As others have noted, we may wish to be done with COVID-19, but it’s not done with us. Two years into this ever-morphing health event, we continue to learn, adapt, and forge ahead. Let’s take a look at the current state of affairs, especially as they affect the people and patients closest to the minds and hearts of long-term care pharmacy.
COVID-19 seems to be a virus designed to wreak maximum havoc on the frail elderly, specifically those with congregate living arrangements. CMS data indicates that as of December 2021, more than 142,000 nursing home residents and more than 2,000 nursing home staff have died from COVID-19, putting an already beleaguered industry further on the ropes.
As with most things catastrophic, the coronavirus appears to have done its worst, and we may be beginning to see something of a recovery. Following an occupancy plunge from 85% in January 2020 to 68% in January 2021 (again from CMS data), recovery has begun. But it may be some time before we understand what our new normal looks like.
The virus has also taken its toll on nursing home staffing. (For a detailed look at the demographics of the long-term care workforce, see this article.) A combination of staff burnout and vaccine reluctance has strained the supply of skilled care employees and created uncertainty about the ability of nursing facilities to care for residents.
The federal government was criticized for its response to the pandemic in its earliest stages, but one remarkable success was the speed in which effective vaccines were developed and approved. Following the implementation of Operation Warp Speed, it took less than a year to get the first vaccines approved under an Emergency Use Authorization (EUA). Vaccinations began in late 2020, and there are now three vaccines approved by the FDA. (Interested in what the Government Accountability Office found about the results of Operation Warp Speed? Read more here.)
The Centers for Disease Control considers a person fully vaccinated two weeks after they have received two doses of the nRNA vaccines (Pfizer or Moderna) or two weeks following vaccination with the Johnson and Johnson vaccine. For people with co-morbidities or who are immunocompromised (including most nursing home residents), the CDC recommends a booster injection with any of the approved vaccines.
Vaccination continues to be the most effective weapon against coronavirus infection and has an added advantage that breakthrough infections, if they occur, tend to be less deadly and debilitating if you’ve already been vaccinated.
Alongside vaccines, the pharmaceutical industry has been busy developing effective treatments for COVID-19 infections, and the FDA has been equally busy reviewing and approving drugs that meet the regulatory standards for public use.
Certain monoclonal antibodies (mABs) have been approved by the FDA under EUA. At this point, the FDA has given authorization for three mABs, or combinations of mABs:
• Bamlanivimab plus etesevimab
• Casirivimab plus imdevimab
These drugs must be infused and are recommended for people who are at serious risk following exposure to the coronavirus. Residents of LTC facilities have high concentrations of individuals fitting this description.
The FDA has approved Pfizer’s Paxlovid (nirmatrelvir tablets and ritonavir tablets, co-packaged for oral use) under an EUA for the treatment of mild-to-moderate coronavirus disease. This drug combination should be initiated as soon as possible after diagnosis and within five days of symptom onset.
Merck’s oral drug molnupiravir has also been approved under an EUA for the treatment of mild-to-moderate COVID-19 in adults. Like Paxlovid, molnupiravir is for those who are at high risk for progression to severe COVID-19, including hospitalization or death, and for whom alternative COVID-19 treatment options authorized by the FDA are not accessible or clinically appropriate.
In October 2020, the FDA gave an EUA to Gilead Science’s Veklury (remdesivir) for the treatment of hospitalized patients with a confirmed diagnosis of COVID-19.
Health experts now believe that the current crisis will subside and eventually move from pandemic to endemic, much like the seasonal flu. COVID and all its variations will be with us for some time to come. As a result, we will need to learn a new rhythm of vaccinate, test, treat, and mitigate.
The long-term care community will need to work overtime to attract and retain qualified staff, improve training, and continue to do more with less. If increased public funding comes, it will likely have strings attached: more frequent surveys, increased penalties for noncompliance, and lower occupancy as families move their loved ones to less-risky care venues.
Through it all, nursing homes will continue to play an important role in providing care to our most vulnerable citizens. None of us knows what the next phase will look like, and the pundits will undoubtedly be proven wrong. It’s up to all of us in this industry to decide what post-COVID long-term care looks like. And I believe we’re up to the challenge.
The X Factors
• Long-term care facilities will have to work overtime to attract, retain, and train staff in the wake of COVID.
• As COVID becomes an endemic, we will need to learn a new rhythm of how to vaccinate, test, treat, and mitigate.
• Our industry should expect more strings tied to public funding and lower occupancy rates – but remains vital to the care of vulnerable seniors.
What X factors do you think COVID-19 has in store for our industry?