In early April, the number of Washington long-term care facilities reporting at least one active COVID-19 case reached its lowest point in a year, since the start of the pandemic. It was 115 facilities, down fivefold from a peak of nearly 600 this January.

The sharp decline in outbreaks, attributable largely to widespread vaccination, is welcome news to the state’s nursing homes, assisted-living facilities and adult family homes. These sites have borne the brunt of the deadly virus, accounting for more than half the state’s COVID-19 deaths since the first cases in the U.S. were confirmed at a Kirkland nursing home. Residents now can move in and out of buildings, and indoor visits have resumed after a year of social isolation.

Over the past few weeks, however, cases have begun ticking up again, according to data from the Washington State Department of Social and Health Services. As of Wednesday, 154 facilities in Washington reported at least one active COVID-19 case in the past two weeks.

Health officials, advocates and site operators cite staff vaccine hesitancy and new, unvaccinated residents moving into buildings and bringing in the virus. The cases, they say, also underscore that even among a largely vaccinated population, when an infection makes its way into a congregate-care setting, it can spread rapidly.

But overall case numbers, as well as updates from facilities on the list, show that many outbreaks are smaller and the cases of illness are less severe than those reported before widespread vaccinations.

In the first week of January, there were 695 new COVID-19 cases, including 87 deaths, connected to long-term care facilities, according to the Washington State Department of Health (DOH). For the past month, new cases have hovered around 50, including 10 new deaths, each week.

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Across the U.S., cases and deaths in nursing homes — the hardest hit sites — have plummeted. From the weekly peak of 33,648 resident cases and 6,038 deaths in late December, which also coincided with the beginning of nursing home vaccinations, the week-by-week number of cases has decreased by 97%, and the number of deaths has decreased by 96%, according to the Centers for Medicare and Medicaid Services.

The state DSHS list doesn’t indicate how many cases are associated with a long-term site, nor does it include a breakdown of whether the positive case is a resident, staff member or visitor. The majority of new cases reported by facilities are staff members who have tested positive, according to DSHS spokesman Chris Wright.

“Vaccine hesitancy remains an issue among long-term-care workers nationwide,” Wright said. “Now that hundreds of millions of doses of vaccine have been administered, hesitant employees can be assured that it is a safe and effective, and we hope they will choose to get vaccinated.”

To be taken off the state DSHS list, a facility must go 28 days without a positive test.

Josephine Caring Community in Stanwood, which last year had one of the largest outbreaks in the state with more than 100 positive cases, was on the DSHS list again in early May. That outbreak consisted of two staff members, who both refused to get a COVID-19 vaccine, according to CEO Terry Robertson.

No Josephine residents have tested positive this year, he said. Nearly all received the vaccine.

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In some facilities, new residents who weren’t vaccinated and had trouble accessing a vaccination clinic have brought the overall vaccination rate down to 60%, according to Deb Murphy, president and CEO of LeadingAge Washington.

“This provides opportunity for the virus to enter and infect high-risk seniors,” Murphy said.

Other outbreaks include those with “breakthrough cases,” meaning that someone acquired the virus despite completing a vaccine regimen. At least six of the COVID-19 cases associated with an outbreak at Avamere Bellingham Healthcare & Rehabilitation Services are breakthrough cases, according to the company that owns the skilled nursing facility in Whatcom County.

“It is important to remember that no vaccine is 100% effective,” Dr. Elizabeth Burns, chief medical officer of the Avamere Family of Companies, said in a prepared statement. “The great news is there are systems in place that track these trends to investigate possible variants or any vaccine quality control issues.”

As of Tuesday, there have been 21 positive cases among Avamere Bellingham residents and staff, Whatcom County Health Department spokesperson Schuyler Shelloner said. The outbreak was first reported by The Bellingham Herald.

There have been 1,471 breakthrough cases identified in Washington, according to DOH, out of more than 3 million people who have been vaccinated. Of those cases, 23 people have died; 12 were associated with long-term care facilities.

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In Spokane, 25 residents and seven staff at Riverview Retirement Community tested positive in an outbreak this month. All the residents and three staff members are considered breakthrough cases, said Spokane Regional Health District spokeswoman Kelli Hawkins.

Riverview President and CEO Mike Drew said they were proud to have gone 15 months without a single positive COVID-19 case, until May 11, when the first person tested positive. It’s unclear how the virus made its way inside. “Quite a few” visitors had come to the site, and some residents had left and come back, he added.

“It’s been kind of a mystery,” Drew said.

At the Spokane facility, 98% of residents received a vaccine, and 52% of staff members were vaccinated at the facility’s clinics — but the staff vaccination rate could be higher because some received shots from other providers. Drew said he continues to encourage staff members, and everyone, to get the COVID-19 shot.

“We feel it’s been a tremendous deterrent, and very, very helpful in preventing more cases,” Drew said. “We are still very strong about saying: Get vaccinated.”