Tragedy and Hope In Elderly Housing

Everyone living in multi-unit public and subsidized housing for elderly and disabled persons is at risk of COVID-19 infection created by the failure of administration and oversight at several levels: national, state, regional/county, municipality, and housing facility. Elderly and disabled persons are at elevated risk for severe consequences and death from COVID-19 because of age, preexisting medical conditions, or a compromised immune system. Life in multi-unit housing compounds the risk of transmission.

The most prudent approach is to increase compliance, oversight, and accountability for public health mandates, and to have an on-site vaccination program for everyone in all multi-unit facilities where elderly and disabled tenants are living, and as soon as possible.

Vaccination for all tenants and staff is part of a comprehensive program that will continue to include masking, distancing, personal hygiene, cleaning of the environment, and frequent rapid testing with publication of the results including number of infections, and with restricted access to individual case information.

 

The risks in housing

The dynamics of social life in housing make tenants vulnerable to COVID, it is like a petri dish for infection. I live in a subsidized apartment building in Peabody. In this facility, with under 90 tenants, almost everyone gets the flu during the season. The flu spreads from one person to another, if one person is infected, everyone catches it. COVID is an airborne disease, like the flu.

In this apartment building, it can be difficult to maintain adequate separation from others to protect against transmission. People mingle in public areas and we all use a small elevator where an infection-carrying aerosol can linger for hours. Not everyone wears a mask despite the state mandates, they ignore notices from the health department and landlord to wear a mask everywhere on the property. People with symptoms like coughing wander the halls. Compliance with COVID mandates is very spotty and management has yet to enforce the rules, and the local health department is reluctant to enforce the rules on site; although tenants are now pressing for action and a new manager is promising several positive steps.

The challenges are everywhere in public and subsidized housing, based on reports including from Cambridge, Chelsea, Lowell, Salem, Somerville, and Franklin County. Managers and tenants do want to know about COVID in their buildings. The policies and practices of landlords in each of these settings differ, and we have very little information that would enable comparison or evaluation of their outcomes. In an opportunity sample of housing facilities in a number of municipalities, based on informal estimates by people in a position to observe, and by our projected estimates of annual outcomes, the annual COVID infection rate ranges from 6% to 15%. A projected 2%-4% of the tenants would die in a year. These are very crude estimates and our difficulty in trying to grasp the extent of the problem only demonstrates the unsatisfactory state of COVID surveillance in multi-unit dwellings in Massachusetts. The Department of Public Health should be doing this work and making the data available to support efforts to cut down on transmission.

Who can control COVID?

The chance for a person to become infected is affected by the person’s age, sex, and existing medical conditions. Four other factors should be managed and controlled much better than at present.

• The prevalence of COVID in the county; the responsibility for controlling the conditions that impact the transmission of disease rests with the Governor, the Department of Public Health, and local health departments.

• In housing, the landlord and management have responsibility for enforcing preventive behavior. The local health department has responsibility for oversight and enforcement.

• In housing and elsewhere, the individual tenant is responsible for masking, distancing, and hand hygiene. Each individual has some control over the number and duration of contacts with other people; reducing the number of interactions reduces exposure.

• Managers and tenants need to know if COVID is present to enable interventions to protect people from transmission and provide aid and support for those infected and in quarantine.

Tenants in elderly/disabled housing are vulnerable

On December 11, 2020, a letter to Governor Baker and Secretary Sudders was sent by Amy Schectman, the President of the Citizens Housing and Planning Association and a large number of landlords and managers of public and subsidized housing for elderly and disabled persons. They wrote to urge a higher priority in vaccination for tenants in housing.

“In fact, many of our residents are more frail than those in assisted living and are nursing home-eligible. Thus, the logic of your plan suggests residents of public and affordable senior housing must be included in phase one and we urge you to make that happen.”

One of those signers, Executive Director of the Cambridge Housing Authority, Michael Johnston said:

“One thing we can say with certainty is that our elderly/disabled housing is home to some of the city’s most vulnerable residents, and the governor should have included them in Phase 1 of the COVID vaccine distribution plan.” Sue Reinert, Public housing Covid deaths disproportionate; CHA frustrated by lack of official health data, Cambridge Day, January 3, 2021.

There are 92,000 elderly and disabled persons in 1,400 public and privately owned subsidized developments in the Commonwealth. COVID is becoming the leading cause of death for people over the age of 45, and the category of people who are 80 and older already number the most deaths from COVID. In the age group of 50-64, one report found the percentage of deaths is 14.4; among those 65-74 years old, the percentage is 20.8; among those 75-54 years, the percentage is 27.4; among those 85 years and older, the percentage is 32.8. Demographic Trends of COVID-19 cases and deaths in the US reported to CDC (Updated January 10, 2020)

A dangerous environment

The lax approach to public health impacting North Shore elderly/disabled housing persists despite the very high rate of infections in Peabody and the surrounding communities in Essex County. County Level Positivity Rates – January 6, 2021

The high prevalence of COVID surely increases the chance of COVID getting into our homes, and thus creates a real and present danger. The Governor is still (from December 22, 2020) allowing indoor gatherings of 10 people, which we know from experience will continue the spread of COVID.

An elderly male person living in Peabody, Essex County who is 60 to 84 years old, with 3 underlying medical conditions; who lives alone and follows the rules on hand hygiene & masking; and who meets indoors with 10 other persons in a week has 283 times higher risk of COVID than the risk of flu. This considers both how prevalent flu is, as well as how serious COVID-19 is compared to the flu. They have an expected chance in that week of catching COVID (0.51%) that is greater than they would have of catching the flu (0.41%).

But if they fail to comply with masking and hand hygiene, the chance of getting infected by COVID jumps to 3.4%. In Franklin County, where the prevalence of COVID is lower, the same type of situation would give a lower chance of getting infected, 1.3%. Based on data from December 29, 2020-January 8, 2021 & https://19andme.covid19.mathematica.org/ and email January 11 from Team 19andMe.

Inaction by community officials

The leaders of 9 North Shore communities in Essex County (Beverly, Danvers, Gloucester, Lynn, Marblehead, Nahant, Peabody, Salem and Swampscott) have decided to wait for things to get worse before they act. They are concerned about the risk to hospital capacity. What are they waiting for? The danger is present. In Peabody, as of December 29, 2020, the case count for the last 14 days was 694, and the average daily incidence rate (new infections per 100,000) was 88.6 for the previous 14 days. The average daily incidence rate in Essex County was 81.1, the highest rate of all counties in the Commonwealth, according to the County Level Positivity Rates – January 6, 2021, Dashboard, Dec 29: Weekly Covid public health report 12.31.2020

An invisible disease

We need constant reminders to protect ourselves against COVID, an invisible disease. Unlike common infections like the cold or flu which create symptoms that others may observe and respond to protect themselves, COVID may not provide a warning. Your neighbor may have COVID and seem perfectly healthy, yet if you both are not routinely masking, distancing, and using hand hygiene, you are more likely to become infected.

Anyone infected with COVID may spread the virus for days before symptoms appear. Analysis of Chelsea public health data covering several months of 2020 revealed that 35% of infected persons had no symptoms. Cristina Alonso and Patrice Basada, Harvard T.H. Chan School of Public Health, Boston University School of Public Health, Academic Public Health Volunteer Corps, Data Analysis Report to the City of Chelsea COVID positive cases: March 3, 2020, through August 9, 2020. October 2020.

A Centers for Disease Control and Prevention (CDC) model of transmission found 59% of all infections may come from people without symptoms. Michael A. Johansson, PhD et al, SARS-CoV-2 Transmission From People Without COVID-19 Symptoms, January 7, 2021, JAMA Netw Open. 2021;4(1):e2035057. doi:10.1001/jamanetworkopen.2020.35057

We must know if COVID is present

Even when a tenant or staff person is diagnosed, landlords and tenants don’t know unless the patient or family remember reports it, because Monica Bharel, the Commissioner of Public Health, forbids sharing even the location of COVID infections except with first responders. Managers of public housing in Cambridge and Chelsea are among those frustrated that they do not have access to public health data that would enable them to help the sick person and protect other tenants.

Managers and tenants need to know if there is a COVID infection in their place where they live and work. Rapid tests for COVID should be administered on-site, frequently, and the results made known to enable speedy responses that can limit the spread of disease and support for people in isolation. A new rapid SARS-CoV-2 antigen detection assay identified even asymptomatic people with high levels of the virus within an hour, enabling rapid public health response. “...Use of these tests could rapidly permit identification and isolation of persons with high levels of virus, disrupting forward transmission chains.”

Failure of compliance with public health mandates

Many people fail to follow the COVID mandates in the public spaces of housing. In some housing developments, including Fairweather Peabody, neither local health departments or landlords enforce the COVID rules to assure the health and safety of tenants. Some tenants, because of age or disability, may find it hard to comply with the rules. They should receive help and guidance. Some tenants cannot afford masks, the landlord should provide masks in sufficient quantity. Some tenants refuse to comply, and the landlord should warn and if necessary, evict; and/or the local health department should warn and fine both the landlord who fails to enforce the COVID rules and the obstinate tenant.

Vaccination distribution

On January 13, 2021, the Governor and his people announced the schedule for rolling out vaccinations. While we applaud this sign of relief, we stand puzzled by the seemingly random timing for specific facilities which are similar, based on arcane administrative distinctions rather than a rational assessment of relative need. Some tenants are already getting their vaccinations, others will be waiting for weeks.

We must act now, but with ethics and fairness.

Going forward

The most prudent approach is to increase compliance, oversight, and accountability for public health mandates, and to have an on-site vaccination program for everyone in all multi-unit facilities where elderly and disabled tenants are living, and as soon as possible.

Vaccination for all tenants and staff is part of a comprehensive program that will continue to include masking, distancing, personal hygiene, cleaning of the environment, and frequent rapid testing with publication of the results including number of infections, and with restricted access to individual case information.

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Evaluation of personal risk

“19 and me” is a tool that can help you understand your personal risk of exposure to COVID-19 https://19andme.covid19.mathematica.org/

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Vaccine rollout information

This was received in an email from SeniorHousingCOVID19@mass.gov ; this is a group of professionals and tenants who meet online to share information about housing for the elderly and disabled.

As you may know, the Center for Disease Control and Prevention (CDC) launched the Federal Pharmacy Partnership Program to deploy vaccines to Long Term Care Facilities. We were glad to see that the CDC included a select few affordable senior housing properties in the FPPP rollout, however, we recognize that the CDC program only included a small number of properties and the full list of affordable senior housing properties in Massachusetts is much larger.

We are pleased to inform you that both residents and staff of public and private low income and affordable senior housing are now included in the first tier of Phase Two of vaccine deployment in the Commonwealth of Massachusetts, which we anticipate to begin later in February.

 The guidance and related information can be found at https://www.mass.gov/info-details/covid-19-vaccinations-for-senior-housing-settings

 This new guidance is applicable to public and private low income and affordable senior housing defined as any residential premises available for lease by older or disabled individuals which is financed or subsidized in whole or in part by state or federal housing programs established primarily to furnish housing rather than housing and personal services. Specifically, this includes the following types of housing properties:

• Public housing properties designated primarily for older adults that are owned/operated by Local Housing Authorities. This includes those public housing properties owned by a Local Housing Authority but managed by a private company.
• Privately owned properties designated for older adults that are financed in whole or part through resources made available from DHCD, MassHousing, or the U.S. Department of Housing and Urban Development (HUD), and in which the majority of units are restricted to residents earning less than 80% of Area Median Income.

There are three vaccination options for staff and residents who were not included in the Federal Pharmacy Partnership Program with CVS and Walgreens. These include:

1. Organizations may leverage existing pharmacy partnerships or an existing relationship with a medical or community health provider to offer an on-site clinic; or
2. Organizations may contact their Local Board of Health (LBOH), if the Board is running clinics, to discuss capacity to provide an on-site clinic; or
3. Residents and staff may schedule an appointment at a provider location, pharmacy, or a Mass Vaccination Site. Additional pharmacy, provider and mass vaccination sites will come on line in the coming weeks.

Any owners, operators, or property managers may reach out to SeniorHousingVaccine@mass.gov with any questions regarding the guidance and vaccine deployment.