Before the coronavirus had reached the Pleasant View Nursing Home in the small Maryland town of Mount Airy, the home’s administrator asked the state health department what she should be doing about the threat.
Some of Rebecca Travels’ staff worked second jobs at other nursing homes, she said, and she wanted to hedge against an outbreak. Nursing care facilities in other states had been hit hard, and she feared for her older residents — who live four to a room.
At first, state officials told her that her facility didn’t qualify for testing under the stringent criteria set out by the federal government amid a nationwide shortage of testing kits, she said. Later, after the first case of the virus had been confirmed within her facility March 26, she said state officials told her using tests on staff would be a “waste of resources,” and that staff with symptoms should just self-isolate.
A week later, six of her 95 residents were dead, and three more deaths were announced Saturday. Dozens of other residents have tested positive for the virus. And according to Gov. Larry Hogan, it was an employee without symptoms — not one Travels would have known to isolate without a test — who likely brought the virus in.
“It’s a tragic situation, one of the most difficult things we’ve been dealing with," Hogan said in a C-SPAN interview Tuesday in which he drew comparisons to other major nursing home outbreaks in Washington, Georgia, Tennessee and Minnesota. “It went like wildfire.”
Said Travels: “It’s just incredibly frustrating. There’s a failing of support from federal resources."
State officials would not answer questions related to their response at Pleasant View specifically or in nursing homes generally, nor would they discuss other aspects of their coronavirus response capabilities. Hogan’s office did not respond to questions about his statements on how the virus arrived at Pleasant View.
But by Friday, he and other state officials were acknowledging a much larger problem: Pleasant View was one of 60 nursing homes across the state where the virus had been detected, Hogan said, with other facilities seeing clusters of up to 10 cases.
Public health experts agreed that a lack of federal support to the state on a range of measures had contributed.
In nursing homes with vulnerable residents, close quarters and staff who work in multiple facilities, the virus is cutting a particularly deadly path. Nurses and other staff who carry heavy workloads and work multiple jobs are helping to speed up the spread.
And the nation’s lack of testing, coupled with its inability to effectively trace the contacts of those who are infected, has left local and state health departments blind in the battle to intervene.
“The general principle is that we have to be making testing available as part of an infection control strategy,” said Dr. Joshua Sharfstein, former Maryland health secretary and now vice dean for public health practice and community engagement at the Johns Hopkins Bloomberg School of Public Health.
“The lack of testing is hindering the development of an effective response strategy, both for nursing homes and for the general public,” Sharfstein said.
That is particularly true given the danger of asymptomatic contagion.
Scientists have been closely studying the degree to which the virus can be spread by people who haven’t yet developed symptoms, or in some cases never get ill, and have raised some concern that common screening practices don’t accurately reflect that risk.
Those people could make up a quarter of all coronavirus cases, Dr. Robert Redfield, director of the Centers for Disease Control and Prevention, said in an interview with NPR Tuesday.
Research in countries where testing has been more widespread, on a per capita basis, suggests asymptomatic cases are a much bigger risk than that. One study in China found that 86% of cases across hundreds of cities went undetected in January because people had mild, limited or no symptoms. China on Wednesday began reporting more than 1,500 lab-confirmed yet asymptomatic cases, spurring concerns of a new wave of infections as the country prepares to end lockdowns.
In Maryland, and in local jurisdictions all across the United States, the fear is that asymptomatic people, including nursing home staff, are carrying and spreading the virus. And without adequate testing and tracing, officials don’t know who they are, where they’ve been, who they’ve been in contact with or how to isolate them to reduce the spread.
Front-line hospital workers have had better access to testing. But they, too, face pressures to remain at work, especially if asymptomatic, given the intense demand for care.
Nursing homes are particularly susceptible to the associated risk, as they are full of vulnerable patients with underlying health conditions, who live in close quarters and are treated by the same nurses. In addition to Pleasant View, coronavirus infections have been identified in recent weeks in nursing homes in Baltimore and in Baltimore and Howard counties, while a Montgomery County facility began isolating residents after an infected person attended an event there.
On Wednesday, officials announced several new clusters in nursing homes across the region, including four cases at another facility in Carroll County: the Carroll Lutheran Village in Westminster. It was not immediately clear which of the facilities, if any, shared staff.
On Thursday, county officials said a total of 18 Pleasant View staffers had tested positive for coronavirus. On Friday, that number increased to 24.
Noting the spread to 60 homes statewide, Frances Phillips, the state’s deputy secretary for public health services, said there was now “clear evidence” the spread was being aided by asymptomatic staffers.
Phillips has issued a mandate requiring all nursing home staff to begin wearing masks, and said state testing capacity is now being set aside to focus on tests from nursing homes, to expedite the process.
Some experts said moves to protect nursing home populations were overdue.
“When you’re talking about nursing homes, you’re talking about some of the most vulnerable populations,” said Trudy Henson, public health program director at the Center for Health and Homeland Security at the University of Maryland School of Law, who has worked with nursing homes to enhance their emergency planning.
Sharfstein said he could not speak directly to the Pleasant View case, but that generally in such settings, “you have the risk of not just one person being infected, but many people being infected" if a virus isn’t stopped in its tracks early.
Testing in such settings should be a top priority for states and local health departments, he said, because “if testing identifies a case, it’s very important to respond quickly with infection control."
Similarly, contact tracing — or tracking an infected individual’s path through society to identify contacts across an array of interactions — is critically important once a case is identified, in part because staff members work in multiple facilities, he and others said.
Crystal Watson, a senior scholar at the Bloomberg School’s Center for Health Security, said large clusters will continue occurring in nursing homes and elsewhere in the United States without massive improvements in both testing and tracing.
“We need a national-level vision for how we can get to that point, identifying every single case and tracing all of their contacts, and we’re going to need a big push from state and local health departments to get there,” Watson said. “We should be aiming to be able to test every contact of every case.”
Contact tracing is extremely labor-intensive. It can involve using infected people’s recollections, contacts, social media and bank transactions to retrace their steps back through their neighborhoods and workplaces, at restaurants and on public transit, reaching out to everyone they may have come in contact with.
Robust testing would, in theory, help reduce the number of people for whom tracing would be required, as it would allow authorities to intervene, and request isolation and quarantines, sooner. In some Asian countries like South Korea, which instituted widespread testing and tracing quickly, society has been left more open because authorities there are confident that, if and when a new case arises, they can contain it.
President Donald Trump claimed last week that the United States is doing a good job responding to the pandemic, testing a million people. But governors, other local officials and public health experts reject that notion.
In his C-SPAN interview, Hogan dismissed a claim by Trump that the United States is doing a good job testing people.
“No, it’s not fixed by any stretch of the imagination," he said of the testing problem. “We can’t produce these things fast enough and get them out fast enough. While we’ve made dramatic improvements in the past few weeks, we have not done enough testing. It’s a big part of the problem. We’re making improvements. It’s just not fast enough.”
Establishing faster testing and sufficient tracing to tackle each case or cluster quickly would be one way out of the current stay-at-home orders that many states have implemented. Dr. Tom Inglesby, director of the Center for Health Security, said social-distancing measures that have hobbled the American economy and sent unemployment skyrocketing could be lifted once “the disease is driven to such a low prevalence that our health departments could again do contact tracing and isolation.”
But "that’s not happening” in a robust way at the moment, he said.
It is unclear exactly how much contact tracing the state and local health departments are doing, or how they have responded to the Pleasant View outbreak in particular, in part because they won’t answer questions about either.
They won’t discuss the decisions not to provide tests to the facility early on, why they at one point provided 27 test kits to Travels only to take them back, or about whether and how they are attempting to trace the contacts of those affiliated with known cases — including Pleasant View staff who also work at other facilities.
Pleasant View is regulated by state and federal agencies. It has received some poor marks in the past — labeled as “much below average” overall compared with other facilities. Its rating on staffing was much below average, while its health inspection and quality of resident care ratings were both below average. But it had not received any serious penalties in the three years before its most recent federal review.
Carroll County Health Officer Ed Singer said last week that the facility had been following proper guidelines before the outbreak.
“To the best of our knowledge, the facility was doing everything they were supposed to be doing,” Singer said.
Travels said she implemented visitor restrictions March 10, screening visitors and health care workers for symptoms. On March 11, Travels called a staff meeting to reiterate the importance of following infection-control protocol. By March 13, Pleasant View received guidance from the Centers for Medicare and Medicaid Services to discontinue communal dining and activities. Travels said she and her assistant were at the facility by 6 the next morning to implement those changes.
“We followed every recommendation to the letter from the minute that it came out,” Travels said.
After she learned of the first confirmed case March 26, Travels said, she again followed federal guidelines, asking her 120 to 130 staff members to inform her of any other jobs they held in facilities where residents could also be at risk. She recommended they inform their other employers that they had contact with a positive case. And she said she trusted her staff did that, but had no way of knowing for certain.
State officials would not say whether they have stepped in to ensure those notifications have been made. They have not publicly identified other nursing homes where Pleasant View staffers work. They have not said how many Pleasant View staff members are being isolated, or are ill, or have been tested — though they finally began arranging testing for staff this past week, county health officials said.
Many residents have been moved out of Pleasant View, either into hospitals or to other facilities. Hogan said Friday 42 residents and staff had been sent to 14 different hospitals.
Leaders of nursing home industry groups say they have for weeks been urging facilities to determine whether any of their staff also work in facilities where coronavirus cases have been confirmed. The groups have stressed that those employees must be barred from coming to work for at least two weeks, said Joe DeMattos, executive director of the Health Facilities Association of Maryland.
But he said that responsibility is resting on the industry, and that state and local health officials are not enforcing it.
Nursing homes are “all scouring their employee lists,” said Kevin Heffner, president of LifeSpan Network, a group representing nursing homes across Maryland. “They’re doing everything to the nth degree to make sure they protect their staff and their residents.”
Industry groups, including LifeSpan, the Health Facilities Association of Maryland and Leading Age Maryland, have been surveying member companies and facilities and coordinating with the state’s Office of Health Care Quality to ensure nursing homes have enough protective equipment for staff, space to isolate patients and backup staff in the event that employees have to be quarantined, Heffner said.
And many, but not all, nursing homes are using medical screening equipment that can help quickly rule out the flu or colds when respiratory illnesses appear, as well as data tracking to detect hot spots of people showing mild symptoms, he said.
“We’re trying to get ahead of things so when the next wave comes, or when things peak, they’re prepared to be able to shift resources around so we’re meeting the need immediately,” Heffner said. “As opposed to, ‘Uh-oh, what do we do now?’ ”
Baltimore Sun reporter Lillian Reed contributed to this article.