Tagged Centers for Disease Control and Prevention

Has the Era of Overzealous Cleaning Finally Come to an End?

This week, the C.D.C. acknowledged what scientists have been saying for months: The risk of catching the coronavirus from surfaces is low.

When the coronavirus began to spread in the United States last spring, many experts warned of the danger posed by surfaces. Researchers reported that the virus could survive for days on plastic or stainless steel, and the Centers for Disease Control and Prevention advised that if someone touched one of these contaminated surfaces — and then touched their eyes, nose or mouth — they could become infected.

Americans responded in kind, wiping down groceries, quarantining mail and clearing drugstore shelves of Clorox wipes. Facebook closed two of its offices for a “deep cleaning.” New York’s Metropolitan Transportation Authority began disinfecting subway cars every night.

But the era of “hygiene theater” may have come to an unofficial end this week, when the C.D.C. updated its surface cleaning guidelines and noted that the risk of contracting the virus from touching a contaminated surface was less than 1 in 10,000.

“People can be affected with the virus that causes Covid-19 through contact with contaminated surfaces and objects,” Dr. Rochelle Walensky, the director of the C.D.C., said at a White House briefing on Monday. “However, evidence has demonstrated that the risk by this route of infection of transmission is actually low.”

The admission is long overdue, scientists say.

“Finally,” said Linsey Marr, an expert on airborne viruses at Virginia Tech. “We’ve known this for a long time and yet people are still focusing so much on surface cleaning.” She added, “There’s really no evidence that anyone has ever gotten Covid-19 by touching a contaminated surface.”

During the early days of the pandemic, many experts believed that the virus spread primarily through large respiratory droplets. These droplets are too heavy to travel long distances through the air but can fall onto objects and surfaces.

In this context, a focus on scrubbing down every surface seemed to make sense. “Surface cleaning is more familiar,” Dr. Marr said. “We know how to do it. You can see people doing it, you see the clean surface. And so I think it makes people feel safer.”

A “sanitization specialist” at an Applebee’s Grill and Bar in Westbury, N.Y., wiping down a used pen last year. Restaurants and other businesses have highlighted extra cleaning in their marketing since the pandemic began.
A “sanitization specialist” at an Applebee’s Grill and Bar in Westbury, N.Y., wiping down a used pen last year. Restaurants and other businesses have highlighted extra cleaning in their marketing since the pandemic began.Hiroko Masuike/The New York Times

But over the last year, it has become increasingly clear that the virus spreads primarily through the air — in both large and small droplets, which can remain aloft longer — and that scouring door handles and subway seats does little to keep people safe.

“The scientific basis for all this concern about surfaces is very slim — slim to none,” said Emanuel Goldman, a microbiologist at Rutgers University, who wrote last summer that the risk of surface transmission had been overblown. “This is a virus you get by breathing. It’s not a virus you get by touching.”

The C.D.C. has previously acknowledged that surfaces are not the primary way that the virus spreads. But the agency’s statements this week went farther.

“The most important part of this update is that they’re clearly communicating to the public the correct, low risk from surfaces, which is not a message that has been clearly communicated for the past year,” said Joseph Allen, a building safety expert at the Harvard T.H. Chan School of Public Health.

Catching the virus from surfaces remains theoretically possible, he noted. But it requires many things to go wrong: a lot of fresh, infectious viral particles to be deposited on a surface, and then for a relatively large quantity of them to be quickly transferred to someone’s hand and then to their face. “Presence on a surface does not equal risk,” Dr. Allen said.

In most cases, cleaning with simple soap and water — in addition to hand-washing and mask-wearing — is enough to keep the odds of surface transmission low, the C.D.C.’s updated cleaning guidelines say. In most everyday scenarios and environments, people do not need to use chemical disinfectants, the agency notes.

“What this does very usefully, I think, is tell us what we don’t need to do,” said Donald Milton, an aerosol scientist at the University of Maryland. “Doing a lot of spraying and misting of chemicals isn’t helpful.”

Still, the guidelines do suggest that if someone who has Covid-19 has been in a particular space within the last day, the area should be both cleaned and disinfected.

“Disinfection is only recommended in indoor settings — schools and homes — where there has been a suspected or confirmed case of Covid-19 within the last 24 hours,” Dr. Walensky said during the White House briefing. “Also, in most cases, fogging, fumigation and wide-area or electrostatic spraying is not recommended as a primary method of disinfection and has several safety risks to consider.”

And the new cleaning guidelines do not apply to health care facilities, which may require more intensive cleaning and disinfection.

Saskia Popescu, an infectious disease epidemiologist at George Mason University, said that she was happy to see the new guidance, which “reflects our evolving data on transmission throughout the pandemic.”

But she noted that it remained important to continue doing some regular cleaning — and maintaining good hand-washing practices — to reduce the risk of contracting not just the coronavirus but any other pathogens that might be lingering on a particular surface.

Dr. Allen said that the school and business officials he has spoken with this week expressed relief over the updated guidelines, which will allow them to pull back on some of their intensive cleaning regimens. “This frees up a lot of organizations to spend that money better,” he said.

Schools, businesses and other institutions that want to keep people safe should shift their attention from surfaces to air quality, he said, and invest in improved ventilation and filtration.

“This should be the end of deep cleaning,” Dr. Allen said, noting that the misplaced focus on surfaces has had real costs. “It has led to closed playgrounds, it has led to taking nets off basketball courts, it has led to quarantining books in the library. It has led to entire missed school days for deep cleaning. It has led to not being able to share a pencil. So that’s all that hygiene theater, and it’s a direct result of not properly classifying surface transmission as low risk.”

Roni Caryn Rabin contributed reporting

Many Children With MIS-C Had No Covid-19 Symptoms

Pediatricians should be vigilant, experts said, after the release of the largest U.S. study of the syndrome, MIS-C, that can strike young people weeks after their coronavirus infection.

Many children and teenagers who developed the mysterious inflammatory syndrome that can emerge several weeks after contracting the coronavirus never had classic Covid-19 symptoms at the time of their infection, according to the largest study so far of cases in the United States.

The study, led by researchers from the Centers for Disease Control and Prevention, found that in over 1,000 cases in which information about whether they got sick from their initial Covid-19 illness was available, 75 percent of the patients did not experience such symptoms. But two to five weeks later, they became sick enough to be hospitalized for the condition, called Multisystem Inflammatory Syndrome in Children (MIS-C), which can affect multiple organs, especially the heart.

Published Tuesday in JAMA Pediatrics, the study said that “most MIS-C illnesses are believed to result from asymptomatic or mild Covid-19” followed by a hyper-inflammatory response that appears to occur when the patients’ bodies have produced their maximum level of antibodies to the virus. Experts do not yet know why some young people, and a smaller number of adults, respond this way.

“It means primary-care pediatricians need to have a high index of suspicion for this because Covid is so prevalent in the society and children often have asymptomatic disease as their initial Covid infection,” said Dr. Jennifer Blumenthal, a pediatric intensivist and pediatric infectious disease specialist at Boston Children’s Hospital, who was not involved in the study.

The researchers evaluated 1,733 of the 2,090 cases of the syndrome in people age 20 and younger that had been reported to the C.D.C. as of January.

The findings show that although the syndrome is rare, it can be serious. The C.D.C’s data only included patients who were hospitalized. Over 90 percent of those young people experienced symptoms involving at least four organ systems and 58 percent needed treatment in intensive care units.

Many experienced significant heart issues: over half developed low blood pressure, 37 percent developed cardiogenic shock and 31 percent experienced cardiac dysfunction involving their heart’s inability to pump adequately. The study said that a significantly higher percentage of patients who had not had Covid-19 symptoms experienced those heart problems, compared with those who had initial coronavirus symptoms. A greater percentage of initially asymptomatic patients also ended up in intensive care.

“Even the kids with severe MIS-C, who were in the I.C.U. — the vast majority of them did not have a preceding illness that they recognized,” said Dr. Roberta DeBiasi, chief of infectious diseases at Children’s National Hospital in Washington, D.C., who was not involved in the research.

The study provided the most detailed demographic and geographic picture of the syndrome to date. About 34 percent of the patients were Black and 37 percent were Hispanic, reflecting the way that the coronavirus has disproportionately affected members of those communities. As the pandemic went on, the authors wrote, the proportion of patients who were white increased, comprising 20 percent of all cases. People of Asian heritage comprised just over 1 percent of patients.

Overall, nearly 58 percent of the patients were male, but the proportion was not the same across all ages. The youngest group — newborn to age 4 — had roughly equal numbers of boys and girls, and the male-to-female ratio increased in the older groups until it was more than two-to-one male to female in the 18-to-20 group.

The vast majority of patients (nearly 86 percent) were younger than 15. The study found that those under 5 had the lowest risk of serious heart complications and were less likely to need intensive care. Patients 10 and older were significantly more likely to develop issues like shock, low blood pressure and myocarditis (inflammation of the heart muscle).

“I think that’s similar to what we saw with Covid, that the older kids seemed to have more severe disease,” Dr. DeBiasi said. “And that’s because what makes people really sick from the Covid is the inflammatory aspect of it, so maybe these older kids, for whatever reasons, make more inflammation, whether that’s in primary Covid or MIS-C.”

Still, significant numbers of the youngest patients developed heart problems. In the newborn-to-4 age group, 36 percent had low blood pressure, 25 percent had shock and 44 percent were treated in the I.C.U.

Patients of all ages in the study had about the same occurrence of some of the less-common heart issues linked to the syndrome, including coronary aneurysms and fluid buildup. Children 14 and under were more likely to have rash and red eyes, while those older than 14 were more likely to have chest pain, shortness of breath and cough. Abdominal pain and vomiting afflicted about two-thirds of all patients.

There were 24 deaths recorded, spread across all age groups. There was no information in the study about whether patients had underlying medical conditions, but doctors and researchers have reported that young people with MIS-C were often previously healthy and significantly more likely to be healthy than the relatively small number of young people who become seriously ill from initial Covid infections.

Of the 1,075 patients for whom information about initial Covid illness was available, only 265 had symptoms at that time. They were more likely to be older — their median age was 11, while the median age of those with asymptomatic Covid infections was 8. But that could be because “younger children can’t express their concerns as well,” said Dr. Blumenthal, who co-wrote an editorial about the study.

“We don’t necessarily know if there’s actually less symptomatology in the very young population, ” she said.

Similarly unclear are the reasons behind the study’s finding that in the first wave of MIS-C, from March 1 to July 1, 2020, young people were more prone to a few of the most serious heart complications. Dr. DeBiasi said that did not match the experience of her hospital, where “the kids were sicker in the second wave.”

The study documented two waves of MIS-C cases that followed surges in overall coronavirus cases by about a month or more. “The most recent third peak of the Covid-19 pandemic appears to be leading to another MIS-C peak perhaps involving urban and rural communities,” the authors wrote.

The study found that most of the states where the rate of MIS-C cases per population was highest were in the Northeast, which had the first surge of cases, and the South. By contrast, most states with high per-population rates of children with Covid-19 but low rates of MIS-C were in the Midwest and West. While the concentration of cases spread from large cities to smaller towns over time, it wasn’t as pronounced as the overall pandemic trends, the authors said.

Dr. Blumenthal said that geographic pattern could reflect that the “understanding of the complications of the disease” hadn’t caught up to its prevalence in different regions or that many states with lower rates of MIS-C have less ethnically diverse populations. “It could also be something about Covid itself, although we don’t know that,” she said. “Right now, we don’t know anything about how the variants necessarily affect children.”

The study represented only the strictest criteria for MIS-C, excluding about 350 reported cases that met the C.D.C. definition of the syndrome but had a negative antibody test or primarily involved respiratory symptoms. Dr. DeBiasi said there are also many probable MIS-C cases that are not reported to the C.D.C. because they don’t meet all the official criteria.

“These probable MIS-C kids, in real life that’s a big chunk of kids,” she said. In addition, while the focus so far has been on serious cases, “there’s another whole group of kids that may actually have mild MIS-C.”

If a community has experienced a recent coronavirus surge, then “just because the kid says, ‘I never had Covid or my parents never had it,’ that doesn’t mean the kid in front of you doesn’t have MIS-C,” Dr. DeBiasi said. “If your city has Covid, then get ready.”

Many Children With Serious Inflammatory Syndrome Had No Covid Symptoms

Pediatricians should be vigilant, experts said, after the release of the largest U.S. study of the syndrome, MIS-C, that can strike young people weeks after their coronavirus infection.

Many children and teenagers who developed the mysterious inflammatory syndrome that can emerge several weeks after contracting the coronavirus never had classic Covid-19 symptoms at the time of their infection, according to the largest study so far of cases in the United States.

The study, led by researchers from the Centers for Disease Control and Prevention, found that in over 1,000 cases in which information about whether they got sick from their initial Covid-19 illness was available, 75 percent of the patients did not experience such symptoms. But two to five weeks later, they became sick enough to be hospitalized for the condition, called Multisystem Inflammatory Syndrome in Children (MIS-C), which can affect multiple organs, especially the heart.

Published Tuesday in JAMA Pediatrics, the study said that “most MIS-C illnesses are believed to result from asymptomatic or mild Covid-19” followed by a hyper-inflammatory response that appears to occur when the patients’ bodies have produced their maximum level of antibodies to the virus. Experts do not yet know why some young people, and a smaller number of adults, respond this way.

“It means primary-care pediatricians need to have a high index of suspicion for this because Covid is so prevalent in the society and children often have asymptomatic disease as their initial Covid infection,” said Dr. Jennifer Blumenthal, a pediatric intensivist and pediatric infectious disease specialist at Boston Children’s Hospital, who was not involved in the study.

The researchers evaluated 1,733 of the 2,090 cases of the syndrome in people age 20 and younger that had been reported to the C.D.C. as of January.

The findings show that although the syndrome is rare, it can be serious. The C.D.C’s data only included patients who were hospitalized. Over 90 percent of those young people experienced symptoms involving at least four organ systems and 58 percent needed treatment in intensive care units.

Many experienced significant heart issues: over half developed low blood pressure, 37 percent developed cardiogenic shock and 31 percent experienced cardiac dysfunction involving their heart’s inability to pump adequately. The study said that a significantly higher percentage of patients who had not had Covid-19 symptoms experienced those heart problems, compared with those who had initial coronavirus symptoms. A greater percentage of initially asymptomatic patients also ended up in intensive care.

“Even the kids with severe MIS-C, who were in the I.C.U. — the vast majority of them did not have a preceding illness that they recognized,” said Dr. Roberta DeBiasi, chief of infectious diseases at Children’s National Hospital in Washington, D.C., who was not involved in the research.

The study provided the most detailed demographic and geographic picture of the syndrome to date. About 34 percent of the patients were Black and 37 percent were Hispanic, reflecting the way that the coronavirus has disproportionately affected members of those communities. As the pandemic went on, the authors wrote, the proportion of patients who were white increased, comprising 20 percent of all cases. People of Asian heritage comprised just over 1 percent of patients.

Overall, nearly 58 percent of the patients were male, but the proportion was not the same across all ages. The youngest group — newborn to age 4 — had roughly equal numbers of boys and girls, and the male-to-female ratio increased in the older groups until it was more than two-to-one male to female in the 18-to-20 group.

The vast majority of patients (nearly 86 percent) were younger than 15. The study found that those under 5 had the lowest risk of serious heart complications and were less likely to need intensive care. Patients 10 and older were significantly more likely to develop issues like shock, low blood pressure and myocarditis (inflammation of the heart muscle).

“I think that’s similar to what we saw with Covid, that the older kids seemed to have more severe disease,” Dr. DeBiasi said. “And that’s because what makes people really sick from the Covid is the inflammatory aspect of it, so maybe these older kids, for whatever reasons, make more inflammation, whether that’s in primary Covid or MIS-C.”

Still, significant numbers of the youngest patients developed heart problems. In the newborn-to-4 age group, 36 percent had low blood pressure, 25 percent had shock and 44 percent were treated in the I.C.U.

Patients of all ages in the study had about the same occurrence of some of the less-common heart issues linked to the syndrome, including coronary aneurysms and fluid buildup. Children 14 and under were more likely to have rash and red eyes, while those older than 14 were more likely to have chest pain, shortness of breath and cough. Abdominal pain and vomiting afflicted about two-thirds of all patients.

There were 24 deaths recorded, spread across all age groups. There was no information in the study about whether patients had underlying medical conditions, but doctors and researchers have reported that young people with MIS-C were often previously healthy and significantly more likely to be healthy than the relatively small number of young people who become seriously ill from initial Covid infections.

Of the 1,075 patients for whom information about initial Covid illness was available, only 265 had symptoms at that time. They were more likely to be older — their median age was 11, while the median age of those with asymptomatic Covid infections was 8. But that could be because “younger children can’t express their concerns as well,” said Dr. Blumenthal, who co-wrote an editorial about the study.

“We don’t necessarily know if there’s actually less symptomatology in the very young population, ” she said.

Similarly unclear are the reasons behind the study’s finding that in the first wave of MIS-C, from March 1 to July 1, 2020, young people were more prone to a few of the most serious heart complications. Dr. DeBiasi said that did not match the experience of her hospital, where “the kids were sicker in the second wave.”

The study documented two waves of MIS-C cases that followed surges in overall coronavirus cases by about a month or more. “The most recent third peak of the Covid-19 pandemic appears to be leading to another MIS-C peak perhaps involving urban and rural communities,” the authors wrote.

The study found that most of the states where the rate of MIS-C cases per population was highest were in the Northeast, which had the first surge of cases, and the South. By contrast, most states with high per-population rates of children with Covid-19 but low rates of MIS-C were in the Midwest and West. While the concentration of cases spread from large cities to smaller towns over time, it wasn’t as pronounced as the overall pandemic trends, the authors said.

Dr. Blumenthal said that geographic pattern could reflect that the “understanding of the complications of the disease” hadn’t caught up to its prevalence in different regions or that many states with lower rates of MIS-C have less ethnically diverse populations. “It could also be something about Covid itself, although we don’t know that,” she said. “Right now, we don’t know anything about how the variants necessarily affect children.”

The study represented only the strictest criteria for MIS-C, excluding about 350 reported cases that met the C.D.C. definition of the syndrome but had a negative antibody test or primarily involved respiratory symptoms. Dr. DeBiasi said there are also many probable MIS-C cases that are not reported to the C.D.C. because they don’t meet all the official criteria.

“These probable MIS-C kids, in real life that’s a big chunk of kids,” she said. In addition, while the focus so far has been on serious cases, “there’s another whole group of kids that may actually have mild MIS-C.”

If a community has experienced a recent coronavirus surge, then “just because the kid says, ‘I never had Covid or my parents never had it,’ that doesn’t mean the kid in front of you doesn’t have MIS-C,” Dr. DeBiasi said. “If your city has Covid, then get ready.”

Can Vaccinated People Spread the Virus? We Don’t Know, Scientists Say.

Researchers pushed back after the C.D.C. director asserted that vaccinated people “do not carry the virus.”

The Centers for Disease Control and Prevention on Thursday walked back controversial comments made by its director, Dr. Rochelle P. Walensky, suggesting that people who are vaccinated against the coronavirus never become infected or transmit the virus to others.

The assertion called into question the precautions that the agency had urged vaccinated people to take just last month, like wearing masks and gathering only under limited circumstances with unvaccinated people.

“Dr. Walensky spoke broadly during this interview,” an agency spokesman told The Times. “It’s possible that some people who are fully vaccinated could get Covid-19. The evidence isn’t clear whether they can spread the virus to others. We are continuing to evaluate the evidence.”

The agency was responding in part to criticism from scientists who noted that current research was far from sufficient to claim that vaccinated people cannot spread the virus.

The data suggest that “it’s much harder for vaccinated people to get infected, but don’t think for one second that they cannot get infected,” said Paul Duprex, director of the Center for Vaccine Research at the University of Pittsburgh.

In a television interview with MSNBC’s Rachel Maddow, Dr. Walensky referred to data published by the C.D.C. showing that one dose of the Moderna or Pfizer-BioNTech vaccine was 80 percent effective at preventing infection, and two doses were 90 percent effective.

That certainly suggested that transmission from vaccinated people might be unlikely, but Dr. Walensky’s comments hinted that protection was complete. “Our data from the C.D.C. today suggests that vaccinated people do not carry the virus, don’t get sick,” she said. “And that it’s not just in the clinical trials, it’s also in real-world data.”

Dr. Walensky went on to emphasize the importance of continuing to wear masks and maintain precautions, even for vaccinated people. Still, the brief comment was widely interpreted as saying that the vaccines offered complete protection against infection or transmission.

In a pandemic that regularly spawns scientific misunderstanding, experts said they were sympathetic to Dr. Walensky and her obvious desire for Americans to continue to take precautions. It was only Monday that she said rising caseloads had left her with a sense of “impending doom.”

“If Dr. Walensky had said most vaccinated people do not carry virus, we would not be having this discussion,” said John Moore, a virologist at Weill Cornell Medicine in New York.

“What we know is the vaccines are very substantially effective against infection — there’s more and more data on that — but nothing is 100 percent,” he added. “It is an important public health message that needs to be gotten right.”

Misinterpretation could disrupt the agency’s urgent pleas for immunization, some experts said. As of Wednesday, 30 percent of Americans had received at least one dose of a vaccine and 17 percent were fully immunized.

“There cannot be any daylight between what the research shows — really impressive but incomplete protection — and how it is described,” said Dr. Peter Bach, director of the Center for Health Policy and Outcomes at Memorial Sloan Kettering Cancer Center in New York.

“This opens the door to the skeptics who think the government is sugarcoating the science,” Dr. Bach said, “and completely undermines any remaining argument why people should keep wearing masks after being vaccinated.”

All of the coronavirus vaccines are spectacularly successful at preventing serious disease and death from Covid-19, but how well they prevent infection has been less clear.

Clinical trials of the vaccines were designed only to assess whether the vaccines prevent serious illness and death. The research from the C.D.C. on Monday brought the welcome conclusion that the vaccines are also extremely effective at preventing infection.

The study enrolled 3,950 health care workers, emergency responders and others at high risk of infection. The participants swabbed their noses each week and sent the samples in for testing, which allowed federal researchers to track all infections, symptomatic or not. Two weeks after vaccination, the vast majority of vaccinated people remained virus-free, the study found.

Follow-up data from clinical trials support that finding. In results released by Pfizer and BioNTech on Wednesday, for example, 77 people who received the vaccine had a coronavirus infection, compared with 850 people who got a placebo.

“Clearly, some vaccinated people do get infected,” Dr. Duprex said. “We’re stopping symptoms, we’re keeping people out of hospitals. But we’re not making them completely resistant to an infection.”

The number of vaccinated people who become infected is likely to be higher among those receiving vaccines made by Johnson & Johnson and AstraZeneca, which have a lower efficacy, experts said. (Still, those vaccines are worth taking, because they uniformly prevent serious illness and death.)

Infection rates may also be higher among people exposed to a virus variant that can sidestep the immune system.

Cases across the country are once again on the upswing, threatening a new surge. Dr. Walensky’s comment came just a day after she made an emotional appeal to the American public to continue taking precautions.

“I am asking you to just hold on a little longer, to get vaccinated when you can, so that all of those people that we all love will still be here when this pandemic ends,” she said.

Given the rising numbers, it’s especially important that immunized people continue to protect those who have not yet been immunized against the virus, experts said.

“Vaccinated people should not be throwing away their masks at this point,” Dr. Moore said. “This pandemic is not over.”

Is It Safe to Go Back to Group Exercise Class at the Gym?

Indoor fitness classes, which often result in heavy breathing in poorly ventilated rooms, can be risky. Here’s a guide to help you decide if your gym is doing enough to prevent the spread of Covid-19.

Last summer, a 37-year-old fitness instructor in Hawaii taught a spin class to 10 people. He was perched on a bike in the front of the room, facing his students as he shouted instructions and encouragement. The doors and windows were closed, but three large floor fans created a breeze to keep everyone cool. As a precaution against Covid-19, all the bikes were spaced at least six feet apart. (At the time, the gym didn’t require people to wear masks.)

But just four hours after class, the instructor began feeling fatigued. By the morning he had chills, body aches, a cough and other respiratory symptoms. Soon, he tested positive for Covid-19, and eventually, everyone who attended his class that day tested positive, too.

The outbreak didn’t stop there, though. A 46-year-old fitness instructor who attended the spin class went on to infect another 11 people during personal training sessions and kickboxing classes over the next few days, before falling ill himself and landing in intensive care.

The case of the Hawaii spin instructor was alarming because of the efficiency with which the virus left his respiratory tract and swirled around the enclosed classroom, reaching every person in the room. Among epidemiologists, that’s known as a 100 percent attack rate, and it’s a lesson in why group fitness classes, which often encourage high-energy huffing and puffing in poorly ventilated classrooms present such a daunting challenge to infection control.

At the same time, most public health experts agree that the drop in physical activity and weight gain that many people experienced during a year of pandemic living presents another set of risks to human health, and that communities need to find a balance between infection control and allowing people to return to their favorite fitness activities.

In the United States, gyms and fitness programs have reopened in some capacity in every state, allowing an estimated 73 million eager members to return to exercise. For the first time in more than a year, indoor group fitness classes were allowed to resume in New York City as of Monday, albeit at 33 percent capacity, and face coverings will be required.

The good news is that it’s possible to lower the risk of group fitness classes by improving ventilation, limiting class size, wearing a mask and increasing physical distance between participants.

Linsey Marr, an engineering professor at Virginia Tech and one of the world’s leading experts on viral transmission, is an avid exerciser herself and longed to return to her CrossFit sessions as the pandemic wore on. She worked with the owner of the gym, examining building plans and calculating potential class size and ventilation patterns in the facility.

Dr. Marr said the challenge with group fitness classes is that the participants often are breathing heavily. During a workout, people exhale and inhale at far higher volumes than when at rest.

“If someone is there who happens to be infected, they are releasing more virus into the air,” Dr. Marr said. “And the people around them are breathing heavily too, so they’re taking more in. You get this multiplicative factor. You’re breathing four times as hard, and the person who is sick is breathing four times as hard, so you’re breathing in 16 times more than you would under nonexercise conditions.”

Because of the potential for heavy breathing, Dr. Marr suggested increasing the physical distance between participants at the workout space to 10 feet rather than the standard recommendation of six feet. To achieve that level of spacing, it required limiting the class size at Dr. Marr’s workouts to just 10 people.

The facility took additional measures to minimize the chances of infection.

The solution was to open multiple garage-style doors, even in the middle of the Virginia winter. To make sure the ventilation was adequate, the gym acquired a carbon dioxide monitor to measure the buildup of carbon dioxide in a room. Because humans exhale carbon dioxide, its level can be an indicator of how well a room is ventilated.

Under everyday conditions, such as while shopping at a supermarket, an indoor carbon dioxide reading of 800 parts per million suggests that ventilation levels are adequate to reduce the risk of breathing in other people’s exhaled germs. But given the heavy breathing that occurs during a workout, Dr. Marr advised trying to keep indoor carbon dioxide levels even lower, to around 500 parts per million, and to increase ventilation if the number begins to creep toward 600.

Wearing a mask during exercise is recommended by the Centers for Disease Control and Prevention, but Dr. Marr noted that with heavy breathing, mask material can quickly get moist and lose its effectiveness. “The level of protection provided by masks is so variable that we cannot rely on them alone,” she said.

So far, the strategy seems to be working. Dr. Marr said her gym hasn’t experienced any coronavirus outbreaks, even though her state doesn’t require gym goers to wear masks while exercising. “We figured out if we kept all the doors open it should be pretty low risk,” she said. “But it was cold!”

There was one instructor who contracted the virus from somewhere outside the facility, but the well-ventilated room and rules about physical distancing appear to have protected 50 people who were exposed to him during several different classes.

While Dr. Marr’s gym is just a single case study, it shows that group fitness classes can continue safely during the pandemic, provided the facility focuses on ventilation and enforces distancing precautions and capacity limits. (Dr. Marr notes that CrossFit Inc. invited her to join its medical advisory board in December, and she helped craft a set of safety recommendations.)

We asked Dr. Marr and other experts to answer questions about how participants can decide whether their fitness class is safe to attend. Here’s what they had to say.

Does the type of exercise in the classroom make a difference?

Yes. While Covid can spread in any type of indoor class, risk is likely to go up as exercise intensity increases because breathing rates increase.

The volume of air someone breathes in and out every minute is called the “minute ventilation rate,” said Dr. Michael Koehle, the director of the Environmental Physiology Laboratory at the University of British Columbia and an expert on respiration during exercise. It naturally rises more during strenuous workouts, such as spin or dance classes, than in lighter workouts, such as yoga or Pilates.

“At low intensities — yoga, Pilates and some strength work — you can breathe more through your nose, which is a natural filter,” said Dr. Koehle. “Another very important factor is that it is more comfortable to wear a mask during strength training and lower-intensity exercise than high-intensity exercise. People should still be wearing masks indoors.”

This past August, an outbreak occurred among high-intensity exercisers at a fitness facility in Chicago. Everyone brought their own weights and mats, but not everyone wore masks. In that case, 55 out of 81 people (68 percent) who attended classes over an eight-day period at one facility came down with Covid-19. Early in the pandemic, 112 people in South Korea who took part in Zumba classes, or spent time with someone who did, were infected.

How will I know if the room has adequate ventilation?

While gyms and fitness classes are advised to meet certain ventilation standards, it’s tough for the average person to know whether a building ventilation system is adequate for infection control. “High ceilings are good,” said Dr. Marr. “If you can smell someone else, that’s a bad sign.”

Ideally, a group class should be held in a room with open windows and doors on opposite sides of the room to allow for cross ventilation. A classroom with only one entrance and no windows — a common situation in many gyms — probably does not have adequate ventilation to keep you safe. Adding several portable air cleaners to a space that lacks more doors or windows could help. “It would be much better if you can get cross ventilation — opening doors or windows on opposite sides,” said Dr. Marr. “That’s what we specified in my gym, at least two open on opposite sides.”

Do fans help?

Overhead exhaust fans or window fans that pull air out of the room are fine. But avoid any class that uses fans to recirculate air and cool down the room. Fans that recirculate air in the room just increase the risk of viral spread.

How far apart should I stand?

While six feet of distancing is recommended by public health officials for most situations, Dr. Marr advises extending it to at least 10 feet — in front of you, to either side, and behind you — during exercise.

The rules vary by state. In Massachusetts, for instance, indoor classes must have enough room for people to stand 14 feet apart. If barriers between participants are installed, then six feet is considered adequate. South Carolina requires a 10-foot by 10-foot area (100 square feet) per person; New Jersey requires twice that. Montana has required fitness classes to take place outdoors, while South Dakota has no guidance. (You can find more details about different state requirements here.)

How many people should be in the class?

States have different rules for class size, with some limiting attendance to 25 percent to 40 percent of capacity, and others allowing no more than nine or 10 people per class. Dr. Marr notes that class size is best determined by how far apart people can stand. When people keep 10 feet of distance from one another on all sides, that often limits the class size to 10 people or fewer. If you can’t achieve that much space between you and other participants, including the instructor, it’s time to find a new class.

Do I need to wear a mask?

It’s a good idea to wear a mask, and many states require them, but you can’t rely on your mask to protect you entirely. Mask quality varies, and during exercise, masks get moist, reducing their filtering efficiency. And while many gyms require masks to enter, mask wearing often is not enforced or even required during exercise classes.

In the Chicago and Hawaii outbreaks, most people were not wearing masks. At the Hawaii gym, two participants wore masks during kickboxing sessions, but their infected instructor did not, and both became ill. The C.D.C. advises that “to reduce SARS-CoV-2 transmission in exercise facilities, employees and patrons should wear a mask, even during high-intensity activities.”

Is there a way to monitor the air in my fitness class?

Not every facility will have a carbon dioxide monitor, but it’s worth asking your facility if they have one in the group fitness room and whether you can check it. If the carbon dioxide levels are below 600 parts per million (the closer to 500 the better), it’s a sign that the room ventilation is adequate for exercise. If the numbers start to increase, ask to open a window or door — or leave the class. When Dr. Marr was attending an indoor swimming pool, she noticed ventilation levels in the room were poor, so she left.

Is there a way to know if my gym has made a commitment to Covid safety precautions?

The International Health, Racquet and Sportsclub Association, an industry group, has an initiative called the IHRSA Active & Safe Commitment to follow industry best practices to provide a safe environment. Facilities that sign the pledge promise to adhere to physical distancing and mitigation measures, safety protocols and contact tracing.

The IHRSA urges the gym to have a list of protocols on its website and at the facility. At the bare minimum, protocols should include ventilation and fresh air exchange, capacity limits, distancing protocols and a clear mask policy. “I would specifically ask about ventilation practices, if mask wearing at all times is mandatory, and if classes and equipment were to be spaced out to allow for appropriate social distancing,” said Cedric Bryant, president and chief science officer for the American Council on Exercise.

What if I’ve been vaccinated?

Your risk for contracting coronavirus or developing serious illness drops dramatically if you’ve been vaccinated, but people who are vaccinated are still advised to take the same precautions as everyone else in public settings. And in most states, the people most likely to go to gyms or instruct a fitness class are younger and healthier, and therefore less likely to be among the first groups to be vaccinated. According to the IHRSA, 73 percent of gym and fitness class participants are 55 and younger.

Does cleaning and disinfection make a difference?

While everyone should wash their hands and wipe down gym equipment, patrons should not judge a gym solely on how often it promises to clean and sanitize an area. “We should still do what we did before, which is wipe down your machine when you’re done,” said Dr. Marr. “Maintaining a normal level of cleaning is appropriate. But any extra time and effort a gym has, put it toward cleaning the air.”

Dr. Marr notes that proper ventilation, physical distancing and class size limits will have the biggest impact on your safety. She recently posted on Twitter that ventilation is so important, she even had a nightmare about it.

“I had my first Covid-19 related nightmare (that I remember),” Dr. Marr’s tweet read. “I finished a hard, group workout in a gym. I looked around and panicked because I saw that all the doors were closed.”

Do you have a health question? Ask Well

How to Celebrate the Spring Holidays Safely With Your Family

Easter, Passover and Ramadan will be a little less lonely this year as more people get vaccinated. But experts say we can’t let down our guard just yet.

The weather is warming, the days are looking brighter and the number of people getting vaccinated is on the rise. So can we finally celebrate the spring holidays together like we used to, back when we could see the bottom halves of everyone’s faces?

Well, not exactly.

Although coronavirus cases and deaths are declining nationwide and the Centers for Disease Control and Prevention recently issued new, looser safety guidelines for vaccinated people, the agency recommended against unmasked indoor gatherings with unvaccinated people except in certain circumstances.

We asked public health experts to help us understand the latest guidance and offer advice on how to safely observe upcoming holidays like Easter, Passover and Ramadan.

Do we need to wear masks and stay six feet apart?

According to the C.D.C., if the people in your home have been fully vaccinated, meaning at least two weeks have passed since each person’s final shot, you can spend time together unmasked with the unvaccinated members of one other household — either indoors or outdoors — without physical distancing. But this holds true only if all of the unvaccinated people are not at increased risk of severe illness if they were to contract Covid-19, the agency said.

The risk of transmission between a vaccinated household and an unvaccinated household “is incredibly low,” said Dr. Joshua Barocas, an infectious diseases physician at Boston Medical Center.

And when both households are vaccinated, the risk is even lower, he added.

Erica Fleischer, 42, a public policy expert and mother of two who lives in Chicago, said her family would typically celebrate Passover Seder, held on the first two nights of the eight-day holiday, at her in-laws’ home, surrounded by as many as 20 people.

Last year they met virtually, but this year, given the new C.D.C. guidance, her unvaccinated family will have a small dinner with her in-laws, who have each received the vaccine.

Ms. Fleischer said she feels “pretty confident” the risks of infecting one another are low. “I think I actually needed more convincing than my in-laws did.”

Dr. Shaun Din, 35, a radiation oncologist in Manhattan, is planning to spend part of the holy month of Ramadan with nearby family members. Five of the eight adults, including Dr. Din and his parents, have been vaccinated, so the family feels comfortable meeting unmasked on weekends for the evening iftars that break each daylong fast.

“Last year was very lonely, not being able to celebrate together,” Dr. Din said. “Ramadan is difficult, but the communal aspect of all of us going through it and then breaking the fast together is something that’s very fun.”

Can we invite more than one household?

If you are fully vaccinated and you would like to invite other fully vaccinated friends over for dinner, the C.D.C. says that “it is likely a low risk,” and there is no need to wear masks or stay physically distanced.

Even so, keep the get-together small. The C.D.C. advises against medium- or large-size gatherings (though it hasn’t defined what constitutes medium or large).

“Variants are circulating, and the vaccines might not be quite as effective against them,” said Linsey Marr, a professor of civil and environmental engineering at Virginia Tech who studies viruses in the air.

If you plan to mix unvaccinated people from multiple households, experts suggest holding the gathering outside, staying six feet apart and wearing masks.

And if you decide to spend time indoors with unvaccinated people from other households, wear a mask and open the windows to improve the ventilation, said Shelly Miller, a mechanical engineering professor at the University of Colorado, Boulder, who studies airborne disease transmission in enclosed spaces. She also suggested using a HEPA filter air cleaner certified by the Association of Home Appliance Manufacturers.

What about unvaccinated kids?

The coronavirus vaccine is not currently available to most children because clinical trial results are still forthcoming.

Say there are two healthy families of four. If the kids aren’t vaccinated in either household but all of the adults are, you might consider inviting people inside as long as the windows are open and everyone is wearing masks, said Dr. Asaf Bitton, a primary care physician who runs a public health research laboratory at Brigham and Women’s Hospital in Boston. If the kids in neither household are vaccinated and only one set of adults has been vaccinated, he and other experts said an outdoor gathering with masks and distancing would be safest.

You may also be wondering if your unvaccinated children can finally get a hug and kiss from their healthy, vaccinated grandma. On this question, the experts’ opinions diverged. But in general, if everyone is healthy and you’re comfortable accepting some degree of risk, a hug or kiss is probably fine.

“The likelihood that my kid transmits a virus that ends up causing severe disease in my vaccinated parents is very, very low,” Dr. Barocas said.

Similarly, he added, it’s unlikely that a vaccinated adult would transmit the virus to a child. That said, the experts advised doing what feels right to you and your family.

“I think everyone going into that visit needs to understand that we’re balancing risks and benefits,” said Dr. Adam Ratner, director of the division of pediatric infectious diseases at Hassenfeld Children’s Hospital at N.Y.U. Langone. But, he added, if the grandparents are vaccinated, “I am pro hugging and kissing.”

Jennifer Rogers, 46, an attorney in Philadelphia, said her husband and two children, 8 and 11, will celebrate Easter by visiting her parents’ home for several hours. They’re planning on having an outdoor Easter egg hunt and whacking away at a coronavirus-shaped piñata. But the kids, who will be joined by Ms. Rogers’s sister and her sister’s son, will all be wearing masks. Ms. Rogers and her husband are both vaccinated, but they are planning to wear masks too, because their family will have recently returned from a Florida vacation.

“It still feels like a loss, like it’s not the same as it’s been,” said Ms. Rogers, whose family typically stays overnight at her parents’ home during the holiday.

Can our fully vaccinated relatives fly out to see us?

The C.D.C. is still saying no.

“We know that after mass travel, after vacations, after holidays, we tend to see a surge in cases,” the C.D.C. director, Dr. Rochelle Walensky, said last week on MSNBC. “And so, we really want to make sure — again with just 10 percent of people vaccinated — that we are limiting travel.”

We are also still learning whether vaccinated people without symptoms can unknowingly carry infections to the households that they are visiting, Dr. Bitton said.

“Travel in little metal tubes and crowded airports and taxi cabs brings risks of transmission,” he added.

Danielle Nuzzo, 36, a communications manager whose family celebrates both Easter and Passover, lives in California with her husband and 2-year-old daughter, across the country from both sets of grandparents. As soon as the grandparents got vaccinated, they asked if they could visit during the holidays, she said. But Ms. Nuzzo and her husband are not vaccinated yet, and they didn’t feel comfortable hosting anyone who had just hopped off a plane. In the end, they decided they will celebrate just like they did last year, over Zoom.

“It’s really hard. It’s emotional,” Ms. Nuzzo said. “We want her to know who her grandparents are and see them. But we also want to do what’s right and just be safe.”

If your family does decide to travel, the C.D.C. recommends first getting fully vaccinated for the coronavirus, if you are eligible, and also getting a Covid-19 test one to three days before the trip. All travelers, regardless of whether they are vaccinated or not, must wear a mask; try to stay at least six feet from others; get tested again three to five days after your trip and quarantine for seven days, even if your test is negative. (If you don’t get tested, the C.D.C. says you should quarantine for 10 days.)

Check your state and local requirements because different areas have different rules. New York State, for example, says domestic travelers do not need to quarantine during the first three months after being fully vaccinated, provided that they are asymptomatic.

What if my relatives and I disagree about what’s safe?

After a year of public health warnings, some family members might feel uneasy about loosening the rules while others might be anxious to get back to normal.

Last year, ahead of the Thanksgiving holiday, Claudia W. Allen, a clinical psychologist and the director of the Family Stress Clinic at the University of Virginia School of Medicine, told The New York Times that if there are differences of opinion, it’s important not to pass judgment, start lecturing or assume that your relatives have bad motives.

“The people who are willing to take more risks are usually doing it because they’re valuing connection. And the people who are less willing to take risks are usually less willing because they are prioritizing safety. Connection and safety are both good,” Dr. Allen said at the time.

The same advice applies for spring holidays. “A new tricky aspect is that some people are vaccinated and others aren’t,” she added this week.

If you’re at odds with a family member, don’t forget to recognize the other person’s good intentions, even if you ultimately have to agree to disagree, Dr. Allen said. Take a moment to also acknowledge their feelings and the uncertainty of the situation and say, “I totally understand your caution; we each have to try to weigh the risks as best we can.”

Pandemic Raises Concerns About Childhood Lead Poisoning

Pandemic Raises Concerns About Childhood Lead Poisoning

Lead screenings for children plummeted last spring, and stay-at-home orders may have increased household exposure to the toxic metal.

A worker scraping off lead paint. The C.D.C. estimates that more than 20 million housing units in the United States contain lead-based paint, which was essentially banned in 1978.
A worker scraping off lead paint. The C.D.C. estimates that more than 20 million housing units in the United States contain lead-based paint, which was essentially banned in 1978.Credit…Jamie Hooper/Alamy

  • March 11, 2021, 5:00 a.m. ET

Over the past half-century, public health officials have made enormous progress in protecting American children from lead poisoning and the irreversible neurological damage it can cause. Since the 1970s, the percentage of children with high levels of lead in their blood has plummeted.

But in 2020, a new health threat, the coronavirus, endangered these hard-earned gains.

When Covid-19 cases spiked last spring, lockdowns and day care closures confined young children to their homes, where lead exposure can be particularly high. The growing national emergency also delayed lead-removal efforts and disrupted routine childhood lead screenings, leaving health officials unable to identify and treat many children living in lead-laden homes.

Last month, the Centers for Disease Control and Prevention estimated that in the early months of the pandemic, roughly 10,000 children with elevated levels of lead in their blood may have gone undetected.

“Hundreds of thousands of children have missed their essential tests for lead,” said Joseph Courtney, a senior epidemiologist at the C.D.C.’s lead poisoning prevention and environmental health tracking branch, who conducted the analysis. “And it’s something that has potentially permanent lifetime effects.”

There is no safe level of exposure to lead, which can disrupt neurological and cognitive development, causing learning disabilities, behavioral problems and developmental delays.

The C.D.C. estimates that more than 20 million housing units in the United States contain lead-based paint, which was banned in 1978. When the paint flakes, cracks or peels, the lead mixes with dust, which children can ingest or inhale. Young children, whose brains are still developing, are at particular risk.

“The main route of exposure for most children is lead-contaminated dust, from paint getting on their hands or their toys,” said David Jacobs, chief scientist at the National Center for Healthy Housing. “And then normal child behavior at this age is, everything goes in the mouth.”

For that reason, many states recommend or require that children of certain ages have their blood tested for lead. (Federal guidelines require that all children who are enrolled in Medicaid receive blood lead level tests at ages one and two.) Doctors typically perform these tests as part of a child’s regular checkup.

But when the pandemic hit last March, government officials issued stay-at-home orders, and many medical offices closed. Others started conducting appointments virtually. “You can’t do a blood lead test by telemedicine,” said Dr. Stephanie Yendell, senior epidemiology supervisor at the Minnesota Department of Public Health. “You can’t get a blood sample by video call.”

That month in Minnesota, the number of tests for blood lead level fell to 70 percent of what it had been the previous year, Dr. Yendell said. “And then in April, we bottomed out at 43 percent compared to the year before.”

In New York City, which was hit by an early wave of Covid-19 cases, childhood lead screenings declined by 88 percent last April.

Anecdotal reports of these declines soon made their way to the C.D.C., which asked state and local health officials to share their lead screening data so the agency could conduct a more formal analysis. Thirty-four health departments — representing 32 states, plus New York City and Washington, D.C. — ultimately did so.

Paint is the most common cause of childhood lead poisoning, but lead pipes also pose a threat; the longer that water sits stagnant in such pipes, the more lead leeches into it.
Paint is the most common cause of childhood lead poisoning, but lead pipes also pose a threat; the longer that water sits stagnant in such pipes, the more lead leeches into it.Credit…Julio Cortez/Associated Press

Every one of those departments reported a drop-off in testing last spring, Dr. Courtney and his colleagues found. Over the first five months of 2020, roughly 500,000 fewer children had their blood lead levels tested in these districts compared with the same period of 2019. The decline was especially steep in March, April and May, when testing levels fell 50 percent compared to the previous year.

That kind of decline has no precedent, Dr. Courtney said: “There’s nothing like it before.”

Roughly 2 percent of American children have elevated blood lead levels, Dr. Courtney said. If that percentage holds for the children who missed their screenings last year, it would mean that nearly 10,000 of them had significant lead exposures. “And there were 18 states that we didn’t receive data from that probably would have added to that total,” he noted. “So that’s a conservative estimate.”

There is also reason to suspect that lead poisoning is even more prevalent among the children who missed their blood tests last year, experts said. Children of color, and those who live in low-income neighborhoods, are particularly likely to be exposed to lead. Those same communities have been among the hardest hit by the coronavirus and may have faced the biggest obstacles in receiving pediatric checkups last year.

“We’re afraid that the kids who are being missed are probably the kids at higher risk,” Dr. Courtney said. Some states reported that the dip in lead screenings was especially pronounced among children who were on Medicaid, he added.

For lead-poisoned children, the consequences could be devastating. Although there is no way to reverse lead poisoning, nutritional supplements and educational services can help mitigate the harms. Children who miss their lead screenings may not receive these essential interventions.

Moreover, in many cases, it takes an elevated blood lead level to trigger lead removal or remediation efforts. If you don’t test, you don’t find,” said Dr. Morri Markowitz, director of the lead poisoning treatment and prevention program at the Children’s Hospital at Montefiore, in New York City. “If you don’t find, you don’t intervene, and the kid continues to be exposed, continues potentially to be ingesting lead.” He added: “And then it can progress, and by the time you check, things will have gotten worse.”

Even as lead testing rates were falling last spring, the amount of time that children were spending in their homes, where lead exposure is most likely, was rising. The pandemic, and the financial hardships that accompanied it, may also have prompted some families and property owners to postpone essential building repairs and maintenance tasks.

“I’m very concerned that we potentially may have more children who have been exposed if they’ve been in homes with peeling, chipping paint,” said Dr. Joneigh Khaldun, the chief medical executive for the state of Michigan and chief deputy director for health in the Michigan Department of Health and Human Services. “We just don’t even know it.”

Widespread building closures have created other risks. Although paint is the most common cause of childhood lead poisoning, lead pipes also pose a threat. The longer that water sits stagnant in such pipes, the more lead leeches into it; schools and day care centers that shut down last year could find their water dangerously contaminated when they reopen.

“There’s likely to be high lead levels in some taps,” said Jennifer Hoponick Redmon, a senior environmental health scientist at RTI International, a nonprofit research organization based in North Carolina. “Water needs to be flushed at schools and child care centers — and really, all places that are closed — before people start using the water again for drinking and cooking.”

There is some evidence that lead poisoning rates may have risen slightly last year. Health officials in Massachusetts said they detected a 3 percent increase in the prevalence of lead poisoning among young children between mid-March and mid-August 2020. “While this may seem like a small increase, it is concerning, as we normally see rates of lead poisoning decline each year,” said Jan Sullivan, acting director of the Bureau of Environmental Health at the Massachusetts Department of Public Health.

And in New York City, preliminary data suggests that the share of young children with elevated blood lead levels was essentially flat over the first three-quarters of 2020, after years of steady declines.But not all health departments have found these patterns, and many are still analyzing their data from last year. Of course, if the children who face the biggest lead hazards are the ones who skipped their screenings , a rise in lead poisoning may not show up in the testing data, experts said.

Early evidence suggests that blood lead testing did begin to rebound in the second half of 2020. “But it still fell below the levels of previous years and did not nearly make up for the number of children missed earlier in the year,” Dr. Courtney said.

In Michigan, where childhood lead testing was about one-third lower in 2020 than in 2019, health officials are now trying to make up lost ground. They are organizing mobile lead testing events, to be held across the state, and planning a major media campaign.

“We’re going to put some money behind it, have some commercials and a real intentional focus on making sure people are aware of the risk of lead and that they know how and where to get tested,” said Dr. Khaldun. “We are really focused on making sure we don’t have other unintended consequences of the pandemic.”

Why I Overcame My Vaccine Hesitancy

Personal Health

Why I Overcame My Vaccine Hesitancy

The more people who become immune to the virus, the less this scourge will be able to mutate and evade the vaccines already available

Credit…Gracia Lam
Jane E. Brody

  • March 1, 2021, 5:00 a.m. ET

Had I been polled last fall, I would have registered as a Covid vaccine skeptic. I told anyone who asked that I was going to wait at least six months after a vaccine was approved, by which time I hoped we’d know more about the degree and possibly the duration of its effectiveness and its potential side effects, especially in the elderly.

I was hardly alone in my concern that political influence might result in premature approval of a vaccine before its safety was well established.

Well, that hesitancy quickly dissipated after listening to reports from the directors of the Food and Drug Administration and the Centers for Disease Control and Prevention and several vaccine experts I know and trust, all of whom gave an enthusiastic thumbs-up to both the Pfizer and Moderna vaccines.

So in mid-January, when Gov. Andrew M. Cuomo of New York announced that residents 75 and older would qualify for the vaccine, I found a computerized link to schedule an appointment five days later.

At the mass vaccination site I went to in Brooklyn, everyone I encountered was cheerful, patient and reassuring, even the young woman checking me in who couldn’t find me on her list of 3 p.m. appointments. “Don’t worry,” she said reassuringly, “you’ll get the vaccine.”

At the next window, a young man from Nigeria checked my ID and Medicare card and figured out what had happened. Turned out I had inadvertently booked a 3 a.m. appointment, not realizing the site was open 24-7. Another “don’t worry,” and I moved on to a young technician from Florida who painlessly injected the Moderna vaccine into my left arm.

I then sat in a holding tent for 15 minutes to be sure I would have no serious reactions. The next day I got a text: “Hi Jane, It’s time for your daily v-safe check-in” and a link to a C.D.C. site that asked: How are you feeling today? (Good, Fair, Poor); Have you had a fever or felt feverish today? (yes, no); followed by a symptom check, first at the injection site for pain, redness, swelling or itching and then generally for chills, headache, joint pains, muscle or body aches, fatigue or tiredness, nausea, vomiting, diarrhea, abdominal pain and rash or any other symptoms I wanted to report.

Finally, I was asked several overall health impact questions about my ability to work and do my normal daily activities and whether I needed to consult a health care professional. I received the same text at the same time each day for more than a week, and was also given a link if I wanted to send a report to the Vaccine Adverse Event Reporting System.

The second dose, administered 34 days later, went even more smoothly. By then I’d spoken to dozens of others of various ages who had gotten both shots. Only two reported bad reactions — fever, nausea, extreme fatigue — that lasted a day or two. I was prepared for the worst, but it never happened. My arm, shoulder and neck hurt the first night, but most of the pain was gone the next morning. Although my son was on call in case I couldn’t walk my dog, his help wasn’t needed. I was even able to swim that afternoon.

But I assure you, even if I’d had a bad post-vaccine reaction, I would have sucked it up as a small price to pay for protection against a most devastating and too-often deadly disease like Covid-19. And I will continue to urge everyone and anyone I meet to do their damnedest to get immunized against Covid-19, especially now that potentially more potent variants are beginning to appear and spread.

The more people who become immune to the virus, the less this scourge will be able to mutate and evade the vaccines already available and the updated versions of vaccines scientists are now scrambling to produce.

Some people, hearing that vaccinated people may still be able to spread the infection and should continue to wear masks and practice social distancing which I will definitely do even after being fully immunized, question whether it pays to get the vaccine. Absolutely, it pays.

While there’s a chance that an immunized person might be able to infect others, existing evidence suggests the risk is very small. Far more important is unimpeachable data that the vaccines are lifesaving. They nearly eliminate the risk of severe illness, hospitalization and death from the virus. Of the 32,000 people who got the vaccine in the Pfizer and Moderna vaccine trials, only one person developed a severe case of Covid. Even if future mutations of the virus make an annual booster necessary, what’s the big deal? We already do that with the flu shot.

Keep in mind, too, that up to a third of people who develop Covid-19 can end up with debilitating symptoms that persist for many months, perhaps indefinitely for some. This is not always just a bug like the flu or common cold that is over and done with a week later. Eight months after recovering from a rather mild case of Covid, an otherwise healthy middle-aged friend said his lungs still hurt when he exerted himself.

Anecdotal reports that vaccine reactions are sometimes worse after the second of the two shots given for the Pfizer and Moderna vaccines have prompted some people to question whether they need both shots. Again, the only reliable evidence shows that two doses are necessary to achieve maximum protection. Do you buckle your seatbelt only every other time you’re in a car?

Now think of what will be possible once you, your family members and friends have had both shots and then waited the two weeks after the final dose to achieve the maximum level of immunity. While I’ll continue to wear a mask and socially distance in public, I’ll gladly dine indoors at home or in a well-spaced restaurant with fully immunized friends and relatives who are not considered at high risk.

I can’t wait to again attend live performances of classical music and opera and watch movies and plays not on my computer or TV but on the big screen and in the theater with others who can laugh, cry or sneer with me. But until most of us are reliably immune to the coronavirus that has terrified and secluded so many of us for so long, none of this can happen.

Meanwhile, I will continue to present the known facts and try to dispel misleading information about the vaccines. And I’ll hope that celebrities who enjoy the respect of vaccine-hesitant communities will be able to convince their members that controlling Covid infections and spread is critical, not just for their own sake, but for the future of their families, their towns, their country and a life that might again assume some semblance of normal.

C.D.C. Announces $200 Million ‘Down Payment’ to Track Virus Variants

C.D.C. Announces $200 Million ‘Down Payment’ to Track Virus Variants

Scientists say the new investment will help in the next couple of months, but hope that the stimulus package will provide much more.

Dr. Rochelle Walensky, the C.D.C. director, speaking in December. Dr. Walensky laid out an ambitious program on Wednesday to track the numerous coronavirus variants circulating in the U.S.
Dr. Rochelle Walensky, the C.D.C. director, speaking in December. Dr. Walensky laid out an ambitious program on Wednesday to track the numerous coronavirus variants circulating in the U.S.Credit…Hilary Swift for The New York Times
  • Feb. 17, 2021, 4:57 p.m. ET

As lawmakers push for billions of dollars to fund the nation’s efforts to track coronavirus variants, the Biden administration announced on Wednesday a new effort to ramp up this work, pledging nearly $200 million to better identify the emerging threats.

Calling it a “down payment,” the White House said that the investment would result in a significant increase in the number of positive virus samples that labs could sequence. Public health laboratories, universities and programs run by the Centers for Disease Control and Prevention sequenced more than 9,000 genomes last week, according to the database GISAID. The agency hopes to increase its own contribution to 25,000 genomes a week.

“When we will get to 25,000 depends on the resources that we have at our fingertips and how quickly we can mobilize our partners,” Dr. Rochelle Walensky, the C.D.C. director, said at a White House news conference on Wednesday. “I don’t think this is going to be a light switch. I think it’s going to be a dial.”

The program is the administration’s most significant effort to date to address the looming danger of more contagious variants of the virus. A concerning variant first identified in Britain has infected at least 1,277 people in 42 states, although scientists suspect the true number is vastly higher.

Doubling about every 10 days, the B.1.1.7 variant that emerged in Britain threatens to slow or reverse the rapid drop of new coronavirus cases. What’s more, Dr. Walensky said that the nation had seen its first case of B.1.1.7 that had gained a particularly worrying mutation that has been shown in South Africa to blunt the effectiveness of vaccines.

Other worrisome variants have also cropped up in the United States, including one that was first found in South Africa and weakens vaccines.

The F.D.A. is preparing for a potential redesign of vaccines to better protect against the new variants, but those efforts will take months. In the short term, experts say, it is critical to increase sequencing efforts, which are too small and uncoordinated to adequately track where variants are spreading, and how quickly.

Scientists welcomed the new plans from the Biden administration. “It’s a huge step in the right direction,” said Bronwyn MacInnis, a geneticist at the Broad Institute.

Dr. MacInnis said that the “minimal gold standard” would be sequencing 5 percent of virus samples. If cases continue to fall, then 25,000 genomes a week would put the country near that threshold, she said, which is “where we need to be to be detecting not only known threats, but emerging threats.”

Trevor Bedford, an evolutionary biologist at the Fred Hutchinson Cancer Research Center, said there had been “substantial gains” in national sequencing efforts since December. Still, he said that the C.D.C. would also need to make improvements in gathering data about the genomes —such as tieing it to information from contact tracing — and then supporting the large-scale analysis on computers required to quickly make sense of it all.

Senator Tammy Baldwin, Democrat of Wisconsin, has pushed for more federal funding for variant detection.
Senator Tammy Baldwin, Democrat of Wisconsin, has pushed for more federal funding for variant detection.Credit…Alyssa Schukar for The New York Times

“There’s too much of a focus on the raw count that we’re sequencing, rather than turnaround time,” he said.

White House officials cast the sequencing ramp-up as part of a broader effort to test more Americans for the virus. The Department of Health and Human Services and the Defense Department on Wednesday announced substantial new investments in testing, including $650 million for elementary and middle schools and “underserved congregate settings,” like homeless shelters. The two departments are also investing $815 million to speed the manufacturing of testing supplies.

The C.D.C.’s $200 million sequencing investment is dwarfed by a program proposed by some lawmakers as part of an economic relief package that Democratic congressional leaders aim to pass before mid-March. Senator Tammy Baldwin, Democrat of Wisconsin, introduced legislation to enhance its sequencing efforts. House lawmakers have allocated $1.75 billion to the effort.

In an interview, Ms. Baldwin suggested that the government should be aiming to sequence 15 percent of positive virus samples, a goal far beyond what researchers believe is possible in the near term.

“This is intended to create the basis of a permanent infrastructure that would allow us not only to do surveillance for Covid-19, to be on the leading edge of discovering new variants, but also we’d have that capacity for other diseases,” she said of her proposal. “There’s significant gaps in our knowledge.”

Since 2014, the C.D.C.’s Office of Advanced Molecular Detection has used genome sequencing to track diseases like influenza, H.I.V. and food-borne diseases. But when the coronavirus pandemic struck the United States, the C.D.C. was slow to adapt these tools to track the coronavirus. For weeks it struggled simply to establish a test for Covid.

In contrast, Britain started a widely praised sequencing program last March, taking advantage of its nationalized health care system with a central genomics lab. It now sequences up to 10 percent of all positive Covid tests and delivers deep, rapid analysis of the results.

The C.D.C. began ramping up surveillance efforts over the course of 2020, helping academic labs, commercial sequencing companies and public health departments to collaborate and share insights. In November, it invested in a program of its own, called NS3, to analyze coronavirus genomes. Every other week, the agency asks state health departments to send at least 10 samples to its lab for sequencing.

In December, it became clear those efforts would not be enough. Researchers in Britain found a new variant, called B.1.1.7, that was up to 50 percent more transmissible than other variants. Scientists now suspect it is also probably more lethal. In South Africa, another variant called B.1.351 proved not only more contagious, but less vulnerable to several vaccines.

C.D.C. officials began to fear B.1.1.7 had already been spreading widely in the United States, according to one senior federal health official. They began setting up new efforts, including contracts with lab testing companies that were running Covid tests.

Lab technicians Angelica Garces, left, and Sarah Clarke, right, prepared to load human RNA samples into a sequencing machine at Duke University earlier this month.Credit…Pete Kiehart for The New York Times

Dr. Gregory Armstrong, the director of the Advanced Molecular Detection Program, said in an interview that his team came to the conclusion in January that sequencing from 5,000 to 10,000 samples a week would be a good short-term target.

“It’s the starting point,” Dr. Armstrong said. “The more we sequence above that, the more quickly we’ll be able to pick up these variants.”

At a White House news conference later that month, Jeffrey D. Zients, the White House’s Covid-19 response coordinator, acknowledged how difficult reaching that goal would be.

“We are 43rd in the world in genomic sequencing — totally unacceptable,” he said, citing December data from the GISAID database. In a subsequent interview, he corrected himself, saying that the U.S. was behind 31 other nations.

In the early days of the administration, Dr. Walensky spoke of an initial goal for the C.D.C. of sequencing 7,000 genomes a month. Since then, the labs have not come close to that figure.

The agency’s National Genomic Surveillance Dashboard showed that they logged just 96 genomes in the week of Feb. 6. The following week, the figure rose to 1,382 genomes. Dr. Walensky’s new target of 25,000 genomes a week will require a significant increase.

Caitlin Rivers, an epidemiologist at Johns Hopkins Bloomberg School of Public Health, said putting $200 million quickly into monitoring variants was a welcome development in advance of what she hoped would be longer-term improvements. “Time is of the essence,” she said. “An initial investment to expand genomic surveillance while the supplemental funding package comes together is a smart move.”

But she warned that the plan won’t be able to spring instantly into action. It may take a month just to get the basic improvements in place. By then, B.1.1.7 may already dominate U.S. cases and could jeopardize the current decline.

The larger program in the stimulus package will be crucial to managing the pandemic in the long run, Dr. Rivers said.

“We may not be able to get very far as relates to B.1.1.7, but what’s the next one, three months from now, or six months, or next winter?” she asked. “It’s not always just the thing in front of you. It’s what’s coming around the corner.”

Scientists to C.D.C.: Set Air Standards for Workplaces Now

Scientists to C.D.C.: Set Air Standards for Workplaces Now

The agency has not fully reckoned with airborne transmission of the coronavirus in settings like hospitals, schools and meatpacking plants, experts said.

Production of N95 masks at a facility in Fort Worth, Texas, earlier this month. “It’s time to stop pussyfooting around the fact that the virus is transmitted mostly through the air,” said one expert.
Production of N95 masks at a facility in Fort Worth, Texas, earlier this month. “It’s time to stop pussyfooting around the fact that the virus is transmitted mostly through the air,” said one expert.Credit…Cooper Neill for The New York Times
Apoorva Mandavilli

  • Feb. 17, 2021, 12:01 a.m. ET

Nearly a year after scientists showed that the coronavirus can be inhaled in tiny droplets called aerosols that linger indoors in stagnant air, more than a dozen experts are calling on the Biden administration to take immediate action to limit airborne transmission of the virus in high-risk settings like meatpacking plants and prisons.

The 13 experts — including several who advised President Biden during the transition — urged the administration to mandate a combination of masks and environmental measures, like better ventilation, to blunt the risks in various workplaces.

On Friday, the Centers for Disease Control and Prevention issued new guidelines for reopening schools, but quickly passed over improved ventilation as a precaution. It was only in July that the World Health Organization conceded that the virus can linger in the air in crowded indoor spaces, after 239 experts publicly called on the organization to do so.

In a letter to the administration, scientists detailed evidence supporting airborne transmission of the virus. It has become even more urgent for the administration to take action now, the experts said, because of the slow vaccine rollout, the threat of more contagious variants of the virus already circulating in the United States, and the high rate of Covid-19 infections and deaths, despite a recent drop in cases.

“It’s time to stop pussyfooting around the fact that the virus is transmitted mostly through the air,” said Linsey Marr, an expert on aerosols at Virginia Tech.

“If we properly acknowledge this, and get the right recommendations and guidance into place, this is our chance to end the pandemic in the next six months,” she added. “If we don’t do this, it could very well drag on.”

The letter was delivered on Monday to Jeffrey D. Zients, coordinator of the Biden administration’s Covid-19 response; Dr. Rochelle Walensky, director of the Centers for Disease Control and Prevention; and Dr. Anthony S. Fauci, director of the National Institute of Allergy and Infectious Diseases.

Dr. Anthony S. Fauci, left, and Jeffrey D. Zients, President Biden’s Covid-19 response coordinator, at the White House last month.
Dr. Anthony S. Fauci, left, and Jeffrey D. Zients, President Biden’s Covid-19 response coordinator, at the White House last month.Credit…Doug Mills/The New York Times

The letter urged the C.D.C. to recommend the use of high-quality masks, such as N95 respirators, to protect workers at high risk of infection. At present, health care workers mostly rely on surgical masks, which are not as effective against aerosol transmission of the virus.

Many workers vulnerable to infection are people of color, who have borne the brunt of the epidemic in the United States, the experts noted.

Mr. Biden has directed the Occupational Safety and Health Administration, which sets workplace requirements, to issue emergency temporary standards for Covid-19, including those regarding ventilation and masks, by March 15.

But OSHA will only mandate standards that are supported by guidance from the C.D.C., said David Michaels, an epidemiologist at George Washington University and one of the signatories.

(Dr. Michaels led OSHA during the Obama administration; the agency has not had a permanent leader since his departure.)

“Until the C.D.C. makes some changes, OSHA will have difficulty changing the recommendations it puts up because there’s an understanding the government has to be consistent,” Dr. Michaels said. “And C.D.C. has always been seen as the lead agency for infectious disease.”

Public health agencies, including the W.H.O., have been slow to acknowledge the importance of aerosols in spreading the coronavirus. It was only in October that the C.D.C. recognized that the virus can sometimes be airborne, after a puzzling sequence of events in which a description of how the virus spreads appeared on the agency’s website, then vanished, then resurfaced two weeks later.

But the agency’s recommendations on workplace accommodations did not reflect this change.

Early in the pandemic, the C.D.C. said health care workers did not need N95 respirators, and could even wear bandannas to protect themselves. It also did not recommend face coverings for the rest of the population.

The agency has since revised those recommendations. It recently recommended that people wear two masks or improve the fit of their surgical masks to protect from the virus.

“But they don’t talk about why you need a better fitting mask,” said Dr. Donald Milton, an aerosol expert at the University of Maryland. “They’re acknowledging the importance of breathing it in and the route of transmission, and yet they don’t say it clearly in their various web pages.”

Election workers in Lansing, Mich., sorted absentee ballots in November while a ventilation duct helped to circulate air.Credit…John Moore/Getty Images

The agency recommends surgical masks for health care workers and says N95 respirators are needed only during medical procedures that generate aerosols, like certain kinds of surgery.

But many studies have shown that health care workers who have no direct contact with Covid-19 patients are also at high risk of infection and should be wearing high-quality respirators, said Dr. Céline Gounder, an infectious disease specialist at Bellevue Hospital Center in New York and an adviser to Mr. Biden during the transition.

“The C.D.C. has not emphasized the risk of aerosol transmission enough,” Dr. Gounder said. “Unfortunately, concerns about supply continue to muddy the discussion.”

Many hospitals still expect their staff to reuse N95 masks per the agency’s recommendation to reuse when supplies are low. But since the masks are no longer in short supply, the agency should change its recommendations, Dr. Gounder said.

“We really do need to stop this reuse and decontamination approach to N95s,” she added. “We’re a year into this, and that’s really not acceptable.”

Hospitals, at least, tend to have good ventilation so health care workers are protected in other ways, the experts said. But in meatpacking plants, prisons, buses or grocery stores, where workers are exposed to the virus for long periods of time, the C.D.C. does not recommend high-quality respirators, nor does it endorse upgrades to ventilation.

“If you go to other workplaces, this idea that aerosol transmission is important is virtually unknown,” Dr. Michaels said. In food processing plants, for example, a refrigerated environment and the lack of fresh air are ideal conditions for the virus to thrive. But the industry has not put in safety measures to minimize the risk, he added.

Employers instead hew to the C.D.C.’s recommendations for physical distancing and cleaning surfaces.

The recent emergence of more contagious variants makes it urgent for the C.D.C. to address airborne transmission of the virus, said Dr. Marr of Virginia Tech. Germany, Austria and France now mandate N95 respirators or other high-quality masks in public transportation and shops.

Dr. Marr was one of the experts who wrote to the W.H.O. last summer to push for an acknowledgment of airborne transmission. She did not expect to be in a similar position again so many months later, she said: “It feels like Groundhog Day.”

As Millions Get Shots, F.D.A. Struggles to Get Safety Monitoring System Running

As Millions Get Shots, F.D.A. Struggles to Get Safety Monitoring System Running

For now, the government has been relying on a patchwork of programs that officials say are hampered by limited size and gaps in data collection.

A drive-through mass vaccination site at Coors Field baseball stadium in Denver last month.
A drive-through mass vaccination site at Coors Field baseball stadium in Denver last month.Credit…Chet Strange/Agence France-Presse — Getty Images

  • Feb. 12, 2021, 5:00 a.m. ET

More than 34 million Americans have received Covid vaccines, but the much-touted system the government designed to monitor any dangerous reactions won’t be capable of analyzing safety data for weeks or months, according to numerous federal health officials.

For now, federal regulators are counting on a patchwork of existing programs that they acknowledge are inadequate because of their small sample size, missing critical data or other problems.

Clinical trials have shown both of the vaccines authorized in the United States — one from Pfizer-BioNTech and the other from Moderna — to be highly protective and safe against the coronavirus.

But even the best trials have limited ability to detect adverse reactions that are rare, those that only occur in certain population groups, or which happen beyond the three-month period studied in the trials. Tracking adverse events once the vaccines are administered to the public at large is essential not just to detect problems but to build confidence in the safety of vaccines.

In interviews, F.D.A. officials acknowledged that a promised monitoring system, known as BEST, is still in its developmental stages. They expect it to start analyzing vaccine safety data sometime soon — but likely not until after the Biden administration reaches its goal of vaccinating 100 million people.

“I’m concerned about this disjointed tracking system,” said Dr. Ashish K. Jha, dean of the Brown University School of Public Health. “We knew these vaccines were coming for at least several months before they got authorized, so we really should have had a well-developed system.”

Dr. Jha and others believe that with all the public attention on the vaccines, any serious adverse reactions will likely be reported somewhere. But, they say, a more systematic approach is crucial.

“It’s critical to track, because it will help build confidence,” Dr. Jha said.

Monitoring is all the more important because the vaccines were developed and approved in record time, with the goal of inoculating most of the U.S. population as quickly as possible.

“It’s the right thing to do, but the fact of the matter is we don’t have enough information and we’re desperately in need of post-market information and monitoring,” said a high-ranking F.D.A. official, who asked not to be named because he was not authorized to discuss the matter publicly.

The government is now relying most on a 30-year-old safety monitoring system that the F.D.A. shares with the Centers for Disease Control and Prevention, and a new smartphone app that people who get vaccinated can download and use to report problems if they wish. The C.D.C. also runs the Vaccine Safety Datalink, a collaboration between the agency and nine health systems that collects vaccine data and electronic medical records of roughly 12 million patients. Although it is well-regarded, it is of limited use because of its small size.

Boxes of the Pfizer-BioNTech vaccine were prepared for shipment at a facility in Portage, Miich., in December.
Boxes of the Pfizer-BioNTech vaccine were prepared for shipment at a facility in Portage, Miich., in December.Credit…Pool photo by Morry Gash

“It’s great for routine stuff, but when it comes to safety surveillance, it’s all about size,” said Dr. Daniel Salmon, director of the Institute for Vaccine Safety at Johns Hopkins University, and a former federal vaccine official. “The bigger it is, the faster you get an answer. Eventually the VSD will get a really good answer — probably one of the best answers of anybody out there because they are so good at doing it. But in a pandemic, time isn’t on our side.”

So far, few serious problems have been reported through these channels and no deaths have conclusively been linked to the vaccines. The 30-year-old initiative, known as the Vaccine Adverse Event Reporting System, or VAERS, relies on self-reported cases from patients and health care providers.

Health officials say that so far, the two vaccines already authorized for use appear to be quite safe. There have been a few severe allergic reactions, including anaphylaxis, but they are treatable and considered rare. The rate at which anaphylaxis has occurred so far — 4.7 cases in every million doses of the vaccine by Pfizer and BioNTech, and 2.5 cases per million for the vaccine by Moderna — are in line with what happens with other widely used vaccines.

Bruising and bleeding caused by lowered platelet counts have also been reported, though it is not known if they are linked to the vaccines, or coincidental. In total, 9,000 adverse events were reported, with 979 serious and the rest classified as nonserious, according to the most recent C.D.C. report available.

In interviews, public health experts, including current and former officials at the F.D.A. and the C.D.C., expressed a need to improve upon old “passive” surveillance, which depends on self-reporting. They said that funding shortages, turf wars and bureaucratic hurdles had slowed preparing BEST, formally called the Biologics Evaluation Safety Initiative, to monitor the Covid vaccines.

An earlier version of BEST was started in 2017, to improve the F.D.A.’s tracking of new blood products and vaccines, but the agency has only used it on a limited basis. It is considered an “active” surveillance system because scientists can use data collected from clinical care to hunt for safety problems, rather than rely on individuals to report health problems that they believe — but often without proof — were caused by the vaccine. BEST is part of the agency’s move toward using more real-world evidence to vet new products or monitor them after approval. The F.D.A. has done some preliminary studies using BEST to evaluate the safety of shingles and flu vaccines.

When the monitoring system is fully up and running, the F.D.A. expects to have access to more than 100 million individual medical records, and will be able to look for signs of safety problems, and then determine whether they are real. But critics say it is folly for the F.D.A. to be launching a new system in the midst of a pandemic. And several C.D.C. officials said the F.D.A. was not giving them a real sense of when the complex system would begin to work.

“It’s been a puzzle to me,” said one C.D.C. official who was not authorized to discuss the issue and asked not to be identified. “F.D.A. talks about this in a way that is really unclear as to what is up and ready to go and what isn’t.”

The headquarters of the F.D.A. in Silver Spring, Md.Credit…Jim Lo Scalzo/EPA, via Shutterstock

But even BEST will suffer from a data problem that is already hindering existing systems: the dearth of health insurance claims to show who got which vaccine, and when. Typically health care providers and patients submit such claims to insurers, but with the vaccines being given at no charge, often at government-sponsored events, few are bothering to file claims. Critics say that federal health officials should have predicted this glitch and prepared for it.

“The current safety surveillance system in the U.S. is dependent on health insurance claims data and electronic health records,” said Dr. Salmon. “If the vaccine data information doesn’t get into the safety system, then that safety system is unable to function.”

In December, the C.D.C. launched V-safe, a smartphone-based system that checks in with individuals who get the Covid vaccine to monitor for side effects. Roughly two million people who have been vaccinated have enrolled, a small fraction of the total number, and of those, one million have responded to text queries and surveys about their post-vaccine health.

At a recent C.D.C. advisory meeting, Dr. Tom Shimabukuro, who oversees Covid-19 vaccine safety for the agency, said he was pleased that the new app had enrolled so many users, but he also acknowledged problems like errors that indicated men and older women to be listed as pregnant.

It’s also unclear how heartily vaccine providers are promoting V-safe. Some health care providers send post-vaccine emails to patients noting its availability, and others merely put a stack of C.D.C. fact-sheets about V-safe in the vaccination room and hope patients pick it up. Even Dr. Jha said he didn’t sign up for it.

Still, Dr. Shimabukuro said he was confident in the current surveillance system. “For the national Covid-19 vaccination program, we have implemented the most intense safety monitoring in the history of the United States,” he said. “We have multiple systems that are complementary to each other, that are able to rapidly collect information, that are able to rapidly assess the safety of immunizations.”

Medical workers filled doses of Moderna’s vaccine at a a drive-through site in Robstown, Texas.Credit…Go Nakamura/Reuters

One factor slowing down BEST is that the F.D.A. has not yet calculated what are called background rates, the levels of certain health problems that normally occur in the non-vaccinated population. These are critical for determining whether the vaccine is actually causing a spike in certain problems, such as heart attacks, strokes, and other issues that the F.D.A. and C.D.C. consider adverse events of special interest, which require close monitoring.

Rather than calculate them on its own, as the C.D.C. does, the F.D.A. sent a proposal out for public comment, in which it detailed how it planned to compute the background rates. They plan to start working on it in the next few weeks. This delay strikes some public health experts as unnecessary.

“It’s a little bit surprising,” said Dr. Peter Lurie, president of the Center for Science in the Public Interest, and a former associate commissioner at the F.D.A. “That doesn’t feel like a mechanism appropriate to the urgency of a pandemic. It seems to me that a few well-placed phone calls to key people in the field would provide as much information as a request for comment.”

Dr. Peter Marks, the director of the F.D.A.’s Center for Biologics Evaluation and Research, which oversees vaccine approval and safety, said the agency needed outside input.

“The background rates are a critical input for our rapid cycle analysis, so we followed a deliberative and transparent process,” he said in an interview. “We needed to develop an approach that could be used in several health care claims data systems and we needed to account for the possibility that health care utilization may have changed during the pandemic.”

Jeffrey Brown, an associate professor at Harvard Medical School and a leader of the F.D.A. program that monitors adverse reactions to drugs, said he is concerned about the lack of insurance claims data and other holes in the vaccine safety surveillance systems.

“It is imperative to have policies that ensure vaccination data are submitted to insurers to enable effective use of the nation’s investment in active safety monitoring,” said Dr. Brown. “It is not only critical to get needles into arms, but also to get data into databases. We still have a chance to get it done well.”

Denise Grady contributed reporting.

Credit…Jessica Hill/Associated Press

Is Your Super Bowl Party a Superspreader Event?

Super Bowl Party or Superspreader Event?

Experts offer tips on how to stay safe. For one, don’t plan on shouting or cheering with your friends.

Credit…Getty Images
Christina Caron

  • Feb. 4, 2021, 5:00 a.m. ET

For millions of football fans, Super Bowl Sunday has become the equivalent of a major holiday. It’s like Thanksgiving, only with way more shouting, drinking, hugging and dipping into shared snacks. But this year, public health experts are urging everyone to tone it down and take special precautions when watching the big game.

“I know that no one wants to be the guy that got hospitalized or died because of the Super Bowl,” said Dr. Joshua Barocas, an infectious diseases physician at Boston Medical Center. “With the highly transmissible variants around and a largely unvaccinated public, we are all at high risk.”

Last year, gatherings to watch Lakers games during the N.B.A. finals were believed to have accelerated the virus’s surge in Southern California, officials in Los Angeles said. And after the fall and winter holidays, coronavirus cases spiked in some parts of the country as people skirted public health guidelines to celebrate with one another.

Now, after what has been nearly a year of social distancing, Sunday’s matchup between the Tampa Bay Buccaneers and the Kansas City Chiefs is beckoning.

“It’s not like Thanksgiving where millions and millions are traveling, but will we see cases linked to Super Bowl parties at people’s homes? I think most definitely yes,” said Joseph G. Allen, an expert on indoor environmental quality at the Harvard T.H. Chan School of Public Health.

According to a recent Seton Hall University survey of more than 1,500 adults across the country, 58 percent said that they will watch the Super Bowl this year. And of those, a quarter are planning to do so with people from outside their households. Another study, from the National Retail Federation, found that 28 percent of those who intend to watch the Super Bowl are planning to either host or attend a party, or watch the game at a bar.

Here are three ways that fans might watch the game this Sunday, ranked from least to most risky, and some guidance from experts on how to stay safe.

Least Risky

With household members

The experts we spoke with echoed recommendations from the Centers for Disease Control and Prevention that the safest way to watch the game is at home with only the people you live with. And in recent surveys, most Super Bowl fans have indicated that this is exactly what they’ll do.

Gathering with people from outside your household is taking a risk, Dr. Allen said.

You can still include other family and friends virtually. The C.D.C. recommends connecting with others by sharing recipes, starting text chains or hosting a party online. You can use Zoom, Google Hangouts or streaming services with virtual group watch features.

Sandra Albrecht, an assistant professor of epidemiology at the Columbia University Mailman School of Public Health in New York City, is planning to attend a watch party on Zoom.

“I’m a huge football fan, and I watch the Super Bowl every year,” she said. “But this is one year where my family and I will forgo any in-person parties and will instead enjoy the game in the remote company of family and friends.”

Another potential benefit of sticking with only the people in your household: It can be less stressful. You don’t have to worry as much about who’s double dipping in the salsa or if the windows are open wide enough.

More Risky

With non-household members — outdoors

When people talk, shout, cheer or laugh outdoors, the tiny droplets of saliva that come out of their mouths are more rapidly dispersed into the environment and become more diluted. That means that when you’re outdoors with others, you’ll be less likely to get infected than if you were indoors with the same group of people.

But the risk is not zero. If you decide to attend an outdoor gathering with people from other households, it’s still important to wear masks the entire time (except when eating) and to stay at least six feet apart, the experts said.

Erin Jackson, 38, and her husband invited 11 guests to watch the Super Bowl on a 100-inch screen in their large backyard in Chapel Hill, N.C.

“We also had a lot of discussions over whether to do anything at all, because we are terrified about not being cautious,” Ms. Jackson said.

So they came up with a few rules: Everyone has to bring their own snacks, the house will be off limits and the chairs will be placed at least six feet apart.

So far, nobody has committed to showing up.

“It felt like an opportunity to reach out to our relatively small group of friends here and let them know we were thinking about them and that we wanted to be spending time with them,” Ms. Jackson said. But, she added, they also recognized that “probably very few would take us up on it.”

If you decide to go to an outdoor venue, like a bar or a restaurant, the C.D.C. recommends calling ahead of time to find out which (if any) precautions they have taken.

Most Risky

With non-household members — indoors

Each of the experts we spoke with, along with the C.D.C., strongly advised against gathering indoors with people you don’t live with. Some evidence suggests that small gatherings have driven virus transmission in certain areas. In December, for example, New York announced that its contact tracing data showed that 70 percent of new Covid-19 cases originated from households and small gatherings.

Even so, meeting indoors might be tempting for fans who live in parts of the country where temperatures are expected to dip below freezing on Sunday.

But if people snack inside someone’s home and talk loudly throughout the game, “such conditions are ideal for the spread of the coronavirus,” said Linsey Marr, a professor of civil and environmental engineering at Virginia Tech who studies viruses in the air. “People can spread the disease without feeling any symptoms.”

If you decide to take the risk, make sure to wear a mask at all times and stay at least six feet from others. And if you want to eat and drink, “do it outside and distanced from others,” Dr. Marr said.

If you’re the host of the party, keep the guest list as small as you can, ideally just one or two people from outside your household. Alternatively, if you’ve been invited to a party, try to find out how many people will be attending and what size party you would be most comfortable with. Don’t feel pressured to stay for the entire game; Dr. Marr suggested dropping by for the length of a quarter to diminish your exposure to others.

Finally, make sure the windows and doors are cracked open. “Even just a few inches can make a big difference to improve ventilation,” Dr. Marr said.

More Ways to Protect Yourself and Others

If you gather with others, the C.D.C. says there are general precautions you can take to stay as safe as possible. Try to avoid shouting, cheering loudly or singing, which can increase the amount of respiratory droplets in the air. Instead, clap, stomp your feet or use noisemakers.

The C.D.C. also recommends bringing your own food, drinks, plates, cups and utensils.

If people drink too much alcohol, they might let their guard down or relax the rules. So be mindful of how the people around you are behaving and control how much you’re consuming so that you can keep a clear head.

Finally, don’t get lulled into a false sense of security. Even if everyone has been fully vaccinated, it can take a week or two after the second shot to build peak protection. And while vaccinated people are less likely to get severe Covid-19, experts don’t yet know if they can still spread the virus to others, said Dr. Asaf Bitton, a primary care physician at Brigham and Women’s Hospital who specializes in public health.

Finally, remember that negative Covid tests are no guarantee of safety. The virus may not have been detectable on the day of the test or the result could be a false negative.

“One test at one point in time is just not going to give you the clarity that you need to know that it’s safe for your groups to get together,” Dr. Bitton said.

Pregnant Women Get Conflicting Advice on Covid-19 Vaccines

The W.H.O. and the C.D.C. provide differing views, and experts partly blame a lack of data because expectant mothers have been excluded from clinical trials.

Yes, You Still Need to Wear a Mask

Personal Health

Yes, You Still Need to Wear a Mask

Short of a total lockdown, universal mask-wearing is the most effective way to slow the relentless rise in hospitalizations and deaths from Covid-19.

Credit…Gracia Lam
Jane E. Brody

  • Jan. 25, 2021, 5:00 a.m. ET

As a professional health writer and concerned citizen, the ache in my heart deepens with each new report of the devastation wrought by the novel coronavirus, the cause of immeasurable — and still increasing — personal and economic pain for people caught in its deadly spikes.

In a recent five-week period, 100,000 Americans died from complications of Covid-19, a toll that took the country four months to reach last spring.

My distress is magnified by the knowledge that it didn’t have to be this bad. One simple measure — consistent wearing of face coverings in public — could have helped to stem the agony. In December, the Centers for Disease Control and Prevention reiterated advice first given in July: “Wear a mask over your nose and mouth. Everyone should wear a mask in public settings and when around people who don’t live in your household, especially when other social distancing measures are difficult to maintain.”

Masks, the agency emphasized, protect both the wearer and those the wearer encounters in the course of daily life.

Now, with the emergence of a highly contagious variant of the virus and the chaotic attempts to distribute and administer vaccines to hundreds of millions of vulnerable Americans, short of a total lockdown, universal mask-wearing is the most effective way to slow the relentless rise in hospitalizations and deaths from Covid-19.

It will take many months to immunize everyone willing and able to get a Covid vaccine. Meanwhile, we’re facing another tsunami of deadly coronavirus infections as the new variant sweeps through swaths of still-unprotected millions.

As with many other measures not taken by the last administration to minimize the spread of Covid-19, mask-wearing was left up to the states to mandate and enforce. Masks became a political football, and the former president publicly ridiculed opponents who wore them. Some elected officials even made the ridiculous, baseless claim that masks not only don’t thwart the spread of the virus, they actually enhance it. I wonder if they also ignored parents and teachers who told them to cover their mouths when they coughed or sneezed.

I also wonder about the economic savvy of our former president and the governors who have resisted issuing mask mandates, some of whom got Covid-19 themselves yet clamored to open the economy. Goldman Sachs estimated last June that implementing a nationwide mask mandate could have a potential impact on the U.S. GDP of one trillion dollars.

Lately, as I await my second vaccine shot, I’ve become increasingly aware of how many people walk, run or cycle without a mask or, if they have a mask, wear it ineffectively. I’ve taken to speaking up more often: “Please wear your mask” or “The mask should cover your nose and mouth.” Among the ignorant responses: “I don’t need a mask when I’m outside,” “I already had Covid so I can’t get it again or give it to you,” and my favorite while walking on a four-foot-wide path, “I stay six feet away from people.”

Although six-foot social distancing is not totally arbitrary, it’s based on limited evidence among airline passengers and may not apply at all, for example, to the unmasked cyclists shouting to one another as they ride past me or to the heavy-breathing runners I pass.


Covid-19 Vaccines ›


Answers to Your Vaccine Questions

While the exact order of vaccine recipients may vary by state, most will likely put medical workers and residents of long-term care facilities first. If you want to understand how this decision is getting made, this article will help.

Life will return to normal only when society as a whole gains enough protection against the coronavirus. Once countries authorize a vaccine, they’ll only be able to vaccinate a few percent of their citizens at most in the first couple months. The unvaccinated majority will still remain vulnerable to getting infected. A growing number of coronavirus vaccines are showing robust protection against becoming sick. But it’s also possible for people to spread the virus without even knowing they’re infected because they experience only mild symptoms or none at all. Scientists don’t yet know if the vaccines also block the transmission of the coronavirus. So for the time being, even vaccinated people will need to wear masks, avoid indoor crowds, and so on. Once enough people get vaccinated, it will become very difficult for the coronavirus to find vulnerable people to infect. Depending on how quickly we as a society achieve that goal, life might start approaching something like normal by the fall 2021.

Yes, but not forever. The two vaccines that will potentially get authorized this month clearly protect people from getting sick with Covid-19. But the clinical trials that delivered these results were not designed to determine whether vaccinated people could still spread the coronavirus without developing symptoms. That remains a possibility. We know that people who are naturally infected by the coronavirus can spread it while they’re not experiencing any cough or other symptoms. Researchers will be intensely studying this question as the vaccines roll out. In the meantime, even vaccinated people will need to think of themselves as possible spreaders.

The Pfizer and BioNTech vaccine is delivered as a shot in the arm, like other typical vaccines. The injection won’t be any different from ones you’ve gotten before. Tens of thousands of people have already received the vaccines, and none of them have reported any serious health problems. But some of them have felt short-lived discomfort, including aches and flu-like symptoms that typically last a day. It’s possible that people may need to plan to take a day off work or school after the second shot. While these experiences aren’t pleasant, they are a good sign: they are the result of your own immune system encountering the vaccine and mounting a potent response that will provide long-lasting immunity.

No. The vaccines from Moderna and Pfizer use a genetic molecule to prime the immune system. That molecule, known as mRNA, is eventually destroyed by the body. The mRNA is packaged in an oily bubble that can fuse to a cell, allowing the molecule to slip in. The cell uses the mRNA to make proteins from the coronavirus, which can stimulate the immune system. At any moment, each of our cells may contain hundreds of thousands of mRNA molecules, which they produce in order to make proteins of their own. Once those proteins are made, our cells then shred the mRNA with special enzymes. The mRNA molecules our cells make can only survive a matter of minutes. The mRNA in vaccines is engineered to withstand the cell’s enzymes a bit longer, so that the cells can make extra virus proteins and prompt a stronger immune response. But the mRNA can only last for a few days at most before they are destroyed.

I’ve also heard a few people say, “I already got the vaccine, so I don’t need a mask.” This may be the most dangerous excuse of all. First, although the vaccines are very good, they’re not perfect, and chances are these vaccine recipients haven’t been checked for strong antibodies to the virus. Second, we don’t yet know if the vaccines, while highly effective in preventing sickness and death, will also prevent asymptomatic infection that can spread the virus to others.

As Jeremy Howard, a data scientist at the University of San Francisco, said of mask refusers: “How would you feel if you made your best friend sick, or killed your friend’s mother?”

Last February, after the World Health Organization, with no supporting data, advised against wearing a mask unless you were already sick, Mr. Howard amassed an international team of 19 scientists to review the evidence for mask-wearing, expecting to find “that masks were a waste of time,” he said in an interview. Instead, he said, the team found that “the data on the benefit of masks is really compelling.” The results of their exhaustive study were published recently in PNAS, the peer-reviewed Proceedings of the National Academy of Sciences.

Mr. Howard said that preliminary reports of their findings resulted “in all sorts of abuse, including death threats” from mask resisters. But that has not kept him from repeating that “wearing any kind of mask will greatly help to keep you from accidentally infecting others, which is important for the community and the economy. About half of coronavirus infections are spread by people who don’t know they’re sick, and the new variant is much more transmissible.”

A Chinese study found that the viral load in the upper respiratory tracts of infected people without symptoms can be just as high as those with symptoms, and simply talking and breathing can spread virus-laden droplets and aerosols. And because the virus resides in high amounts in the nose and throat, sneezing can spew an infectious cloud 10 or more times further than coughing.

Which brings me to the question of whether the face coverings most people use are sufficiently protective. I now know that the bandannas, exam masks and the slim neoprene masks I’ve been using for the last 11 months are better than nothing but not very good. They provide too many routes for virus-carrying particles to reach an unsuspecting nose or mouth.

I should have followed the advice my colleague Tara Parker-Pope offered months ago on upgrading your mask.

“Masks,” Mr. Howard said, “need a nose wire to provide a close fit and proper filtration material, like a nanofiber, that filters very small particles.”

He and his co-authors concluded that for most of us, KN95 masks, especially those with bands that fit around the head, are currently the best to prevent contracting and spreading the virus.

Another option is the KF94 mask or, if it’s not too uncomfortable, doubling up on masks for added protection.

KN95 masks meet foreign certification standards and are designed to filter out 95 percent of particles down to 0.3 microns in size. (The gold standard N95 masks, which meet U.S. certification standards, should be reserved for health care and emergency personnel who are most likely to interact with Covid-infected individuals.)

Powecom KN95 masks have an emergency use authorization from the Food and Drug Administration. I just ordered a packet of 11 on Amazon for $23.80 and I expect to be using them for many months after I’m vaccine-protected. I might still be able to transmit the virus and I want to set a good example for my fellow citizens.

One Mask Is Good. Would Two Would Be Better?

One Mask Is Good. Would Two Would Be Better?

Health experts double down on their advice for slowing the spread of the coronavirus.

A double-mask wearer in New York City in April.
A double-mask wearer in New York City in April.Credit…Kena Betancur/Getty Images
Katherine J. Wu

  • Jan. 12, 2021, 12:51 p.m. ET

Football coaches do it. President-elects do it. Even science-savvy senators do it. As cases of the coronavirus continue to surge on a global scale, some of the nation’s most prominent people have begun to double up on masks — a move that researchers say is increasingly being backed up by data.

Double-masking isn’t necessary for everyone. But for people with thin or flimsy face coverings, “if you combine multiple layers, you start achieving pretty high efficiencies” of blocking viruses from exiting and entering the airway, said Linsey Marr, an expert in virus transmission at Virginia Tech and an author on a recent commentary laying out the science behind mask-wearing.

Of course, there’s a trade-off: At some point, “we run the risk of making it too hard to breathe,” she said. But there is plenty of breathing room before mask-wearing approaches that extreme.

A year into the Covid-19 pandemic, the world looks very different. More than 90 million confirmed coronavirus infections have been documented worldwide, leaving millions dead and countless others with lingering symptoms, amid ongoing economic hardships and shuttered schools and businesses. New variants of the virus have emerged, carrying genetic changes that appear to enhance their ability to spread from person to person.

And while several vaccines have now cleared regulatory hurdles, the rollout of injections has been sputtering and slow — and there is not yet definitive evidence to show that shots will have a substantial impact on how fast, and from whom, the virus will spread.

Through all that change, researchers have held the line on masks. “Americans will not need to be wearing masks forever,” said Dr. Monica Gandhi, an infectious disease physician at the University of California, San Francisco, and an author on the new commentary. But for now, they will need to stay on, delivering protection both to mask-wearers and to the people around them.

The arguments for masking span several fields of science, including epidemiology and physics. A bevy of observational studies have suggested that widespread mask-wearing can curb infections and deaths on an impressive scale, in settings as small as hair salons and at the level of entire countries. One study, which tracked state policies mandating face coverings in public, found that known Covid cases waxed and waned in near-lockstep with mask-wearing rules. Another, which followed coronavirus infections among health care workers in Boston, noted a drastic drop in the number of positive test results after masks became a universal fixture among staff. And a study in Beijing found that face masks were 79 percent effective at blocking transmission from infected people to their close contacts.

Recent work by researchers like Dr. Marr is now pinning down the basis of these links on a microscopic scale. The science, she said, is fairly intuitive: Respiratory viruses like the coronavirus, which move between people in blobs of spittle and spray, need a clear conduit to enter the airway, which is crowded with the types of cells the viruses infect. Masks that cloak the nose and mouth inhibit that invasion.

The point is not to make a mask airtight, Dr. Marr said. Instead, the fibers that comprise masks create a haphazard obstacle course through which air — and any infectious cargo — must navigate.

“The air has to follow this tortuous path,” Dr. Marr said. “The big things it’s carrying are not going to be able to follow those twists and turns.”

Experiments testing the extent to which masks can waylay inbound and outbound spray have shown that even fairly basic materials, like cloth coverings and surgical masks, can be at least 50 percent effective in either direction.

Several studies have reaffirmed the notion that masks seem to be better at guarding people around the mask-wearer than mask-wearers themselves. “That’s because you’re stopping it right at the source,” Dr. Marr said. But, motivated by recent research, the Centers for Disease Control and Prevention has noted that there are big benefits for those who don masks as well.

Masks awaiting disinfecting at the Battelle N95 decontamination site in Somerville, Mass.
Masks awaiting disinfecting at the Battelle N95 decontamination site in Somerville, Mass.Credit…Michael Dwyer/Associated Press

The best masks remain N95s, which are designed with ultrahigh filtration efficiency. But they remain in short supply for health workers, who need them to safely treat patients.

Layering two less specialized masks on top of each other can provide comparable protection. Dr. Marr recommended wearing face-hugging cloth masks over surgical masks, which tend to be made with more filter-friendly materials but fit more loosely. An alternative is to wear a cloth mask with a pocket that can be stuffed with filter material, like the kind found in vacuum bags.

But wearing more than two masks, or layering up on masks that are already very good at filtering, will quickly bring diminishing returns and make it much harder to breathe normally.

Other tweaks can enhance a mask’s fit, such as ties that secure the fabric around the back of the head, instead of relying on ear loops that allow masks to hang and gape. Nose bridges, which can help the top of a mask to fit more snugly, offer a protective boost as well.

Achieving superb fit and filtration “is really simple,” Dr. Gandhi said. “It doesn’t need to involve anything fancy.”

No mask is perfect, and wearing one does not obviate other public health measures like physical distancing and good hygiene. “We have to be honest that the best response is one that requires multiple interventions,” said Jennifer Nuzzo, a public health expert at Johns Hopkins University.

Mask-wearing remains uncommon in some parts of the country, in part because of politicization of the practice. But experts noted that model behavior by the nation’s leaders might help to turn the tide. In December, President-elect Joseph R. Biden Jr. implored Americans to wear masks for his first 100 days in office, and said he would make doing so a requirement in federal buildings and on planes, trains and buses that cross state lines.

A large review on the evidence behind masking, published this month in the journal PNAS, concluded that masks are a key tool for reducing community transmission, and is “most effective at reducing spread of the virus when compliance is high.”

Part of the messaging might also require more empathy, open communication and vocal acknowledgment that “people don’t enjoy wearing masks,” Dr. Nuzzo said. Without more patience and compassion, simply doubling down on restrictions to “fix” poor compliance will backfire: “No policy is going to work if no one is going to adhere.”

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Pressure Grows for States to Open Vaccines to More Groups of People

Pressure Grows for States to Open Vaccines to More Groups of People

Some states are already expanding eligibility to people 65 and over, even though millions of people the C.D.C. recommends go first — health care workers and nursing home residents — have yet to get shots.

Gov. Ron DeSantis of Florida, right, during vaccinations at the John Knox Village nursing home in Pompano Beach, Fla., last month.
Gov. Ron DeSantis of Florida, right, during vaccinations at the John Knox Village nursing home in Pompano Beach, Fla., last month.Credit…Marta Lavandier/Associated Press
Abby Goodnough

  • Jan. 9, 2021, 12:00 p.m. ET

Just weeks into the country’s coronavirus vaccination effort, states have begun broadening access to the shots faster than planned, amid tremendous public demand and intense criticism about the pace of the rollout.

Some public health officials worry that doing so could bring even more chaos to the complex operation and increase the likelihood that some of the highest-risk Americans will be skipped over. But the debate over how soon to expand eligibility is intensifying as deaths from the virus continue to surge, hospitals are overwhelmed with critically ill patients and millions of vaccine doses delivered last month remain in freezers.

Governors are under enormous pressure from their constituents — especially older people, who vote in great numbers and face the highest risk of dying from the virus — to get the doses they receive into arms swiftly. President-elect Joseph R. Biden Jr.’s decision, announced Friday, to release nearly all available doses to the states when he takes office on Jan. 20, rather than holding half to guarantee each recipient gets a booster shot a few weeks after the first, is likely to add to that pressure.

Some states, including Florida, Louisiana and Texas, have already expanded who is eligible to get a vaccine now, even though many people in the first priority group recommended by the Centers for Disease Control and Prevention — the nation’s 21 million health care workers and three million residents of nursing homes and other long-term care facilities — have not yet received a shot.

On Friday afternoon, New York became the latest state to do so, announcing that it would allow people 75 and over and certain essential workers to start receiving a vaccine on Monday.

But reaching a wider swath of the population requires much more money than states have received for the task, many health officials say, and more time to fine-tune systems for moving surplus vaccine around quickly, to increase the number of vaccination sites and people who give the shots, and to establish reliable appointment systems to prevent endless lines and waits.

Some states’ expansions have led to frantic and often futile efforts by older people to get vaccinated. After Florida opened up vaccinations to anyone 65 and older late last month, the demand was so great that new online registration portals quickly overloaded and crashed, people spent hours on the phone trying to secure appointments and others waited overnight at scattered pop-up sites offering shots on a first-come first-served basis.

Similar scenes have played out in parts of Texas, Tennessee and a handful of other states.

Still, with C.D.C. data suggesting that only about a third of the doses distributed so far have been used, Alex M. Azar II, the health and human services secretary, told reporters this past week: “It would be much better to move quickly and end up vaccinating some lower-priority people than to let vaccines sit around while states try to micromanage this process. Faster administration would save lives right now, which means we cannot let the perfect be the enemy of the good.”

Boxes of Moderna’s vaccine were prepared for shipment at a distribution center in Olive Branch, Miss., last month.
Boxes of Moderna’s vaccine were prepared for shipment at a distribution center in Olive Branch, Miss., last month.Credit…Pool photo by Paul Sancya

The C.D.C. guidelines were drawn up by an independent committee of medical and public health experts that advises the agency on immunization practices; it deliberated for months about who should get vaccinated initially, while supplies were still very limited. The committee weighed scientific evidence about who is most at risk of getting very sick or dying from Covid-19, as well as ethical questions, such as how best to ensure equal access among different races and socioeconomic groups.

Although the committee’s recommendations are nonbinding, states usually follow them; in this case, the committee suggests that states might consider expanding to additional priority groups “when demand in the current phase appears to have been met,” “when supply of authorized vaccine increases substantially” or “when vaccine supply within a certain location is in danger of going unused.”

Dr. Kevin Ault, an obstetrician at the University of Kansas Medical Center who serves on the advisory committee that came up with the C.D.C. guidelines, said that it was reasonable for states to start vaccinating new groups before finishing others, but that they should be careful about exacerbating inequities and biting off more than they can chew.

“Obviously if you’re going to vaccinate that group you need to have a well-thought-out plan in hand,” he said, referring to the over-65 population. “Having people camping out for vaccine is less than ideal, I would say.”

He added, “We put a lot of thought and effort into our guidelines, and I think they are good.”

After the first vaccines were given in mid-December, a dichotomy emerged between governors who were adhering precisely to the guidelines and others who moved quickly to populations beyond health care workers and nursing home residents.

Until Friday, Gov. Andrew M. Cuomo of New York, a Democrat, had threatened to penalize hospitals that provided shots to people who are not health care workers. By contrast, Gov. Ron DeSantis of Florida, a Republican, traveled to retirement communities around his state to emphasize the importance of getting people 65 and older, who number more than five million there, immunized fast.

“In Florida we’ve got to put our parents and grandparents first,” Mr. DeSantis said at The Villages, the nation’s largest retirement community, just before Christmas.

Gov. Andrew Cuomo of New YorkCredit…Andrew Kelly/Reuters
Gov. Mike DeWine of OhioCredit…Tony Dejak/Associated Press
Gov. Greg Abbott of TexasCredit…Eric Gay/Associated Press
Gov. Larry Hogan of MarylandCredit…Jonathan Ernst/Reuters

Decisions on how soon to expand eligibility for the shots have not fallen neatly along partisan lines.


Covid-19 Vaccines ›


Answers to Your Vaccine Questions

While the exact order of vaccine recipients may vary by state, most will likely put medical workers and residents of long-term care facilities first. If you want to understand how this decision is getting made, this article will help.

Life will return to normal only when society as a whole gains enough protection against the coronavirus. Once countries authorize a vaccine, they’ll only be able to vaccinate a few percent of their citizens at most in the first couple months. The unvaccinated majority will still remain vulnerable to getting infected. A growing number of coronavirus vaccines are showing robust protection against becoming sick. But it’s also possible for people to spread the virus without even knowing they’re infected because they experience only mild symptoms or none at all. Scientists don’t yet know if the vaccines also block the transmission of the coronavirus. So for the time being, even vaccinated people will need to wear masks, avoid indoor crowds, and so on. Once enough people get vaccinated, it will become very difficult for the coronavirus to find vulnerable people to infect. Depending on how quickly we as a society achieve that goal, life might start approaching something like normal by the fall 2021.

Yes, but not forever. The two vaccines that will potentially get authorized this month clearly protect people from getting sick with Covid-19. But the clinical trials that delivered these results were not designed to determine whether vaccinated people could still spread the coronavirus without developing symptoms. That remains a possibility. We know that people who are naturally infected by the coronavirus can spread it while they’re not experiencing any cough or other symptoms. Researchers will be intensely studying this question as the vaccines roll out. In the meantime, even vaccinated people will need to think of themselves as possible spreaders.

The Pfizer and BioNTech vaccine is delivered as a shot in the arm, like other typical vaccines. The injection won’t be any different from ones you’ve gotten before. Tens of thousands of people have already received the vaccines, and none of them have reported any serious health problems. But some of them have felt short-lived discomfort, including aches and flu-like symptoms that typically last a day. It’s possible that people may need to plan to take a day off work or school after the second shot. While these experiences aren’t pleasant, they are a good sign: they are the result of your own immune system encountering the vaccine and mounting a potent response that will provide long-lasting immunity.

No. The vaccines from Moderna and Pfizer use a genetic molecule to prime the immune system. That molecule, known as mRNA, is eventually destroyed by the body. The mRNA is packaged in an oily bubble that can fuse to a cell, allowing the molecule to slip in. The cell uses the mRNA to make proteins from the coronavirus, which can stimulate the immune system. At any moment, each of our cells may contain hundreds of thousands of mRNA molecules, which they produce in order to make proteins of their own. Once those proteins are made, our cells then shred the mRNA with special enzymes. The mRNA molecules our cells make can only survive a matter of minutes. The mRNA in vaccines is engineered to withstand the cell’s enzymes a bit longer, so that the cells can make extra virus proteins and prompt a stronger immune response. But the mRNA can only last for a few days at most before they are destroyed.

Gov. Larry Hogan of Maryland, a Republican, announced Tuesday that he would immediately switch to what he called the “Southwest Airlines model” for vaccine allocation, referring to the airline’s open seating policy. “We’re no longer going to be waiting for all the members of a particular priority group to be completed,” he said, “before we move on to begin the next group in line.”

Gov. Mike DeWine of Ohio, a Republican, urged patience in a news briefing Tuesday as he declined to estimate when the state would start vaccinating people beyond the first priority group, known as “1a.”

“We’re asking every health department, ‘Don’t go outside 1a, stay within your lane,’” he said, adding about the vaccines, “This is a scarce commodity.”

By Thursday Mr. DeWine had set a date for people 80 and older to start getting the vaccine — Jan. 19 — and said he would phase in everyone 65 and older, as well as teachers, by Feb. 8.

The reasons so many doses received by states have not yet been administered to the first priority group are manifold. The fact that vaccination began around Christmas, when many hospital employees were taking vacation, slowed things. More health care workers are refusing to get the vaccine than many of their employers expected, and some hospitals and clinics received more doses than they needed but felt constrained by state rules from giving them to people outside the first priority groups. Some initially worried they could not even offer leftover doses in open vials to people in lower priority groups and let them go to waste.

Frontline health care workers and people age 65 and older waited to be vaccinated at a sports complex in Fort Myers, Fla., last month.Credit…Octavio Jones for The New York Times

And federal funding for vaccination efforts has been slow to reach states and localities: They got only $350 million through the end of last year, a little more than $1 per resident of the country. The economic rescue package that Congress passed in December included $8 billion for vaccine distribution that state health officials had long sought, but the first tranche of it, about $3 billion, is only now starting to be sent out.

“There was great funding in the development of these products, great funding in the infrastructure to ship them and get them out,” said Dr. Steven Stack, commissioner of the Kentucky Department for Public Health. “But then there was no funding provided of meaning for administering the vaccine, which is the last mile of this journey.”

The C.D.C. has recommended that a “1b” group consisting of people 75 and older and certain essential workers, including teachers, corrections officers and grocery store employees, be vaccinated next. The second group is much larger, about 50 million people. And the third recommended priority group — people 65 to 74, anyone 16 and older with high-risk medical conditions, and essential workers not already reached — numbers almost 130 million.

Pfizer and Moderna have pledged to deliver enough vaccine doses for 100 million people to each get the two necessary shots by the end of March, and many more in the second quarter. Several other vaccine candidates are far along in the pipeline, and if approved for emergency use here could help ramp up distribution more quickly.

The C.D.C. committee initially considered recommending that a wide range of essential workers get vaccinated before older Americans. Its rationale was that many essential workers are low-wage people of color, who have been hit disproportionately hard by the virus and had limited access to good health care. That sparked a backlash, and several governors, including Mr. DeSantis, quickly made clear they would cater to older people first.

Alex M. Azar, the health and human services secretary, left, and Surgeon General Jerome Adams, right, during a vaccination at George Washington University Hospital on Dec. 14.Credit…Pool photo by Jacquelyn Martin-Pool

Dr. Mark McClellan, who formerly headed the F.D.A. and now runs Duke University’s health policy center, said that while pushing ahead to vaccinate older people and other particularly vulnerable groups would accelerate the overall effort, “we’re going to be missing a lot of higher-risk individuals along the way.”

“I do worry about that becoming uneven in terms of access,” he said during a press briefing, “with lower-income groups, minority groups maybe in a tougher position if we don’t make it very easy for people in these high-risk groups to get vaccinated.”

Dr. Marcus Plescia, the chief medical officer for the Association of State and Territorial Health Officials, said he was surprised to hear federal officials like Mr. Azar and Dr. Jerome Adams, the surgeon general, advocate expanding vaccine access so broadly so soon.

“We didn’t come up with priority populations to slow things down, but because we knew there would be limited numbers of doses,” Dr. Plescia said. “If we try to do this in an equitable, fair way, it’s not going to be as fast as if our only goal is to get vaccine into as many arms as possible.”

Whether or not they are widening access now, governors are ramping up pressure on hospitals to use their allocated doses more quickly. Mr. Cuomo threatened to fine those that did not use their initial allocations by the end of this past week and not send them any more.

Mr. Hogan warned hospitals this past week, “Either use the doses that have been allocated to you or they will be directed to another facility or provider.”

He Was Hospitalized for Covid-19. Then Hospitalized Again. And Again.

Credit…Emily Rose Bennett for The New York Times

He Was Hospitalized for Covid-19. Then Hospitalized Again. And Again.

Significant numbers of coronavirus patients experience long-term symptoms that send them back to the hospital, taxing an already overburdened health system.

Credit…Emily Rose Bennett for The New York Times

Pam Belluck

  • Dec. 30, 2020, 3:00 a.m. ET

The routine things in Chris Long’s life used to include biking 30 miles three times a week and taking courses toward a Ph.D. in eight-week sessions.

But since getting sick with the coronavirus in March, Mr. Long, 54, has fallen into a distressing new cycle — one that so far has landed him in the hospital seven times.

Periodically since his initial five-day hospitalization, his lungs begin filling again; he starts coughing uncontrollably and runs a low fever. Roughly 18 days later, he spews up greenish-yellow fluid, signaling yet another bout of pneumonia.

Soon, his oxygen levels drop and his heart rate accelerates to compensate, sending him to a hospital near his home in Clarkston, Mich., for several days, sometimes in intensive care.

“This will never go away,” he said, describing his worst fear. “This will be my going-forward for the foreseeable future.”

Nearly a year into the pandemic, it’s clear that recovering from Covid-19’s initial onslaught can be an arduous, uneven journey. Now, studies reveal that a significant subset of patients are having to return to hospitals, sometimes repeatedly, with complications triggered by the disease or by the body’s efforts to defeat the virus.

Even as vaccines give hope for stopping the spread of the virus, the surge of new cases portends repeated hospitalizations for more patients, taxing medical resources and turning some people’s path to recovery into a Sisyphean odyssey that upends their lives.

“It’s an urgent medical and public health question,” said Dr. Girish Nadkarni, an assistant professor of medicine at Mount Sinai Hospital in New York, who, with another assistant professor, Dr. Anuradha Lala, is studying readmissions of Covid-19 patients.

Data on rehospitalizations of coronavirus patients are incomplete, but early studies suggest that in the United States alone, tens of thousands or even hundreds of thousands could ultimately return to the hospital.

A study by the Centers for Disease Control and Prevention of 106,543 coronavirus patients initially hospitalized between March and July found that one in 11 was readmitted within two months of being discharged, with 1.6 percent of patients readmitted more than once.

In another study of 1,775 coronavirus patients discharged from 132 V.A. hospitals in the pandemic’s early months, nearly a fifth were rehospitalized within 60 days. More than 22 percent of them needed intensive care, and 7 percent required ventilators.

And in a report on 1,250 patients discharged from 38 Michigan hospitals from mid-March to July, 15 percent were rehospitalized within 60 days.

Recurring admissions don’t just involve patients who were severely ill the first time around.

“Even if they had a very mild course, at least one-third have significant symptomology two to three months out,” said Dr. Eleftherios Mylonakis, chief of infectious diseases at Brown University’s Warren Alpert Medical School and Lifespan hospitals, who co-wrote another report. “There is a wave of readmissions that is building, because at some point these people will say ‘I’m not well.’”

Many who are rehospitalized were vulnerable to serious symptoms because they were over 65 or had chronic conditions. But some younger and previously healthy people have returned to hospitals, too.

When Becca Meyer, 31, of Paw Paw, Mich., contracted the coronavirus in early March, she initially stayed home, nursing symptoms such as difficulty breathing, chest pain, fever, extreme fatigue and hallucinations that included visions of being attacked by a sponge in the shower.

Ms. Meyer, a mother of four, eventually was hospitalized for a week in March and again in April. She was readmitted for an infection in August and for severe nausea in September, according to medical records, which labeled her condition “long haul Covid-19.”

Because she couldn’t hold down food, doctors discharged her with a nasal feeding tube connected to protein-and-electrolyte formula on a pole, which, she said, “I’m supposed to be attached to 20 hours a day.”

Feeding tube issues required hospitalization for nearly three weeks in October and a week in December. She has been unable to resume her job in customer service, spent the summer using a walker, and has had a home health nurse for weeks.

“It’s been a roller coaster since March and I’m now in the downswing of it, where I’m back to being in bed all the time and not being able to eat much, coughing a lot more, having more chest pain,” she said.

Readmissions strain hospital resources, and returning patients may be exposed to new infections or develop muscle atrophy from being bedridden. Mr. Long and Ms. Meyer said they contracted the bacterial infection C. difficile during rehospitalizations.

“Readmissions have been associated, even before Covid, with worse patient outcomes,” Dr. Mylonakis said.

Some research suggests implications for hospitals currently overwhelmed with cases. A Mount Sinai Hospital study of New York’s first wave found that patients with shorter initial stays and those not sick enough for intensive care were more likely to return within two weeks.

Dr. Lala, who co-wrote the study, said the thinking at overstretched hospitals was “we have a lack of resources, so if the patients are stable get them home.” But, she added, “the fact that length of stay was indeed shorter for those patients who return is begging the question of: Were we kicking these people out the door too soon?”

Many rehospitalized patients have respiratory problems, but some have blood clots, heart trouble, sepsis, gastrointestinal symptoms or other issues, doctors report. Some have neurological symptoms like brain fog, “a clear cognitive issue that is evident when they get readmitted,” said Dr. Vineet Chopra, chief of hospital medicine at the University of Michigan, who co-wrote the Michigan study. “It is there, and it is real.”

Dr. Laurie Jacobs, chairwoman of internal medicine at Hackensack University Medical Center, said causes of readmissions vary.

“Sometimes there’s a lot of push to get patients out of the hospital, and they want to get out of the hospital and sometimes they’re not ready,” so they return, she said. But some appropriately discharged patients develop additional problems or return to hospitals because they lack affordable outpatient care.

Antibiotics and other medications belonging to Mr. Long.
Antibiotics and other medications belonging to Mr. Long.Credit…Emily Rose Bennett for The New York Times

Mr. Long’s ordeal began on March 9. “I couldn’t stand up without falling over,” he said.

His primary physician, Dr. Benjamin Diaczok, immediately told him to call an ambulance.

“I crawled out to the front door,” recalled Mr. Long. He was barefoot and remembers sticking out his arm to prop open the door for the ambulance crew, who found him facedown.

He awoke three days later, in the hospital, when he accidentally pulled out the tubes to the ventilator he’d been hooked up to. After two more days, he’d stabilized enough to return to the apartment where he lives alone, an hour north of Detroit.

Mr. Long had some previous health issues, including blood clots in his lungs and legs several years ago and an irregular heartbeat requiring an implanted heart monitor in 2018. Still, before Covid-19, he was “very high-functioning, very energetic,” Dr. Diaczok said.

Now, Mr. Long said: “I’ve got scarred lungs, pulmonary fibrosis, and I’m running right around 75-to-80 percent lung capacity.”

He was rehospitalized in April, May, June, July, August and September, requiring oxygen and intravenous antibiotics, potassium and magnesium.

“Something must have happened to his lungs that is making them more prone for this,” Dr. Diaczok said.

Mr. Long, a former consultant on tank systems for the military, is also experiencing brain fog that’s forced a hiatus from classes toward a Ph.D. in business convergence strategy.

“I read 10 pages in one of my textbooks and then five minutes later, after a phone call, I can’t remember what I read,” he said.

“It’s horrible, ”Dr. Diaczok said. “This is a man that thinks for a living, and he can’t do his job.”

And his heart arrhythmia, controlled since 2018, has resurfaced. Unless Mr. Long, who is 6-foot-7, sleeps at an incline on his couch, his heart skips beats, causing his monitor to prompt middle-of-the-night calls from his doctor’s office. Unable to lie in bed, “I don’t sleep through the night.”

Small exertions — “just to stand up to go do the dishes” — are exhausting. In July, he tried starting physical therapy but was told he wasn’t ready.

In August, he got up too fast, fell and “I was very confused,” he recalled. During that hospital readmission, doctors noted “altered mental status” from dehydration and treated him for pneumonia and functional lung collapse.

In late October, Mr. Long developed pneumonia again, but under Dr. Diaczok’s guidance, managed at home with high-dose oral antibiotics.

In December, when a pulmonologist administered a breathing test, “I couldn’t make it six seconds,” he said.

Mr. Long repeatedly measures his temperature and pulse oxygen, and can feel in his chest when “trouble’s coming,” he said. Determined to recover, he tries to walk short distances. “Can I make it to take out the trash?” he’ll ask himself. On a good day, he’ll walk eight feet to his mailbox.

“I’m going to be around to walk my daughters down the aisle and see my grandkids,” said Mr. Long, voice cracking. “I’m not going to let this thing win.”

Covid-19: How Much Herd Immunity is Enough?

Scientists initially estimated that 60 to 70 percent of the population needed to acquire resistance to the coronavirus to banish it. Now Dr. Anthony Fauci and others are quietly shifting that number upward.

How Much Herd Immunity Is Enough?

How Much Herd Immunity Is Enough?

Scientists initially estimated that 60 to 70 percent of the population needed to acquire resistance to the coronavirus to banish it. Now Dr. Anthony Fauci and others are quietly shifting that number upward.

Dr. Anthony S. Fauci in March. “We really don’t know what the real number is,” he said recently.
Dr. Anthony S. Fauci in March. “We really don’t know what the real number is,” he said recently.Credit…Doug Mills/The New York Times
Donald G. McNeil Jr.

  • Dec. 24, 2020, 5:00 a.m. ET

At what point does a country achieve herd immunity? What portion of the population must acquire resistance to the coronavirus, either through infection or vaccination, in order for the disease to fade away and life to return to normal?

Since the start of the pandemic, the figure that many epidemiologists have offered has been 60 to 70 percent. That range is still cited by the World Health Organization and is often repeated during discussions of the future course of the disease.

Although it is impossible to know with certainty what the limit will be until we reach it and transmission stops, having a good estimate is important: It gives Americans a sense of when we can hope to breathe freely again.

Recently, a figure to whom millions of Americans look for guidance — Dr. Anthony S. Fauci, an adviser to both the Trump administration and the incoming Biden administration — has begun incrementally raising his herd-immunity estimate.

In the pandemic’s early days, Dr. Fauci tended to cite the same 60 to 70 percent estimate that most experts did. About a month ago, he began saying “70, 75 percent” in television interviews. And last week, in an interview with CNBC News, he said “75, 80, 85 percent” and “75 to 80-plus percent.”

In a telephone interview the next day, Dr. Fauci acknowledged that he had slowly but deliberately been moving the goal posts. He is doing so, he said, partly based on new science, and partly on his gut feeling that the country is finally ready to hear what he really thinks.

Hard as it may be to hear, he said, he believes that it may take close to 90 percent immunity to bring the virus to a halt — almost as much as is needed to stop a measles outbreak.

Asked about Dr. Fauci’s conclusions, prominent epidemiologists said that he might be proven right. The early range of 60 to 70 percent was almost undoubtedly too low, they said, and the virus is becoming more transmissible, so it will take greater herd immunity to stop it.

Dr. Fauci said that weeks ago, he had hesitated to publicly raise his estimate because many Americans seemed hesitant about vaccines, which they would need to accept almost universally in order for the country to achieve herd immunity.

Now that some polls are showing that many more Americans are ready, even eager, for vaccines, he said he felt he could deliver the tough message that the return to normal might take longer than anticipated.

“When polls said only about half of all Americans would take a vaccine, I was saying herd immunity would take 70 to 75 percent,” Dr. Fauci said. “Then, when newer surveys said 60 percent or more would take it, I thought, ‘I can nudge this up a bit,’ so I went to 80, 85.

“We need to have some humility here,” he added. “We really don’t know what the real number is. I think the real range is somewhere between 70 to 90 percent. But, I’m not going to say 90 percent.”

Doing so might be discouraging to Americans, he said, because he is not sure there will be enough voluntary acceptance of vaccines to reach that goal. Although sentiments about vaccines in polls have bounced up and down this year, several current ones suggest that about 20 percent of Americans say they are unwilling to accept any vaccine.

Also, Dr. Fauci noted, a herd-immunity figure at 90 percent or above is in the range of the infectiousness of measles.

“I’d bet my house that Covid isn’t as contagious as measles,” he said.

Measles is thought to be the world’s most contagious disease; it can linger in the air for hours or drift through vents to infect people in other rooms. In some studies of outbreaks in crowded military barracks and student dormitories, it has kept transmitting until more than 95 percent of all residents are infected.

Interviews with epidemiologists regarding the degree of herd immunity needed to defeat the coronavirus produced a range of estimates, some of which were in line with Dr. Fauci’s. They also came with a warning: All answers are merely “guesstimates.”

“You tell me what numbers to put in my equations, and I’ll give you the answer,” said Marc Lipsitch, an epidemiologist at Harvard’s T.H. Chan School of Public Health. “But you can’t tell me the numbers, because nobody knows them.”

The only truly accurate measures of herd immunity are done in actual herds and come from studying animal viruses like rinderpest and foot-and-mouth disease, said Dr. David M. Morens, Dr. Fauci’s senior adviser on epidemiology at the National Institute of Allergy and Infectious Diseases.

When cattle are penned in corrals, it is easy to measure how fast a disease spreads from one animal to another, he said. Humans move around, so studying disease spread among them is far harder.

The original assumption that it would take 60 to 70 percent immunity to stop the disease was based on early data from China and Italy, health experts noted.

Epidemiologists watching how fast cases doubled in those outbreaks calculated that the virus’s reproduction number, or R0 — how many new victims each carrier infected — was about 3. So two out of three potential victims would have to become immune before each carrier infected fewer than one. When each carrier infects fewer than one new victim, the outbreak slowly dies out.

Two out of three is 66.7 percent, which established the range of 60 to 70 percent for herd immunity.

The French aircraft carrier Charles de Gaulle arriving in the port of Toulon in April, carrying infected sailors.
The French aircraft carrier Charles de Gaulle arriving in the port of Toulon in April, carrying infected sailors.Credit… Marine Nationale, via Agence France-Presse — Getty Images

Reinforcing that notion was a study conducted by the French military on the crew of the aircraft carrier Charles de Gaulle, which had an outbreak in late March, said Dr. Christopher J.L. Murray, director of the University of Washington’s Institute for Health Metrics and Evaluation.

The study found that 1,064 of the 1,568 sailors aboard, or about 68 percent, had tested positive for the virus.

But the carrier returned to port while the outbreak was still in progress, and the crew went into quarantine, so it was unclear whether the virus was finished infecting new sailors even after 68 percent had caught it.

Also, outbreaks aboard ships are poor models for those on land because infections move much faster in the close quarters of a vessel than in a free-roaming civilian population, said Dr. Natalie E. Dean, a biostatistician at the University of Florida.

More important, the early estimates from Wuhan and Italy were later revised upward, Dr. Lipsitch noted, once Chinese scientists realized they had undercounted the number of victims of the first wave. It took about two months to be certain that there were many asymptomatic people who had also spread the virus.

It also became clearer later that “superspreader events,” in which one person infects dozens or even hundreds of others, played a large role in spreading Covid-19. Such events, in “normal” populations — in which no one wears masks and everyone attends events like parties, basketball tournaments or Broadway shows — can push the reproduction number upward to 4, 5 or even 6, experts said. Consequently, those scenarios call for higher herd immunity; for example, at an R0 of 5, more than four out of five people, or 80 percent, must be immune to slow down the virus.

Further complicating matters, there is a growing consensus among scientists that the virus itself is becoming more transmissible. A variant “Italian strain” with the mutation known as D614G has spread much faster than the original Wuhan variant. A newly identified mutation, sometimes called N501Y, that may make the virus even more infectious has recently appeared in Britain, South Africa and elsewhere.

The more transmissible a pathogen, the more people must become immune in order to stop it.

Dr. Morens and Dr. Lipsitch agreed with Dr. Fauci that the level of herd immunity needed to stop Covid-19 could be 85 percent or higher. “But that’s a guesstimate,” Dr. Lipsitch emphasized.

“Tony’s reading the tea leaves,” Dr. Morens said.

The Centers for Disease Control and Prevention offers no herd immunity estimate, saying on its website that “experts do not know.”

Although W.H.O. scientists still sometimes cite the older 60 to 70 percent estimate, Dr. Katherine O’Brien, the agency’s director of immunization, said that she now thought that range was too low. She declined to estimate what the correct higher one might be.

“We’d be leaning against very thin reeds if we tried to say what level of vaccine coverage would be needed to achieve it,” she said. “We should say we just don’t know. And it won’t be a world or even national number. It will depend on what community you live in.”

Dr. Dean noted that to stop transmission in a crowded city like New York, more people would have to achieve immunity than would be necessary in a less crowded place like Montana.

Even if Dr. Fauci is right and it will take 85 or even 90 percent herd immunity to completely stop coronavirus transmission, Dr. Lipsitch said, “we can still defang the virus sooner than that.”

He added: “We don’t have to have zero transmission in order to have a decent society. We have lots of diseases, like flu, transmitting all the time, and we don’t shut down society for that. If we can vaccinate almost all the people who are most at risk of severe outcomes, then this would become a milder disease.”

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Frontline Workers and People Over 74 Should Get Shots Next, CDC Panel Says

Frontline Workers and People Over 74 Should Get Shots Next, CDC Panel Says

The recommendation was a compromise aimed at getting the coronavirus vaccine to the most vulnerable of two high-risk groups.

Director of nursing education Loraine Hopkins Pepe, left, administers the Pfizer BioNTech COVID-19 vaccine to Dr. Richard Fine, head of anesthesiology, at Einstein Medical Center in Philadelphia, PA.
Director of nursing education Loraine Hopkins Pepe, left, administers the Pfizer BioNTech COVID-19 vaccine to Dr. Richard Fine, head of anesthesiology, at Einstein Medical Center in Philadelphia, PA.Credit…Hannah Yoon for The New York Times
  • Dec. 20, 2020, 3:40 p.m. ET

Striking a compromise between two high-risk population groups, a panel advising the Centers for Disease Control and Prevention voted Sunday to recommend that people 75 and older be next in line to receive the coronavirus vaccine in the United States, along with about 30 million “frontline essential workers,” including emergency responders, teachers and grocery store employees.

The debate about who should receive the vaccine in these early months has grown increasingly urgent as the daily tally of cases has swelled to numbers unimaginable even a month ago. The country has already begun vaccinating health care workers, and on Monday, CVS and Walgreens were to begin a mass vaccination campaign at the nation’s nursing homes and long-term care facilities. This week roughly six million doses of the newly authorized Moderna vaccine are to start arriving at more than 3,700 locations around the country, including many smaller and rural hospitals.

The panel of doctors and public health experts had previously indicated it would recommend a much broader group of Americans defined as essential workers — about 87 million people with jobs designated by a division of the Department of Homeland Security as critical to keeping society functioning — as the next priority population and that elderly people who live independently should come later.

But in hours of discussion on Sunday, the committee members concluded that given the limited initial supply of vaccine and the higher Covid-19 death rate among elderly Americans, it made more sense to allow the oldest among them to go next along with workers at the highest risk of exposure to the virus.

Groups of essential workers, such as construction and food service workers, the committee said, would be eligible for the next wave. Members did clarify that local organizations had great flexibility to make those determinations.

“I feel very strongly we do need to have that balance of saving lives and keeping our infrastructure in place,” said Dr. Helen Talbot, a member of the panel and infectious-disease specialist at Vanderbilt University.

Together, the two groups the committee voted to prioritize on Sunday number about 51 million people; federal health officials have estimated that there should be enough vaccine supply to inoculate all of them before the end of February.

Still, as the first week of vaccinations in the U.S. came to a close, frustrations were flaring about the pace of distribution. Some 128,000 shots had been given in the as of Friday, according to a New York Times database tracking vaccinations — a total that was just slightly more than half the number of new cases reported across the country that same day.

This weekend Gen. Gustave F. Perna, who heads the Trump administration’s distribution effort, apologized for more than a dozen states learning at the last minute that they would receive fewer doses next week of the vaccine manufactured by Pfizer than they had expected. Tensions were also broiling in some states over local decisions regarding which health care workers should get their shots immediately and which should wait.

The director of the C.D.C., Dr. Robert Redfield, will review the panel’s recommendation and decide, likely by Monday, whether to embrace it as the agency’s official guidance to states. The panel, the Advisory Committee on Immunization Practices, emphasized that its recommendations were nonbinding and that every state would be able to fine-tune or adjust them to serve the unique needs of its population.

The 13-to-1 vote came as frustrations flared about the pace of vaccine distribution. Some 128,000 shots have been given in the first five days of the vaccine United States, according to a New York Times database tracking vaccinations — just slightly more than half the number of new cases reported across the country on Friday alone. This weekend, Gen. Gustave F. Perna, who heads the Trump administration’s distribution effort, apologized for at least 14 states learning at the last minute that they would receive fewer doses of the vaccine manufactured by Pfizer next week than they had expected. Tensions were also flaring in some states over local decisions regarding which health care workers should get their shots immediately, and which should wait.

In addition to teachers, firefighters and police, a subgroup of the committee suggested that “frontline essential workers” should include school support staff; day care, corrections personnel, public transit, grocery store and postal workers; and those in working in food production and manufacturing. But the group’s official recommendation is not that specific.

Originally, the committee had signaled last month that they had been inclined to let 87 million essential workers receive vaccines ahead of adults 65 and older. Many had expressed their alarm that essential workers, who are often low-wage people of color, were being hit disproportionately hard by the virus and additionally were disadvantaged because of their lesser access to good health care.

general population.”

How Effective Is the Mask You’re Wearing? You May Know Soon

A C.D.C. division is working with an industry standards group to develop filtration standards — and products that meet them will be able to carry labels saying so.

Fears of a ‘Twindemic’ Recede as Flu Lies Low

Fears of a ‘Twindemic’ Recede as Flu Lies Low

Despite early worries, flu patients are not competing with Covid-19 patients for ventilators, and the threat of dueling outbreaks may be waning.

A free flu shot administered at Comerica Park in Detroit, Mich., last month.
A free flu shot administered at Comerica Park in Detroit, Mich., last month.Credit…Seth Herald/Agence France-Presse — Getty Images
Donald G. McNeil Jr.

  • Dec. 13, 2020, 5:00 a.m. ET

Despite the horrifying surge of Covid-19 cases and deaths in the United States right now, one bit of good news is emerging this winter: It looks unlikely that the country will endure a “twindemic” of both flu and the coronavirus at the same time.

That comes as a profound relief to public health officials who predicted as far back as April that thousands of flu victims with pneumonia could pour into hospitals this winter, competing with equally desperate Covid-19 pneumonia victims for scarce ventilators.

“Overall flu activity is low, and lower than we usually see at this time of year,” said Dr. Daniel B. Jernigan, director of the influenza division of the Centers for Disease Control and Prevention. “I don’t think we can definitively say there will be no twindemic; I’ve been working with flu for a long time, and I’ve been burned. But flu is atypically low.”

Since September, the C.D.C. “FluView” — its weekly report on influenza surveillance — has shown all 50 states in shades of green and chartreuse, indicating “minimal” or “low” flu activity. Normally by December, at least some states are painted in oranges and reds for “moderate” and “high.”

(For one puzzling week in November, Iowa stood out in dark burgundy, indicating “very high” flu levels. But that turned out to be a reporting error, Dr. Jernigan said.)

Of 232,452 swabs from across the country that have been tested for flu, only 496, or 0.2 percent, have come up positive.

That has buoyed the spirits of flu experts.

Dr. William Schaffner, medical director for the National Foundation for Infectious Diseases, which promotes flu shots, said he was recently on a telephone discussion with other preventive medicine specialists. “Everybody was in quiet awe about how low flu is,” he said. “Somebody said: ‘Shh, don’t talk about it. The virus will hear us.’”

Flu numbers are likely to remain low for many more weeks, predicted Kinsa Health, a company that uses cellphone-connected thermometers and historical databases to forecast flu trends.

“Going forward, we don’t expect influenza-like illness to go high,” said Inder Singh, Kinsa’s founder and chief executive. “It looks like the twindemic isn’t going to happen.”

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By The New York Times | Source: Kinsa

A combination of factors is responsible for the remarkably quiet flu season, experts said.

In the Southern Hemisphere, where winter stretches from June through August, widespread mask-wearing, rigorous lockdowns and other precautions against Covid-19 transmission drove flu down to record-low levels. Southern Hemisphere countries help “reseed” influenza viruses in the Northern Hemisphere each year, Dr. Jernigan said.

Also, to keep Covid-19 out, New Zealand and Australia have closed their borders either to all noncitizens or to Americans, so there has been very little air traffic from those Southern Hemisphere countries.

In the United States, the cancellation of large indoor gatherings, closings of schools and use of masks to prevent coronavirus transmission have also driven down levels of all respiratory diseases, including influenza.

In addition, Dr. Jernigan said, a “phenomenal number” of flu shots were manufactured and shipped to pharmacies, hospitals and doctors’ office in August, a month earlier than usual.

As of late November, 188 million doses had been shipped; the old record was 175 million doses shipped last year. Spot shortages were quickly reported in some cities, so experts assumed that large numbers of Americans took them.

However, there is not yet enough data to confirm that assumption. According to a preliminary tally released Dec. 9, about 70 million adults had received the shots through pharmacies or doctors’ offices as of mid-November, compared with 58 million last year.

Although that appears to be a substantial increase, the C.D.C. does not know how many Americans who normally get their flu shots at work were unable to do so this year because of stay-at-home orders, said Dr. Ram Koppaka, the agency’s associate director for adult immunization. There was a big increase in flu shots delivered by pharmacies, and that may represent people who normally would have received the shots at work.

“The best we can say is that it appears that we are now about where we were last year,” Dr. Koppaka said.

Given that vaccines were available early, he added: “I’m disappointed that it’s not better than it is. We need to keep telling people that it’s not too late to get a flu shot.”

Normally, about 80 percent of all adults who get flu shots have had them by the end of November. But about nine million doses of vaccines that were meant for uninsured adults, and which the federal government purchased this year out of fear of a “twindemic,” are still being delivered, Dr. Koppaka said.

The finally tally of how many shots were taken will not be available until summer, after the flu season is over, he said.

Nonetheless, even the preliminary data showed disturbing trends in two important target groups: pregnant women and children. Only 54 percent of pregnant women have received flu vaccine this year, compared with 58 percent by this time last year. And, although about 48 percent of all children got flu shots both last year and this year, the percentage of Black children who got them dropped substantially this year, by 11 percentage points.

Dr. Koppaka said he could not yet account for those drops in coverage. Pregnant women might have been afraid to go to doctors or pharmacies for fear of getting Covid-19, and many Black children might have been missed because public schools that offer vaccines were closed — but that was just speculation, he emphasized.

Although Dr. Koppaka strongly encouraged unvaccinated Americans to get flu shots, the threat of a two-headed pandemic monster appears to be fading.

Because of the coronavirus pandemic, the C.D.C. is not currently posting forecasts on its FluSight page, where it predicts the future course of the flu season.

Kinsa Health, by contrast, is predicting that flu will stay at historic lows through February, when the season typically peaks. The company has a record of accurately predicting flu seasons several weeks ahead of the C.D.C.

C.D.C. surveillance data is based on weekly reports from doctors’ offices and hospitals noting the percentage of patient visits that are for flu symptoms. Because there are delays in reporting, sometimes for weeks, there is a lag between the time a flu arrives in a county and the agency’s confirmation that it is there.

Also, people who catch flu but never see a doctor are not captured in the C.D.C.’s surveillance net. People avoid doctors for many reasons, including a lack of insurance or because, this year, they are afraid of catching the coronavirus.

Kinsa receives about 100,000 readings each day from about two million thermometers connected to smartphones; the company claims it can detect local fever spikes down to the ZIP code level.

Both Covid-19 and flu can drive up the number of reported fevers, but flu outbreaks can be distinguished from Covid ones, Mr. Singh said.

The company has access to decades of historical flu data from 600 cities across the country, and there are patterns to how flu typically spreads in each city based on climate and population density, said Samuel D. Chamberlain, the company’s chief data scientist.

Also, because everyone is susceptible to the new coronavirus, Covid fevers surge and spread much faster across ZIP codes than do those caused by colds and flu, Mr. Singh said.

Moreover, users are asked to enter all their symptoms in the Kinsa app. Loss of smell and taste is a common Covid-19 symptom. Making things even simpler, the app asks users if they have had a positive coronavirus or flu test.

Currently, flu is at less than half its typical level for early December, Mr. Singh said. By February, when cases typically shoot to a sharp peak, its numbers should be down to about one-quarter of a typical seasonal apex, he predicted.

“In theory, the flu virus could be taking a year off,” said Dr. Arthur Reingold, head of epidemiology at the School of Public Health of the University of California, Berkeley.

He recently asked a friend who was treating Covid-19 cases at the University of California, San Francisco, hospital how many flu cases she had seen this year.

“The answer was zero,” he said. “That’s a relief, and certainly a relief to my friends who do clinical work.”

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The Elderly vs. Essential Workers: Who Should Get the Coronavirus Vaccine First?

The Elderly vs. Essential Workers: Who Should Get the Coronavirus Vaccine First?

The C.D.C. will soon decide which group to recommend next, and the debate over the trade-offs is growing heated. Ultimately, states will decide whom to include.

The Department of Homeland Security’s list of essential workers is long and varied, including jobs such as tugboat operators and these grocery store clerks in Brooklyn.
The Department of Homeland Security’s list of essential workers is long and varied, including jobs such as tugboat operators and these grocery store clerks in Brooklyn.Credit…Juan Arredondo for The New York Times
  • Dec. 5, 2020, 10:41 a.m. ET

With the coronavirus pandemic surging and initial vaccine supplies limited, the United States faces a hard choice: Should the country’s immunization program focus in the early months on the elderly and people with serious medical conditions, who are dying of the virus at the highest rates, or on essential workers, an expansive category encompassing Americans who have borne the greatest risk of infection?

Health care workers and the frailest of the elderly — residents of long-term-care facilities — will almost certainly get the first shots, under guidelines the Centers for Disease Control and Prevention issued on Thursday. But with vaccination expected to start this month, the debate among federal and state health officials about who goes next, and lobbying from outside groups to be included, is growing more urgent.

It’s a question increasingly guided by concerns over the inequities laid bare by the pandemic, from disproportionately high rates of infection and death among poor people and people of color to disparate access to testing, child care and technology for online schooling.

“It’s damnable that we are even being placed in this position that we have to make these choices,” said the Rev. William J. Barber II, a co-chairman of the Poor People’s Campaign, a national coalition that calls attention to the challenges of the working poor. “But if we have to make the choice, we cannot once again leave poor and low-wealth essential workers to be last.”

Ultimately, the choice comes down to whether preventing death or curbing the spread of the virus and returning to some semblance of normalcy is the highest priority. “If your goal is to maximize the preservation of human life, then you would bias the vaccine toward older Americans,” Dr. Scott Gottlieb, the former Food and Drug Administration commissioner, said recently. “If your goal is to reduce the rate of infection, then you would prioritize essential workers. So it depends what impact you’re trying to achieve.”

The trade-off between the two is muddied by the fact that the definition of “essential workers” used by the C.D.C. comprises nearly 70 percent of the American work force, sweeping in not just grocery store clerks and emergency responders, but tugboat operators, exterminators and nuclear energy workers. Some labor economists and public health officials consider the category overbroad and say it should be narrowed to only those who interact in person with the public.

Essential and Frontline Occupations

About 70 percent of workers in the U.S. have jobs that are considered essential. A subset are considered “frontline” workers, meaning their jobs cannot be performed from home. Hover or tap to see each job.

Essential

Frontline

By Matthew Conlen·Note: States may have differing definitions of essential workers. | Sources: Labor Market Information Institute, Council for Community and Economic Research, National Bureau of Economic Research, U.S. Bureau of Labor Statistics, Cybersecurity and Infrastructure Security Agency

An independent committee of medical experts that advises the C.D.C. on immunization practices will soon vote on whom to recommend for the second phase of vaccination — “Phase 1b.” In a meeting last month, all voting members of the committee indicated support for putting essential workers ahead of people 65 and older and those with high-risk health conditions.

Historically, the committee relied on scientific evidence to inform its decisions. But now the members are weighing social justice concerns as well, noted Lisa A. Prosser, a professor of health policy and decision sciences at the University of Michigan.

“To me the issue of ethics is very significant, very important for this country,” Dr. Peter Szilagyi, a committee member and a pediatrics professor at the University of California, Los Angeles, said at the time, “and clearly favors the essential worker group because of the high proportion of minority, low-income and low-education workers among essential workers.”

That position runs counter to frameworks proposed by the World Health Organization, the National Academies of Sciences, Engineering, and Medicine, and many countries, which say that reducing deaths should be the unequivocal priority and that older and sicker people should thus go before the workers, a view shared by many in public health and medicine.

Dr. Robert Redfield, the C.D.C. director and the nation’s top public health official, reminded the advisory committee of the importance of older people, saying in a statement on Thursday that he looked forward to “future recommendations that, based on vaccine availability, demonstrate that we as a nation also prioritize the elderly.”

Once the committee votes, Dr. Redfield will decide whether to accept its recommendations as the official guidance of the agency. Only rarely does a C.D.C. director reject a recommendation from the committee, whose 14 members are selected by the Health and Human Services secretary, serve four-and-a-half-year terms and have never confronted a task as high in profile as this one.

But ultimately, the decision will be up to governors and state and local health officials. They are not required to follow C.D.C. guidelines, though historically they have done so.

Defining ‘essential’

The drive-through window at a fast food restaurant in Albuquerque. Food service workers have high rates of infection from the coronavirus.
The drive-through window at a fast food restaurant in Albuquerque. Food service workers have high rates of infection from the coronavirus.Credit…Adria Malcolm for The New York Times

There are about 90 million essential workers nationwide, as defined by a division of the Department of Homeland Security that compiled a roster of jobs that help maintain critical infrastructure during a pandemic. That list is long, and because there won’t be enough doses to reach everyone at first, states are preparing to make tough decisions: Louisiana’s preliminary plan, for example, puts prison guards and food processing workers ahead of teachers and grocery employees. Nevada’s prioritizes education and public transit workers over those in retail and food processing.

Share of workers in essential and frontline jobs, by state

By Matthew Conlen·Note: States may have different definitions of essential workers. | Sources: Labor Market Information Institute, Council for Community and Economic Research, National Bureau of Economic Research, U.S. Bureau of Labor Statistics, Cybersecurity and Infrastructure Security Agency

At this early point, many state plans put at least some people who are older and live independently, or people who have medical conditions, ahead of most essential workers, though that could change after the C.D.C. committee makes a formal recommendation on the next phase.

One occupation whose priority is being hotly debated is teaching. The C.D.C. includes educators as essential workers. But not everyone agrees with that designation.

Marc Lipsitch, an infectious-disease epidemiologist at Harvard’s T.H. Chan School of Public Health, argued that teachers should not be included as essential workers, if a central goal of the committee is to reduce health inequities.

“Teachers have middle-class salaries, are very often white, and they have college degrees,” he said. “Of course they should be treated better, but they are not among the most mistreated of workers.”

Elise Gould, a senior economist at the Economic Policy Institute, disagreed. Teachers not only ensure that children don’t fall further behind in their education, she said, but are also critical to the work force at large.

An empty classroom in Ohio. Public health experts disagree on whether teachers should get a top priority for the vaccine.Credit…Kyle Grillot/Reuters

“When you talk about disproportionate impact and you’re concerned about people getting back into the labor force, many are mothers, and they will have a harder time if their children don’t have a reliable place to go,” she said. “And if you think generally about people who have jobs where they can’t telework, they are disproportionately Black and brown. They’ll have more of a challenge when child care is an issue.”

In September, academic researchers analyzed the Department of Homeland Security’s list of essential workers and found that it broadly mirrored the demographics of the American labor force. The researchers proposed a narrower, more vulnerable category — “frontline workers,” such as food deliverers, cashiers and emergency medical technicians, who must work face to face with others and are thus at greater risk of contracting the virus.

By this definition, said Francine D. Blau, a labor economist at Cornell University and an author of the study, teachers belong in the larger category of essential workers. However, when they work in classrooms rather than remotely, she said, would they fit into the “frontline” group. Individual states categorize teachers differently.

Dr. Blau said that if supplies are short, frontline workers should be emphasized. “These are a subset of essential workers who, given the nature of their jobs, must provide their labor in person. Prioritizing them makes sense given the heightened risk that they face.”

The analysis, a working paper for the National Bureau of Economic Research, is in line with other critics, who say that the list of essential workers is too wide-ranging.

“If groups are too large, then you’re not really focusing on priorities,” said Saad B. Omer, director of the Yale Institute for Global Health, who worked on the vaccination frameworks for the W.H.O. and the National Academies.

The essential workers on the federal list make up nearly 70 percent of the American labor force, the researchers said, compared with 42 percent for the frontline workers. Women made up 39 percent of frontline workers and, in certain occupations, far more. Frontline workers’ education levels are lower, as are their wages — on average, just under $22 an hour. The proportion of Black and Hispanic workers is higher than in the broader category of essential workers.

Death vs. transmission

A nursing home resident in Brooklyn being taken to a hospital last April. The C.D.C. recommends that residents of long-term care facilities, along with health care workers, get the very first vaccines.Credit…Lucas Jackson/Reuters

Some health policy experts said that to prioritize preventing deaths rather than reducing virus transmission was simply a pragmatic choice, because there won’t be enough vaccine initially available to make a meaningful dent in contagion. A more effective use of limited quantities, they say, is to save the lives of the most frail.

Moreover, vaccine trial results so far show only that the shots can protect the individuals who receive them. The trials have not yet demonstrated that a vaccinated person would not infect others. Though scientists believe that is likely to be the case, it has yet to be proved.

Harald Schmidt, an expert in ethics and health policy at the University of Pennsylvania, said that it is reasonable to put essential workers ahead of older adults, given their risks, and that they are disproportionately minorities. “Older populations are whiter, ” Dr. Schmidt said. “Society is structured in a way that enables them to live longer. Instead of giving additional health benefits to those who already had more of them, we can start to level the playing field a bit.”

But to protect older people more at risk, he called on the C.D.C. committee to also integrate the agency’s own “social vulnerability index.”

The index includes 15 measures derived from the census, such as overcrowded housing, lack of vehicle access and poverty, to determine how urgently a community needs health support, with the goal of reducing inequities.

In a new analysis of the states’ preliminary vaccine plans, Dr. Schmidt found that at least 18 states intended to apply the index. Tennessee, for one, has indicated that it will reserve some of its early allotments for disadvantaged communities.

Still, some people believe it is wrong to give racial and socioeconomic equity more weight than who is most likely to die.

“They need to have bombproof, fact-based, public-health-based reasons for why one group goes ahead of another,” said Chuck Ludlam, a former Senate aide and biotech industry lobbyist who protested putting essential workers ahead of older people in comments to the committee. “They have provided no explanation here that will withstand public scrutiny.”

Blurred lines, many unknowns

Employees of the Four Seasons Rehabilitation and Nursing in Westland, Mich., demonstrated for better pay and protections during an outbreak of Covid-19 in October.Credit…Emily Elconin/Reuters

Further complicating matters, the different priority groups discussed by the C.D.C. committee are overlapping — many essential workers have high-risk conditions, and some are older than 65. Some states have suggested that they will prioritize only essential workers who come face to face with the public, while others have not prioritized them at all.

Even some people whose allegiance lies with one group have made the case that others should have an earlier claim on the vaccine. Marc Perrone, president of the United Food and Commercial Workers Union, which represents 1.3 million grocery and food processing workers, said that despite the high rate of infection among his members, he thought that older adults should go first.

“Here’s the thing: Everybody’s got a grandmother or grandfather,” Mr. Perrone said. “And I do believe almost everybody in this country would want to protect them, or their aging parents.”

But Dr. Nirav Shah, Maine’s top public health official, said he respectfully disagreed, repeating the explanation he had given his in-laws — who are older but in good health and able to socially distance.

He said: “I’ve told them: ‘You know what? I’m sorry, but there are others that I need to get this vaccine to first, so that when you guys get vaccinated, the world you come back into is ready to receive you.’”

All these plans are, of course, unfurling with essential information still unknown.Many state officials said that as on-the-ground realities emerge, they fully expect their plans to evolve.

One uncertainty: given the high rates of apprehension swirling around this vaccine, how many people in the early groups will actually line up for it?

“If a high proportion of essential workers decline to get the vaccine, states will have to quickly move onto the next group anyway,” said Dr. Prosser, the University of Michigan health analyst. “Because once the vaccines arrive, they will have to be used in a certain amount of time before they degrade.”

Additional work by Jugal K. Patel.

C.D.C. Officials Shorten Recommended Quarantine Periods

C.D.C. Officials Shorten Recommended Quarantine Periods

The agency also urged Americans to stay home during the coming holidays, and to get tested if they do travel.

Signage on California’s Highway 99 advised people to stay home to avoid Covid-19 last month.
Signage on California’s Highway 99 advised people to stay home to avoid Covid-19 last month.Credit…Peter Dasilva/EPA, via Shutterstock
Roni Caryn Rabin

By

  • Dec. 2, 2020, 5:03 p.m. ET

Federal health officials on Wednesday effectively shortened quarantine periods for those who may have been exposed to the coronavirus, hoping to improve compliance among Americans and reduce the economic and psychological toll of long periods of seclusion.

Citing the spiraling number of infections nationwide, officials at the Centers for Disease Control and Prevention also urged Americans again to avoid travel over the holiday season.

“The C.D.C. recommends the best way to protect yourself and others is to postpone travel and stay home,” Dr. Henry Walke, who oversees day-to-day management of pandemic response at the agency, said at a news briefing.

People who choose to travel over the holiday season despite the warnings should consider getting tested for coronavirus infection one to three days before their trip, and again three to five days after return, Dr. Walke and other officials said.

It is the first time the agency has urged testing for domestic travelers; until now, testing was recommended only for Americans traveling internationally. Dr. Walke noted that testing before and after travel “does not eliminate all risk.”

Travelers returning home should keep nonessential activities to a minimum for at least seven days if they are getting tested, and for 10 days if they are not getting tested. (Many states already require travelers to self-quarantine after arrival, though the rules vary from state to state.)

Federal health officials also offered two new ways to shorten quarantine periods. Those without symptoms may end quarantine after seven days if they are tested for the virus and receive a negative result, or after 10 days without a negative test.

P.C.R. or rapid tests are both acceptable, the officials said, and should be taken within 48 hours of the end of the quarantine period. People should continue to watch for symptoms for 14 days.

(Quarantine refers to people who are well but may become ill; isolation refers to those known to be ill.)

Until now, the C.D.C. has recommended a 14-day quarantine period following potential exposure, and Dr. Walke stressed that the full two weeks is still considered ideal and the surest way to curb transmissions.

While a shortened quarantine period may be more palatable to Americans, officials acknowledged that the new guidance might lead to some infections being missed.

“We can safely reduce the length of quarantine, but accepting that there is a small residual risk that a person who is leaving quarantine early could transmit to someone else if they became infected,” said Dr. John Brooks, the chief medical officer for the Covid-19 response at the C.D.C.

Some patients may not develop symptoms until two weeks after exposure, and even longer in a very small fraction of cases. Infected individuals may pass the virus to others before they develop symptoms; recent studies show they are most infectious two days before symptoms begin, and for about five days afterward.

The new recommendations do not have the force of law. Federal officials share them with state and county public health agencies, who make their own determinations based on local conditions and needs.

The agency’s warnings against holiday travel echoed those issued just a week before Thanksgiving. Millions of Americans hit the road nonetheless to spend the holiday with friends and family, though the number of travelers was lower than in a typical year.

“Cases are rising, hospitalizations are increasing, deaths are increasing,” Dr. Walke said. “We need to try to bend the curve, stop this exponential increase.”

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Dr. Cindy Friedman, chief of the travelers health branch at the C.D.C., said the agency was reiterating the message further in advance of the Christmas holiday to provide more time for people to plan ahead, “think about the safest option for them and their families” and make “tough choices.”

“We know it’s a hard decision, and people need time to prepare and have discussions with family and friends and to make these decisions,” Dr. Friedman added. Even a small percentage of infected travelers could “translate into hundreds of thousands of additional infections.”

Hospitals are already overwhelmed in many regions, as cases have been rising rapidly, with the country adding over a million new infections during a recent one-week period, according to data maintained by The New York Times.

Daily deaths have been exceeding 2,000 for the first time since early May, and close to 100,000 Americans are already hospitalized.

“We are at the point now, even before Christmas, that there may not be room at your hospital, because we don’t have enough health care workers to take care of you,” said Michael Osterholm, a member of President-elect Joseph R. Biden Jr.’s Covid-19 advisory board, who also urged Americans to stay home.