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The Dropped Mask Mandate, Public Transport, and New COVID Variants: Here’s What Infectious Disease Experts Are Saying about This Mix

On April 18, a federal judge in Florida struck down the mask mandate that the Centers for Disease Control and Prevention (CDC) enacted on January 29, 2021.

Now, individual transportation entities can make their own policies, which many already have. In less than 24 hours, United, Delta, Southwest, American, JetBlue, Alaska, Spirit and Frontier airlines all decreed masks optional, as did Amtrak. The New York Times reported that some travelers heard the news mid-flight and happily bared their faces. But while some Americans are exhaling in elation, others are concerned they’re trapped in transit.

The decision to lift the mask mandate was a judicial one, not based on public health considerations. So where does that leave you when it comes to protecting yourself and others from infection?

The trouble with the timing

The masking change occurred just as Covid-19 subvariants BA.4, BA.5, and XE—plus more Omicron variants—are arriving on the heels of BA.2, which recently took the lead as the most dominant Covid-19 strain in the world. Read The New COVID-19 Variant, "BA.2"—Get 9 Facts Straight From Medical Specialists

The Covid-19 virus has continued to do exactly what viruses do: mutate and evolve. XE is a new hybrid variant of Omicron and BA.2 that was first spotted in the U.K. “XE is simply a recombinant version of BA.1 and BA.2, and although several countries have seen cases, this is not expected to be a major concern,” Robert Salata, MD, a professor of medicine at the Case Western Reserve University School of Medicine in Cleveland, OH, tells The Healthy.

Meanwhile, Omicron subvariants BA.4 and BA.5 are circulating in several countries within Southern Africa and Europe, as the World Health Organization keeps its eyes on them.

The jury is still out on what these variants are capable of, Salata explains. “It is not clear yet if they are more transmissible or associated with more significant disease than BA.1 or BA.2.” His prediction? There will be an uptick in cases, but not as many as there were with the original Omicron strain. “Whether this will escalate beyond cases to include significant hospitalization and death remains to be seen,” he says.

Two additional variants—BA.2.12 and BA2.12.1—are now spreading in central New York and appear to be closely related to the BA.2 variant, he says.

So far, it seems that Omicron and its subvariants cause milder disease than their predecessors.

So…to mask or not to mask?

In a nutshell, the decision to mask or not to mask on public transportation and in transportation hubs is now up to each individual. That decision should be between you and your healthcare provider, and based on your personal risk profile. “If you’re in a high-risk group, I think you’d want to be more careful and keep wearing your mask and doing as much social distancing as possible,” says William Schaffner, MD, an infectious diseases specialist at Vanderbilt University Medical Center in Nashville. “For those folks, we recommend that they continue to wear masks indoors, and that includes planes, trains, and buses.” This may also be true if you have a close loved one who is older or immunocompromised.

For anyone who’s getting ready to board a flight, ventilation in planes is actually pretty good, despite how cramped you might feel, says S. Wesley Long, MD, PhD, medical director of diagnostic microbiology at Houston Methodist. “I don’t think people should be unduly concerned.”

Of course, adds Long, anyone who wants to still has the right to wear a mask in peace—and in an interview with The Healthy, Robert G. Lahita MD, PhD, director of the Institute for Autoimmune and Rheumatic Disease at Saint Joseph Health in Paterson, NJ and author of Immunity Strong, says that may still be wise. “The American populous is waning as far as wearing masks and practicing social distancing and are not taking these variants—which seem to pop up every three days—very seriously,” Lahita says. Double-masking could make you feel greater assurance, especially aboard trains or buses, where good ventilation may not be such a sure thing.

Mutations will keep coming unless more people are vaccinated

Variants arise in places with significant numbers of non-vaccinated people, including underdeveloped parts of the world, Salata says. The Delta variant, for example, originated in India. “For the most part, having the primary series of two shots, along with a booster, does provide protection against severe disease, hospitalization, and death,” says Salata. If you’re considering the second booster (meaning your fourth Covid shot in total), Lahita suggests discussing the risks and benefits with your doctor.

It’s important to remember: Covid-19 is still spreading

That said, SARS-CoV-2, the virus which causes Covid-19, is still with us. The latest incarnation, BA.2, is even more contagious than its parent, Omicron, which already was “extraordinarily contagious,” says Schaffner.

Transmission is relatively low but starting to creep up and, in a statement issued the same day the ruling came down, the CDC emphasized that “traveling on public transportation increases the risk of getting and spreading Covid-19 . . . Wearing masks that completely cover the mouth and nose reduces the spread of Covid-19.”

Vaccinations are reducing severe cases

The good news is that while cases are trending up, hospitalizations and deaths are heading in the opposite direction. On April 15, the CDC reported that about 66 percent of Americans are now fully vaccinated, while 77.3 percent have at least one vaccine.

The new transportation ruling “is just another reason people need to be vaccinated and boosted and then, if they want, to wear a mask,” suggests Long.

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‘Values of our society’: Nursing homes shut down, close wings amid COVID-19 staffing crunch

A 99-bed nursing home in one of Cleveland’s poorest neighborhoods will close its doors in less than two months.

Like many nursing homes in urban and rural pockets of America, Eliza Bryant Village has struggled to maintain operations during the COVID-19 pandemic. Costs are too high and reimbursement isn’t enough. The home loses more than $100 each day for every resident covered by Medicaid, which represents about 95% of the home’s population.

So the home that describes itself as the oldest, continually operating, African American-founded nursing home in the U.S. will close June 8. Most elderly residents, some having lived there for several years, already have found new facilities. As of April 15, 17 residents were still searching for their next home.

Danny Williams, president and CEO of Eliza Bryant Village, said the nonprofit home’s financial pressure is emblematic of what ails so many nursing facilities nationwide.

“It’s a result of the values of our society – we just don’t value taking care of old, poor people,” said Williams. "If there’s anything good that comes from this, it shines a light on the inequities in the system and may influence policymakers to take some action."

Eliza Bryant is among more than 300 homes that closed or are winding down operations since 2020, according to an analysis of federal data by the American Health Care Association and National Center for Assisted Living, an industry group that represents for-profit nursing homes.

Experts warn even more homes are at risk due to an inadequate system to pay for elder care, a relentless workforce shortage and the lingering effects of the pandemic.

Casting further uncertainly is the Biden administration’s sweeping reforms that would require minimum staffing levels and improved oversight of infection control. The administration’s plan amounts to the most ambitious effort to address nursing home quality, safety and staffing in decades.

On April 11, the Centers for Medicare and Medicaid Services proposed a $320 million pay cut that nursing home operators say will only exacerbate the industry’s challenges.

“Nursing home closures are devastating to residents, their families, staff and the entire health care system," said Mark Parkinson, president and CEO of the American Health Care Association and National Center for Assisted Living. "The chronic underfunding of nursing homes combined with the ongoing toll of the pandemic and a historic labor shortage has been too much to bear for many facilities."

Nursing homes have struggled to attract workers for years, even before the pandemic. A 577-page report issued by the National Academies of Sciences, Engineering and Medicine on April 6 cited decades of underfunding and a lack of accountability on how those funds are spent. One result has been low staff salaries and benefits that made nursing homes a "highly undesirable place of employment," the report said.

The industry’s workforce problems accelerated when the pandemic caused lockdowns, inflation and an ultra-tight job market in which workers became more selective about taking new jobs. Others quit staff positions to take higher-paying gigs with staffing agencies that charged homes up to three times the pre-COVID-19 rates. One industry group urged the Federal Trade Commission to investigate staffing agencies for price gouging.

It’s why nursing homes in big cities and small towns likely will continue to shut down, close wings, or scale back operations, experts say.

“There’s going to be a hollowing out of nursing homes,” said Vincent Mor, a Brown University School of Public Health professor. “The issue of facilities closing is going to be a real factor. They’ll close particularly in rural areas, and they’ll close particularly in communities that mostly serve poor people.”
‘Common story for rural America’

Heidi Thomas had a choice last fall when the Arapahoe, Nebraska, assisted living home where her husband Alan lived for five years announced it was shutting down on Dec. 31.

She could find a new nursing facility in a neighboring town. But she had no interest in driving 30 to 40 miles several times each week in this far-flung region of Southern Nebraska.

So she outfitted their home for Alan, who has Parkinson’s disease and Lewy body dementia, a disease that leads to irreversible mental decline. He does not require complex machines or devices, but he needs constant supervision.

Thomas hired two caregivers from the closed assisted living and nursing facility who watch him during the day while she works as a teacher.

“He doesn’t have a lot of words anymore,” Thomas said. “But he did say that he was really happy to be home.”

The Arapahoe home was operated by Good Samaritan Society, which merged in 2019 with the Sioux Falls, South Dakota-based Sanford Health. Good Samaritan last year shut down nursing facilities in two other Nebraska towns, Ravenna and Valentine.

The Sanford Health-affiliated centers were among 13 nursing homes or assisted living facilities that have closed in Nebraska since the beginning of 2021.

Homes that closed in rural Nebraska before the pandemic typically did so because they didn’t have enough patients or residents to justify remaining open, said Jalene Carpenter, CEO of the Nebraska Health Care Association.

But since the beginning of the pandemic, "It has really been the reverse," Carpenter said. "They have residents to care for or they have (people) they would like to accept. They simply do not have the workforce."

Arapahoe Mayor John Koller said Good Samaritan Society’s closing was "devastating" for the town of just over 1,000, where one-quarter of residents are over 65 and often lived their entire life in the community.

Many residents moved to homes in neighboring towns, making it more difficult for their Arapahoe family members to regularly visit. About 25 to 30 employees had to seek jobs at facilities as far as 60 miles away, Koller said.

The community was notified 60 days before the facility closed, the minimum under federal and state law, Koller said.

"In a town this size, if you lose any employment opportunities, it’s difficult to recover," Koller said. "It’s this common story for rural America. It just continues to erode."

Thomas trained to become a certified nurse assistant so she could work at the home and see her husband during the COVID-19 nursing home lockdowns. For 18 months, between her teaching and nursing assistant jobs, she worked every day. She knew the residents, some of whom had been there for years before they were forced to move farther from family.

"Nobody wants to be lonely," Thomas said. "And that’s what happens when you get stuck somewhere where you don’t know anybody."
Survey: 1 in 4 nursing homes halt admissions

In Wisconsin, a dozen nursing homes have closed facilities since the beginning of the pandemic, and three are winding down operations, according to LeadingAge Wisconsin.

The industry’s workforce shortage has rippled beyond closed homes. Dozens of homes have reduced the number of beds they operate because they don’t have enough workers. Nursing homes have shut down 2,116 beds at nursing facilities since 2020 – the equivalent of about 30 facilities with an average of 70 beds.

The staffing crunch means homes can’t handle everyone who seeks care, said John Sauer, president and CEO of the Wisconsin chapter of LeadingAge. A state economist told his group this year about 22,000 people in Wisconsin seeking full-time employment across all job sectors. At the time, Wisconsin nursing facilities had 23,000 job openings.

“It really is a herculean task to achieve higher staffing than we have now,” Sauer said.

LeadingAge, an association of nonprofit providers of aging services, including nursing homes, polled members nationwide this year and discovered similar results. About 26% of nonprofit homes said they were unable to admit new residents and 25% closed units or reduced available beds.

"There is a question about the long-term sustainability of some homes in some communities," said Katie Smith Sloan, president and CEO of LeadingAge. "It may not be closing the home altogether, but many of our members have taken their beds offline, closed a wing, or converted it to something else."

The Biden administration’s proposal to mandate minimum staffing ratios would be difficult to meet unless accompanied by other significant fixes such as payment, regulatory and immigration reform, Sauer said. The latter could provide guest workers to regions with staff shortages, particularly in rural communities that struggle to draw enough workers.

“Is there support for higher staffing levels, especially in the mission-driven provider community? The answer is yes,” Sauer said. “We have to recognize that there’s just no magic wand we can wave over the long-term care provider community to make that happen.”

The National Academies report described funding for long-term care as inadequate and fragmented. Among the proposed fixes: study and implement state demonstration programs with the goal of creating a new model to pay for long-term care. The report acknowledged such a benefit would be politically challenging. It did not estimate how much such a program might cost or propose how to pay for it.

Williams, of Cleveland’s Eliza Bryant Village, said more equitable funding will be key for homes that serve a larger share of poor residents. His group will maintain other services on its 17-acre campus east of downtown, including an adult day program, at-home care, transportation and an elder justice center for seniors suffering physical, emotional, or financial abuse.

But the losses were far too great to maintain the nursing home.

"Nobody is going to fix it without government support," Williams said. "The fix is coming up with a fair reimbursement plan that covers the actual cost of care."

, COVID-19 , Covid , SARS-COV-2 , Coronavirus

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