The Wall Street Journal - USA (2020-11-16)

A6| Monday, November 16, 2020 **** THE WALL STREET JOURNAL.

U.S. NEWS

Infections Ravage

Nursing Homes in

Rural Parts of U.S.

campuses; public-health mea-

sures such as mask-wearing

that are recommended but not

required in some states; mixed

messages about the dangers of

the virus; and pandemic fa-

tigue.

On Halloween, Zachary

Mathes and Sarah Katz invited

two friends from their “social

bubble” over to watch trick-or-

treaters, sitting socially dis-

tanced outside their Pittsburgh

home. Vigilant for months

about protecting themselves

from the virus, they thought

the small gathering was low-

risk.

When it got cold outside,

the four went to warm up and

eat some snacks in the kitchen,

leaving masks off after dis-

cussing the move first. “We

kind of decided we’re all OK;

that is our friend group that

we are a part of,” said Ms.

Katz.

Days later, they learned the

guests had tested positive for

Covid-19. By then Ms. Katz, a

27-year-old communications

specialist, and Mr. Mathes, a

29-year-old musician, had

symptoms too. “We thought

we were doing everything

right, but we still got sick,”

said Ms. Katz, who is riding

out the illness at home with

her husband.

The virus, having spread for

months, is now more en-

trenched in communities, epi-

demiologists say. “When you

have so many cases in the

community, it is very easy to

get infected inadvertently as

you go about your daily busi-

ness,” said Ali Khan, a veteran

epidemiologist who is dean of

the College of Public Health at

the University of Nebraska

Medical Center. “You don’t

need to go to hot spots any-

more.”

That has made it harder for

people to tell where and how

they got infected and for pub-

lic-health authorities to track

down and stop outbreaks.

Geoffrey Wardle, a lawyer in

Boise, Idaho, suspects he got

the virus while accompanying

his parents to a funeral for a

relative who died in a car acci-

dent. But he said it also could

have been during a weekend

birthday trip with his wife to

California in mid-October.

Mr. Wardle says he has been

careful to wear a mask, wash

his hands and stay away from

people, so when he and his

wife first began to feel con-

gested, they figured they had

whatever cold their 16-year-

old son had just gotten over.

Then a client’s exposure

prompted Mr. Wardle to get

tested.

“I tried to be careful, but

clearly was not careful

enough,” Mr. Wardle would

write to employees after re-

ceiving his positive results.

Days later his wife’s test con-

firmed she was also infected.

Their son was not.

Bruce Dennis, an internist

with a private practice in rural

Ada, Okla., said when the pan-

demic first started it seemed

far removed from the commu-

nity of roughly 17,000 about 85

miles southeast of Oklahoma

City. Gradually, many people

grew skeptical that the virus

was as bad as health officials

warned, he said.

“People stayed in and they

were cautious but they looked

around and they didn’t see

anybody actually sick and no-

body knew anybody who had

been sick, and so that skepti-

cism grew,” Dr. Dennis said.

Now that infected patients

are turning up in earnest—Dr.

Dennis said he’s gone from

seeing a case a week this sum-

mer to a case a day now—pan-

demic fatigue has set in.

“A lot of people just feel

like I’m through with Covid,

I’ve done all I can,” said Dr.

Dennis, who recently suffered

his own bout of the virus,

along with his wife, daughter,

son-in-law, and 6-month-old

grandchild. “It’s now just re-

ally time to start.”

For months after the pan-

demic began, Shawna Sero

stayed cooped up at home in

Cedar Rapids, Iowa, refusing

to go out with friends. With

asthma and a weak immune

system, the 40-year-old was

terrified about getting in-

fected, she said.

But after watching the Iowa

Hawkeyes’ first football game

of the season with her parents

and siblings at home a few

weekends ago, she let her

guard down and decided to go

to a bar with a friend. “I just

wanted to keep having fun,”

she said. “It had been so long.”

Last week, Ms. Sero lay in a

bed in a converted pediatric

unit of Mercy Medical Center

texting with her sister several

floors down. She had been ad-

mitted to the hospital a couple

of days earlier, struggling to

breathe after testing positive

for Covid-19. Her 42-year-old

sister, also Covid-19 positive,

was now in the emergency

room, seeking relief from a

cough so intense it sometimes

made her vomit.

The rest of the family was

showing symptoms too: her

37-year-old brother, Bobby

Sero, who had tested positive

and was texting the sisters

from the master bedroom of

his home where he was holed

up to prevent his wife and five

children from infection; their

father, a 60-year-old diabetic,

who hasn’t wanted to go to the

hospital despite feeling sick;

and their 59-year-old mother,

who moved out at the end of

October after a divorce and

was awaiting test results at

her new Illinois home.

Ms. Sero doesn’t know

whether she passed the dis-

ease on to her family mem-

bers, or the other way around.

Her sister is a security

guard manager whose boy-

friend is a cook at a bar. Her

brother lives elsewhere and

believes he got infected at

work. “I don’t know if I

brought it into the house,” she

said. “It’s so rampant here that

we just don’t even know.”

Ms. Sero is also concerned

she might have spread the ill-

ness beyond her family when,

not knowing she had the virus,

she visited her neighborhood

polling site to cast a ballot on

Election Day. “I had to go

vote,” she said. “And now I feel

miserable because I went and

voted and I had Covid.”

Iowa currently has one of

the sharpest recent increases

in cases in the nation—ranking

third highest, per capita, over

the past week after the Dako-

tas. Cases are rising exponen-

tially, said Eli Perencevich, an

infectious-disease doctor and

epidemiologist at the Univer-

sity of Iowa Carver College of

Medicine. “Everyone is over-

whelmed—they are exhausted

already,” he said.

Mercy Medical Center has

dedicated two of its nine floors

to Covid-19 patients and has

put off elective surgeries. On

one recent day, the hospital

was boarding 12 patients in its

emergency department until

beds for them opened up, said

Tony Myers, the hospital’s vice

president of system quality,

risk and medical affairs.

The hospital is so busy that

it is allowing staff who have

been exposed to Covid-19 to

work if they haven’t tested

positive, and they have to self-

monitor and isolate at home,

Dr. Myers said.

Gov. Kim Reynolds, who has

resisted a statewide mask

mandate, last week banned

gatherings of more than 25

people indoors or 100 people

outdoors, unless participants

are wearing masks. Critics say

that isn’t enough.

“We’re kind of killing the

economy with the lack of these

simple measures,” said Dr. Per-

encevich. But Ms. Reynolds has

been hesitant to impose

tougher restrictions, saying

she’s heard from residents and

small-business owners who

have told her they “can’t af-

ford another shutdown.”

Cedar Rapids Mayor Brad

Hart said he spoke to Ms.

Reynolds about a statewide

mask mandate early in the

pandemic but recognizes that

she represents the whole state

and that what might work for

his community won’t work for

smaller ones. Still, he decided

to issue a mask mandate for

the city in early September.

just at big gatherings, but

when they let their guard

down, such as by not wearing

a mask, while going about

their daily routines or in

smaller social settings that

they thought of as safe—often

among their own families or

trusted friends.

The number of confirmed

cases is rising significantly in

all but a few states, according

to a Wall Street Journal analy-

sis of data from Johns Hopkins

University. Most of the new

cases are in the Midwest,

which is experiencing a major

surge. But even states and cit-

ies that had successfully

beaten the virus down to low

levels are struggling with ris-

ing numbers of illnesses.

“This is clearly a nation-

wide event,” said Michael Os-

terholm, director of the Center

for Infectious Disease Research

and Policy at the University of

Minnesota, who is a member

of President-elect Joe Biden’s

Covid-19 advisory board for

the transition. “We have many

mini-epidemics.”

The number of hospitaliza-

tions has reached a new high,

though hospital stays are

shorter and fewer people are

dying than in the spring, likely

due to more medical knowl-

edge and better treatment.

The seven-day average of new

daily Covid-19 deaths in the

U.S. was above 1,000 last

week. But that average was

still well below the highs seen

in April when the seven-day

average briefly topped 2,

daily deaths.

Disease modelers predict a

difficult winter ahead, as fami-

lies and friends gather; just

how difficult will depend on

the measures that authorities,

businesses and individuals

take now to slow the virus,

public-health experts say.

Some state officials took

new steps last week, including

stricter mask mandates and

tighter restrictions on gather-

ings. In Wisconsin and Chi-

cago, officials issued stay-at-

home advisories, while

Vermont’s governor prohibited

all public and private social

gatherings outside of members

of the same household.

Total shutdowns may not be

necessary, said Celine

Gounder, an infectious-dis-

eases specialist and epidemiol-

ogist at NYU Grossman School

of Medicine and Bellevue Hos-

pital. Enough has been learned

about the virus over the past

many months that interven-

tions can be more targeted to

certain ZIP Codes or types of

gathering places, more like a

dimmer than an on-off light

switch, she said. “I think at

this point we actually know

enough—we’ve learned a lot—

that we’re not going to have to

be quite so draconian in our

measures,” said Dr. Gounder,

who is also on the Covid-

transition advisory board.

Many state and local lead-

ers have been reluctant to re-

turn to the broad lockdowns

imposed in the spring, in large

part because of the severe eco-

nomic and financial conse-

quences for businesses and the

public. The pandemic has al-

ready cost millions of jobs in

the U.S. alone and dented

global output.

Epidemiologists cite several

factors behind the current

surge: colder weather driving

people indoors, including into

bars and restaurants; the re-

turn of students to college

ContinuedfromPageOne

Covid Is

Everywhere

This Time

Medical professionals at United Memorial Medical Center in Houston check on a Covid-19 patient who was flown in from El Paso last week.

CALLAGHAN O’HARE/REUTERS

Note: Includes Puerto Rico

Sources: Johns Hopkins University (cases,

deaths); Census Bureau (population)

Counties with at least

one new death

3,

0

500

1,

1,

2,

2,

counties

MAMJ J ASON

Seven-day rolling average

0

500 counties

MAMJ JASON

Counties with at least ten new

cases per 100,000 residents

250

spreading in the region, the

nursing home saw its first

positive test in late Septem-

ber. Eventually, the outbreak

spread to 35 of the facility’s

68 residents, killing 16.

“It came into our commu-

nity and it came strong, and it

just found its way into our fa-

cility,” said Christen Obresley,

the nursing home’s administra-

tor. She said the infection likely

arrived through an asymptom-

atic staff member, though the

facility had followed state and

federal guidelines on testing

and infection control.

The resurgence in nursing-

home cases and deaths comes

despite new federal require-

ments that facilities in coun-

ties with high Covid-19 rates

test staff as often as twice a

week, in an effort to detect and

stem outbreaks quickly. Many

nursing homes have declined

to use federally provided rapid-

testing equipment, citing con-

cerns including accuracy, yet

face delays in getting results

from labs. Some facilities have

continued to report shortages

of protective gear such as N

masks, a major problem earlier

in the pandemic.

Staffing for many nursing

homes outside large metropol-

itan areas has long been a par-

ticular problem, according to

researchers and nursing-home

administrators. The pandemic

has created a crisis for some

facilities that can’t find tem-

porary workers to fill in when

employees must stay home to

quarantine. “The more isolated

the community, the harder it

is to bring in workforce,” said

Shawnda Schroeder, a re-

search associate professor fo-

cused on rural health at the

University of North Dakota.

Other challenges rural nurs-

ing homes face, researchers

said, can include smaller build-

ings that make it hard to iso-

late infected residents. Rural

nursing homes sometimes lack

easy access to a hospital or

doctor, after closures of many

rural hospitals in recent years.

A CMS spokeswoman said

the agency has “taken an un-

precedented number of public

health actions to support

nursing homes on Covid-19,”

including regulatory moves to

ease staffing crunches and al-

low more use of telehealth.

Guardian Angels Health &

Rehabilitation Center in Hib-

bing, Minn., drew on employ-

ees from other facilities

owned by the same nonprofit.

It put nursing administrators

to work in front-line positions

and brought in some tempo-

rary agency workers, who had

to be put up in hotels. Still, in

an outbreak that affected 39

residents and 30 employees in

September and October, the

facility needed help from five

National Guard members, who

filled in for nine days in early

October. Ten residents died.

“Staffing was tight in the

first place,” said Scot Allen, a

vice president at St. Francis

Health Services of Morris,

which owns the Hibbing facility.

“Then you add in the impact of

Covid...It’s very precarious.”

—Jon Kamp

contributed to this article.

Covid-19 deaths among vul-

nerable nursing-home resi-

dents are surging again, with

the virus increasingly spread-

ing to rural facilities that are

struggling with staff shortages

and other challenges.

Nursing homes reported

more than 1,900 resident

deaths from Covid-19 in the last

week of October, as well as

more than 32,000 confirmed

and suspected cases among

staff and residents, according to

newly released federal data an-

alyzed by The Wall Street Jour-

nal. Those nationwide totals at

the facilities were the highest

since early August, when states

including Texas and Florida

were seeing increases.

This time, the virus is infil-

trating a far-flung range of fa-

cilities, with a growing share

of the deaths occurring in ru-

ral and small-town communi-

ties in states such as Wiscon-

sin, North Dakota and

Montana, where case counts

have climbed rapidly. The pat-

tern tracks how the virus is

spreading more broadly

throughout the U.S., hitting re-

gions that had been largely

spared earlier in the pandemic.

“Nursing homes are not iso-

lated from what happens in the

community,” said Carrie Hen-

ning-Smith, an associate pro-

fessor at the University of Min-

nesota School of Public Health.

“We’re seeing this run rampant

through rural communities.”

Facilities in rural counties

reported 18% of nursing-home

Covid-19 deaths in the week

ended Nov. 1, though they

housed only 10% of the overall

population, according to the

Journal’s analysis of weekly

survey data from the Centers

for Medicare and Medicaid

Services, or CMS. Small-town

counties saw 17% of the nurs-

ing-home deaths, though facil-

ities there have only 12% of

the total residents.

At Lutheran Sunset Home, a

91-bed facility in Grafton, N.D.,

55 residents and 46 staffers

have been infected since an

outbreak started in late Octo-

ber, after Covid-19 infections

hit a high rate in the sur-

rounding county. Five resi-

dents infected with the coro-

navirus have died.

Staffers followed recom-

mended precautions, but “it

still spread like wildfire,” said

Trevor Tompkins, the adminis-

trator of the nonprofit facility.

“To put it bluntly, we’re in hell.”

The trend is a turnaround

from the spring, when nursing

homes in large cities such as

New York were seeing major

outbreaks. Facilities in the

most urban counties repre-

sented around one-third of

nursing-home deaths in late

May and early June, and only

9% in the most recent week of

the data. Rural nursing homes

were tied to only 4% of the

deaths in late May, compared

with their recent share of 18%.

Overall, U.S. long-term-care

facilities have been tied to

more than 90,000 Covid-

deaths since the start of the

pandemic, according to a Wall

Street Journal tally of recent

state, local and federal data.

Over time, long-term-care

deaths have tended to repre-

sent around 40% of all

Covid-19 deaths.

Northern Montana Care

Center, in Havre, didn’t have a

single case of Covid-

through the spring and sum-

mer. But after Covid-19 began

BYTOMMCGINTY

ANDANNAWILDEMATHEWS

Large central metro Large fringe metro

Medium metro

Small metro

Small city/town Rural

0

10,

20,

30,

4 0,

June July Aug. Sept. Oct. Nov.

Sources: WSJ analysis of data released by the Centers for Medicare and Medicaid Services;

National Center for Health Statistics (urban/rural classifications)

*Case counts include confirmed and suspected staff and resident Covid-19 cases.

Covid-19 infection rates within nursing homes have

reversed course geographically, with the highest levels now

in rural counties and the lowest in urban areas.

Rural Shift

Weekly number of new Covid-19 cases in nursing

homes by county type*

90K

Covid-19 deaths have been tied

to long-term-care facilities

Holly Farrar, her husband, Casey Farrar, and their 6-month-old

Hudson all had Covid-19, as did her parents.

FARRAR FAMILY