it has a recombinant hemagglutinin protein that is genetically identical to the one in the strain of the flu virus — a perfect match.

“In traditional quadrivalent standard-dose inactivated influenza vaccines (SD-IIV4), chicken eggs are used to manufacture the influenza virus,” the authors wrote. “Mutations in the hemagglutinin protein during egg-based manufacturing can result in mismatch between the selected strain and the vaccine strain.”

If standard-dose vaccines were already preventing most cases of influenza and breakthrough cases were uncommon, preventing 15% of breakthrough cases wouldn’t be much of a public health perk, according to the researchers. 

“However, since standard-dose vaccines prevent at most 40 to 60% of influenza cases annually, reducing the incidence of breakthrough influenza by 15% would provide a substantial public health benefit, especially during more severe influenza seasons,” they said.

The scientists used data from the Vaccine Effectiveness, Networking, and Universal Safety study database, which contained data on vaccine records from the 2015-16 through 2020-21 flu seasons. The researchers examined the link between whether or not a person got vaccinated with how often they used antibiotics, sought healthcare, were admitted to the hospital, or had a risk for death. All of the data was based on 244, 642 people over the age of 65 who visited healthcare clinics for upper respiratory infections, or URIs.

The study included 127 ,216 unvaccinated people and 117 426 vaccinated people. The mean age of people who were vaccinated was 82, compared to 77 years old in the unvaccinated group. There were 65.3% females in the vaccinated group, and 61.2% females in the group of people who didn’t get a flu vaccine. 

People who got flu shots had a low risk for frequent antibiotic use, a higher risk ratio for healthcare visits, a lower rate for hospital admission, and a lower rate for death.

“Our results suggest that the seasonal influenza vaccine might help to reduce inappropriate AMU [antimicrobial use] for URIs, although care should be taken when interpreting the results,” the study authors wrote. “This indirect benefit would be another reason to recommend seasonal influenza vaccination to the general population to enhance AMR [antimicrobial resistance] countermeasures in society.”

The authors noted that they only studied older adults, so they weren’t sure if getting flu vaccines was linked to less antibiotic use in children or younger adults. This past summer, a similar study found that the people who received flu shots had fewer prescriptions for antibiotics and needed to be on those antibiotics for less time compared to people who didn’t get influenza vaccinations.

Some parts of the country are seeing increased flu activity, though it’s still low in Colorado, Montana, North Dakota, South Dakota, Utah and Wyoming, lab reports indicate. Levels of flu were stable in other parts of the country.

On the whole, visits to outpatient clinics for flu care expanded by 2.3%. Four regions in the Southeast and West part had slight increases in flu hospitalizations, but the hospitalizations were low in other parts of the country.

When scientists looked at flu samples, 78% were influenza A. Of the subtypes of flu, almost  94% were the 2009 H1N1 virus.

Meanwhile, deaths from COVID-19 increased by 4.2% from the previous week, according to a separate CDC report. The number of deaths from COVID-19 climbed in some states, especially Oregon, the data showed. But emergency room visits dropped by 11.9% compared to the week before, and positive tests slipped by 0.7% to 9.5%.

Hospitalizations for COVID-19 decreased by over 5% compared to the previous week. Levels are low for most of the country, except for parts of the upper Midwest and Northwest US, where several counties are in the moderate range. 

The news comes after White House officials met last Wednesday with other health leaders to discuss how to protect older adults in long-term care facilities from infections. The officials want to increase the amount of people getting vaccines, as this is the first fall/winter season with three vaccines available for flu, COVID-19 and RSV. The group discussed obstacles to getting more people vaccinated, which includes communication challenges and worker shortages.

Nursing homes that conduct rapid, on-site testing of residents who exhibit flu-like symptoms can lead to earlier detection of outbreaks and reduce hospitalization rates, according to new research. 

Facilities using the rapid tests became more adept at “spotting and halting” outbreaks that flu cases fell from 22% in the first year of the study to 3% in the final year, said the researchers from the University of Wisconsin School and Medicine and Public Health. Emergency room visits at facilities that conducted rapid testing dropped by 22%, hospitalizations fell 21%, and the length of hospital stays plummeted 36%, the research said.

“This study demonstrates the profound effect of early detection of influenza in long-term care facilities,’’ said lead author Jonathan Temte, MD, PhD, professor of family medicine and community health at the UW School of Medicine and Public Health. “Nursing homes are collections of very vulnerable individuals, so anything we can do to protect them is very important.”

The study took place in 20 nursing homes in Wisconsin over the course of three flu seasons from 2016 to 2019. Half of the facilities followed their normal flu protocols of testing patients whose symptoms meet the standard definition of influenza. Nasal swabs were sent to off-site labs for analysis, which could take up to three days to communicate results, resulting in a delay of administering antivirals to residents. The remaining facilities used a broader definition of symptoms — sometimes as minor as a new runny nose without an accompanying fever — and used rapid, on-site tests that could yield results in as fast as 15 minutes. The study noted that fevers and other symptoms tend not to present in older patients. 

“The quicker results helped stamp out flu outbreaks,” Temte said. “Time is of the essence for managing influenza because the virus proliferates very quickly.”

Nine of the 10 nursing homes that used the on-site, rapid test wanted to continue with that process after the research ended. The test kits cost approximately $12 each compared to $2,883, which is the cost of an average, per-day hospital stay.

Protecting patients through surveillance could be a critical tool for nursing homes.

While almost all US hospitals mandate flu vaccination for their healthcare workers, comparatively few nursing homes do. Previous studies have shown the long-term care workforce has the lowest share of workers vaccinated against influenza.

Pressure is ratcheting up to ensure coverage, with a new Centers for Medicare & Medicaid Service rule requiring reporting of staff doses received annually between Oct. 1 and March 31. The Influenza Vaccination Coverage among Healthcare Personnel measure was added to the Quality Reporting Program as part of the FY 2023 SNF PPS Final Rule.The study was published in the Journal of the American Medical Directors Association.

The Administration for Strategic Preparedness and Response (ASPR), announced Wednesday that United States jurisdictions now have more access to oseltamivir (Tamiflu), including doses from the Strategic National Stockpile. The move comes after the agency last week extended states the flexibility to use millions of doses stored in state stockpiles and typically reserved for flu pandemics. 

Flu activity started early in the season and remains high, although it seems to be declining in some areas, according to the Centers for Disease Control and Prevention’s latest report. The agency has meanwhile received “numerous anecdotal reports of availability issues for generic oseltamivir,” and cautioned that these shortages may continue in some areas of high flu prevalence.

“Today we are taking action so that every jurisdiction can meet the increased demand for Tamiflu this flu season,” HHS Secretary Xavier Becerra said in a statement. “State stockpiles can be utilized, and if jurisdictions need access to the Strategic National Stockpile, they now have it to respond to the current seasonal flu outbreak.”

In addition, the Centers for Disease Control and Prevention has published a health advisory with interim guidance for clinicians on prioritizing oseltamivir (generic or Tamiflu) during this period of reduced availability. 

When availability of oseltamivir or other antivirals is limited, antiviral treatment should be given to flu patients at the highest risk of severe disease, such as older adults, and those who are hospitalized, the CDC guidance states.

If oseltamivir is unavailable, outpatients at increased risk for complications who present with uncomplicated influenza can be treated with oral baloxavir, inhaled zanamivir, or intravenous peramivir, depending upon age and contraindications, the agency said.

Related articles:

Tamiflu reduces length of hospital stay, readmissions in older adults: study

Speaking at a member webinar hosted by the American Health Care Association/National Center for Assisted Living, Ashish Jha, MD, MPH, outlined factors aimed at reducing the transmission of influenza, COVID-19 and respiratory syncytial virus (RSV) among residents and staff.

Levels of these three respiratory viruses are high, he reported: The worst flu season in the last decade is yet to peak, COVID-19 cases are up by 60% and hospitalizations have risen 20% in the last two weeks and RSV is still filling hospital beds. The concern, Jha said, is that a lot of people will get infected and sick, straining the ability of healthcare systems to care for patients.

But with two difficult seasons behind them, nursing homes have “an opportunity to have a very different winter” Jha said. He recommended that facilities take the following steps:

Ensure that all residents and staff are up-to-date on flu and COVID-19 vaccinations: For the same reasons that last year’s flu shot is no longer effective, new and more immune-evasive variants mean updated COVID-19 shots are needed as well. There is also waning immunity to COVID-19, particularly in older and high-risk Americans, Jha said.

Make good use of treatments and testing: Regular testing of residents for respiratory viruses is a critical step in halting further transmission and identifying who will benefit from treatment, such as COVID-19 oral antiviral pills. The data has shown that people can get Paxlovid “in almost any circumstance,” he noted.

Improve indoor air quality: At least 90% of viral illness is transmitted indoors, and in places without great ventilation, Jha said. Even small measures taken to improve air flow and air cleanliness — such as introducing portable air filters or scheduling HVAC system servicing or upgrades — has been shown to make a dramatic difference in keeping respiratory transmission risk low. 

Jha also asked operators to reach out to AHCA/NCAL and LeadingAge with input on the barriers they face to achieving those goals. For example, “dozens, if not hundreds” of long-term care facilities have reached high levels of vaccination with updated bivalent COVID-19 shots. But others are struggling to do so, with relatively small proportions of residents vaccinated, he said.

Federal agencies are working with industry advocates “to make sure we are actively delivering on and addressing those barriers,” Jha said. “This winter can be different if we work together,” he added.

The full webinar recording is accessible to AHCA/NCAL members.

Related articles:

CDC: RSV hospitalizations soar among seniors while vaccine remains on horizon

New wave of flu cases, COVID-19 hospitalizations hits U.S., impacting seniors

Simultaneous flu and COVID shots work well in older adults, study finds

Forty four U.S. states reported high or very high flu activity last week. Hospitalizations for all three respiratory viruses are straining healthcare systems, CDC Director Rochelle Walensky said in a media briefing.

Preventable deaths

In the briefing, Walensky thanked healthcare workers for their diligent work in fighting repeated viral surges since the pandemic started. 

“We now face yet another surge of illness. Another moment of overstretched capacity and really one of tragic and often preventable death,” she told listeners.

Colder weather and indoor gatherings have likely contributed to the viral spikes, Walensky said. In addition, flu vaccinations are down, with rates for adults aged 65 and older and other vulnerable groups at levels lower than last year. COVID booster vaccine uptake has also lagged in this age group. 

At last count, nursing home residents have received updated booster shots at a rate of 44%, and the same is true of about 31% of U.S. adults aged 65 and older overall. But booster numbers are nowhere near 94%, the rate at which seniors received the original series of shots, NBC has reported. 

Internist Sandra Fryhofer, MD, who also joined the call, said the flu season is off to a rough and early start.

“[W]ith COVID and RSV also circulating, it’s a perfect storm for a terrible holiday season,” said Fryhofer, who is chair of the American Medical Association.

Impact on seniors

COVID cases are rising as well, increasing 27% in the week ending Dec. 2. New hospital admissions are chiefly among seniors aged 70 years and older, followed by those aged 60 to 69, according to a New York Times report on CDC data, from Dec. 5.

And hospitalizations for respiratory syncytial virus rates also remain higher than usual in seniors, although they appeared to be trending downward at the end of November. The disease has caused a spike of infections in the elderly along with unusual hospitalization levels for children this fall. 

CDC mulls tracker change

Along with getting vaccinated against flu and boosted for COVID-19, Walensky urged Americans to take extra precautions against transmission. This included mask wearing where community viral transmission is high.

In response to the unprecedented “tripledemic” of viruses this season, the agency is considering changing its COVID-19 community level tracker to include other viral illnesses, Walensky added. This system was originally developed to inform healthcare providers of local COVID-19 transmission risk and provide evidence for taking mitigation measures.

Related articles:

In advance of possible flu surge, vaccination for seniors may lower need for antibiotics

Seniors hit hardest as flu rate shoots up in 30 states

Seasonal flu vax guidance released, with drug preferences for seniors

Researchers from Kaiser Permanente and Harvard University estimated flu-associated prescribing for five antibiotic classes: macrolides, aminopenicillins, protected aminopenicillins, quinolones and third-generation cephalosporins.

The results showed a “modest benefit” of increased flu vaccination for reducing antibiotic prescribing. In older adults, the effect was seen in macrolides for people aged 50 years and older and in third generation cephalosporins among adults aged 65 and older, the researchers reported.

In addition, in adults aged 25 years and older, investigators found that 45% to 84% of influenza-associated antibiotic prescribing was for respiratory diagnoses not caused by bacteria. 

The findings suggest that vaccination and other measures to reduce unnecessary antibiotic prescribing “may further contribute to the mitigation of antimicrobial resistance,” they wrote.

Tough flu season in store?

The findings come as federal health officials raise concerns about the potential for an especially harsh flu season. As of Oct. 28, the Centers for Disease Control and Prevention continued to report early increases in seasonal influenza activity in the United States, especially in the southeast and south-central areas. The cumulative U.S. hospitalization rate was higher that week than it has been in 12 years. 

Monitoring of countries in the Southern hemisphere, often a harbinger of what is to come, have shown an earlier-than-usual uptick in cases with hospitalizations up year-over-year. The number of U.S. nursing homes reporting at least one flu-positive test among residents is also rising, although it remains low, at 0.5%.

With an expectation that COVID-19 cases will rise as well this season, officials are campaigning for older adults to get vaccinated for flu along with receiving an updated, bivalent COVID-19 booster shot. This year, the CDC has for the first time preferentially advised older patients to take an adjuvanted or high-dose flu vaccine over standard vaccines whenever possible. These include:

• Quadrivalent high-dose inactivated influenza vaccine (HD-IIV4);
• Quadrivalent recombinant influenza vaccine (RIV4); or 
• Quadrivalent adjuvanted inactivated influenza vaccine (aIIV4). 

Related articles:

Seasonal flu vax guidance released, with drug preferences for seniors

Driven by pandemic lessons, CDC advisers mull endorsing high-dose flu vaccines for seniors