Winter Brings Increased COVID-19 Deaths in Nursing Homes Once Again, Analysis Finds

Deaths appear to have peaked as the rate of workers who are up to date on vaccinations declined

AARP

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Published February 16, 2023

More than 1,300 nursing home residents died from COVID-19 over a four-week period ending Jan. 22, according to a new AARP analysis of federal data. The toll represents the highest death rate since the omicron variant surge last winter. It’s also likely to mark the third year in a row that deaths have peaked in winter.

As deaths rose, only about half of nursing home residents nationwide and less than a quarter of health care staff were up to date on their COVID-19 vaccinations. That left roughly 600,000 nursing home residents and 1.6 million staff behind on shots as of Jan. 22.

AARP’s findings are “pretty disheartening,” says Priya Chidambaram, a senior policy analyst at the Kaiser Family Foundation who also tracks COVID-19 in nursing homes. “With the really low rates of vaccination and the really high rates of death, we come to the natural conclusion that maybe higher vaccination rates and booster rates could have prevented some of those deaths.”

Vaccination rates in nursing homes have been lagging for months. Bivalent boosters, designed to protect against the omicron subvariants as well as previous strains, have been available since fall, but the percentage of residents who are up to date on vaccinations has crept up just 11 percentage points nationwide, to 51 percent, between mid-October 2022 and mid-January 2023.

Over the same period, the rate of up-to-date nursing home workers has actually declined by 3 percentage points nationwide, to 22 percent.

Residents and staff are considered “up to date” once they’ve gotten the bivalent booster, or if they completed their primary vaccination series or had another booster within the past two months.

“The downward trend in staff vaccination is particularly concerning,” says Jennifer Schrack, an associate professor in the epidemiology of aging division at the Johns Hopkins Bloomberg School of Public Health. “People have COVID fatigue. They want to go back to normal. This is ironic because vaccination is likely the best way for us to return to some state of normalcy.”

AARP’s analysis once again found considerable variation among state vaccination rates. Arizona had the least number of residents — only 32 percent — up to date on shots, while South Dakota had the most, at 78 percent. California continued to lead the way with the most workers up to date, however, less than half (44 percent) of all workers achieved that status. Tennessee reported the lowest percentage of up-to-date workers, at just 10 percent.

Another peak?

While it’s still too early to be sure, deaths have likely peaked this winter, according to AARP’s Ari Houser, a senior methods adviser and coauthor of the analysis. Weekly data shows that the highest death rate among residents occurred in the first week of January, before declining each week after. Two weeks of more recent nursing home data from the Centers for Disease Control and Prevention (CDC) also shows that both cases and deaths since January 22 are down by roughly one-third from the rates during AARP’s analysis period.

“There certainly could be further increase later in the season," says Houser, "but I would suspect that we saw our winter wave peak in this past month.”

While a death peak in winter tracks with past patterns of the virus, the peak this time appears to be much lower than in past winters. Over a four-week period of the omicron surge last winter, more than triple the number of resident deaths were reported, compared with this reporting period. And in the previous winter, when COVID-19 vaccines were just becoming available and the virus hit its highest peak, the death toll was about 15 times higher — more than 20,000 dead in just four weeks.

Still, 1,300 resident deaths in one month is too high, according to R. Tamara Konetzka, a professor of public health sciences at the University of Chicago. “While the risk [of COVID-19] may always be higher in winter, we shouldn’t consider more than a thousand nursing home deaths per month a new normal,” she says. “We have tools to bring that number down.”

Calls for more action

Nursing home experts and resident advocates are calling for more effort to help protect the nursing home population. “Unfortunately, much of the policy focus on nursing homes that emerged at the beginning of the pandemic has waned,” says Konetzka. “In a desire to move on and declare the pandemic over, we are leaving nursing home residents vulnerable.”

The federal government contracted with CVS, Walgreens and some other pharmacies to conduct on-site vaccine clinics at most of the nation’s nursing homes in late 2020 and early 2021, and the efforts proved successful in getting residents their primary series of COVID-19 shots quickly. A federal mandate requiring almost all workers of nursing homes participating in Medicare and/or Medicaid to be vaccinated with a primary series, effective as of early 2022, also greatly helped staff uptake. Both the resident and staff vaccination rates reached almost 90 percent, with many states well above that rate, according to AARP’s analyses.

But no campaign of this scale has been in place for subsequent shots. Also, no part of the federal vaccine mandate requires workers to stay up to date with vaccinations. While some states have issued their own booster mandates for workers, or have helped coordinate administration clinics, the majority haven’t, leaving facilities to work it out on their own. Many operators have reported battling high rates of vaccine hesitancy, a lack of awareness or confusion around the bivalent boosters, a lack of staff to administer the shots, plus pandemic fatigue among their communities.

In late December, AARP wrote to the Centers for Medicare & Medicaid Services (CMS), which regulates the country’s 15,000-plus nursing homes who participate in Medicare and/or Medicaid, urging “more action” to increase up-to-date vaccination rates. The letter called out the agency for weakening the enforcement of its COVID-19 staff vaccination requirements and asked for heightened consequences for noncompliance. It also urged increased education on the shots and proactive outreach to nursing homes with low up-to-date rates to establish on-site vaccination clinics.

CMS said in early January that on-site vaccination clinics for residents and staff were being conducted across the country and that the agency and its partners were continuing to reach out to nursing homes to offer assistance, education and support.

“We really hope you will take these groups up on these offers,” said CMS Administrator Chiquita Brooks-LaSure during a call with nursing homes stakeholders. “Getting the updated vaccine is the most important tool that we have to prevent serious illness, hospitalization and death from COVID-19. And nursing home residents, who are often particularly susceptible to severe outcomes from the virus, deserve the highest level of protection that we can offer.”

More than 180,000 nursing home residents and workers have died from COVID-19 during the pandemic, which accounts for roughly a sixth of the country’s entire COVID-19 death toll.

AARP’s analysis, conducted by the AARP Public Policy Institute and the Scripps Gerontology Center at Miami University in Ohio, draws primarily on data from the Nursing Home COVID-19 Public File by the Centers for Medicare & Medicaid Services. Most nursing homes are federally certified and required to submit data to the government each week.

The ongoing analysis captures data only from nursing homes participating in Medicare and/or Medicaid, not from all long-term care facilities — such as assisted living, independent living, memory care and others — as some other tallies do. An updated analysis will be released next month as new federal data becomes available. Read more about the analysis.

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