At a press conference Thursday, state officials painted a grim reality of coronavirus spread in New Hampshire.
The two-week average of positive cases had doubled in three weeks and showed no sign of slowing. Hospitalizations were steadily increasing. Northern parts of the state, which had largely been spared during the first wave, were experiencing alarming outbreaks.
One spot of good news came from an unlikely source – nursing homes. Cases of COVID-19 in nursing homes, which once comprised the bulk of the state’s numbers, have petered out to a weekly average of 12 cases, a decline from the 54-case weekly average the state saw in May.
“What we’re seeing now is that the transmission and the spread of this virus has largely moved out of those facility outbreak settings and into the general community,” said Ben Chan, the state epidemiologist.
The virus, which thrived in nursing homes during the “first wave” in New Hampshire, has largely taken host in the community this time around – spreading in hockey rinks and over dinner tables instead.
Chan said one explanation for the virus’s changing epidemiology is the precautions nursing homes have agonized over for the last eight months.
Brendan Williams, the president of the New Hampshire Health Care Association, said the facilities have learned a lot about how to contain the virus. Homes have implemented rigorous testing procedures, stringent personal protective equipment requirements, and restrictions on outside visitors and group activities.
Epidemiologists have dubbed the strategy the “swiss cheese model” – even though each precaution isn’t perfect, creating holes in the protective barrier, the hope is that if enough layers are stacked together, they will create an impermeable wall against COVID-19. Furthermore, as testing has become more prevalent and PPE has become more available, each layer has fewer holes.
“We know how to prevent and control the spread of this pandemic virus,” Chan said. “We’re seeing that play out and work within the long-term care facilities.”
But even meticulous plans with layers of protection have holes. An alternative interpretation of the low numbers is that they represent the calm before the storm.
While Williams thinks the facilities have done a great job implementing safety precautions, he said high rates of community spread almost always mean trouble for nursing homes.
Nationally, new weekly cases among nursing home residents rose nearly fourfold from the end of May to late October in states experiencing surges of COVID cases, according to the Associated Press. Chan said given the spread within counties, he expects more cases and clusters to appear in long-term care facilities in the coming weeks.
Though the graphs don’t reflect it, it’s possible that this wave of COVID is following a similar trajectory to the first wave – except now, we have more information.
In March, there wasn’t a large spike in community transmission before the widespread outbreaks in nursing homes. But there also weren’t nearly as many tests performed as there are now. Since early April, the average number of tests a week has increased about tenfold.
“It mostly has to do with where you pay attention to it,” said Daniel Stadler, a geriatric doctor at Dartmouth-Hitchcock. “An isolated case in the community doesn’t cause a lot of attention and maybe gets missed, especially if we’re talking about someone asymptomatic. We didn’t see it until it was out of control in many ways.”
Stadler said while it was easy to miss some community cases, the cases in nursing homes during the first wave were impossible to ignore – it spread rapidly and left some nursing homes with nearly half of their residents dead.
Until the trajectory of nursing home cases is clear, Williams won’t celebrate the low number of cases.
“I’m not going to declare victory,” Williams said. “I’m pleased facilities are making progress but the fact that the virus can run through the White House with a daily testing regime shows it can certainly get into any long-term care facility.”