Tagged your-feed-healthcare

Breast Cancer Centers Urge Annual Scans, Counter to U.S. Guidelines

A panel recommends biennial screenings, starting at 50, but a new study took issue with the way hundreds of centers are telling women 40 and up to come in yearly. Some experts contend that frequent mammograms can “do more harm than good.”

My last breast cancer screening was “b.c.” — before Covid — just a few weeks before the mysterious new disease was detected in China. The timing was perfect: Everything was normal, and by the time we went into lockdown, my to-do list no longer included a mammogram.

But by November 2020, exactly one year after that scan, I started getting barraged by phone calls and text messages telling me I was due for another one.

“MAMMO MATTERS,” screamed one in all capital letters. “Breast cancer does not take a break during pandemics, and neither should you.” I was well aware that national health guidelines recommend a mammogram only every other year for women at average risk for breast cancer. But there has been a cacophony of advice in recent years as different groups recast their recommendations, often contradicting one another. So the messages were unnerving.

It turns out my imaging center is not alone in badgering women to have mammograms more frequently than the U.S. Preventive Services Task Force deems optimal. A recent study found that hundreds of breast centers tell women who are not at elevated risk of cancer to have a routine scan every year, and to start at 40.

The task force, however, recommends regular mammograms every two years starting at 50. Its guidelines do recommend that women in their 40s discuss mammography with their doctors, evaluate the risks and benefits and come to an individual decision. (The panel’s recommendations extend to age 74; it has said there is not enough evidence to make recommendations past that age.)

The new study, published in JAMA Internal Medicine on March 15, was accompanied by a rather scathing editorial that said extra screening can do “more harm than good.”

“I don’t think breast cancer centers that have clear financial benefits from increasing mammography should be the ones that are giving out patient advice, particularly when it conflicts with the patient’s primary care provider’s advice and the task force’s advice,” said Dr. Rita F. Redberg, editor in chief of JAMA Internal Medicine, who co-wrote the editorial along with Dr. Anand R. Habib and Dr. Deborah Grady.

The American College of Radiology took umbrage, shooting back that it was “outrageous” to assert that breast cancer centers were promoting mammograms for financial reasons, and that the radiologists’ had a different set of guidelines.

When the pandemic started, both routine screenings and appointments triggered by troubling symptoms like the discovery of a lump were delayed as facilities shut down. Even when they reopened, many patients were reluctant to go in.

But Dr. Dana Smetherman, who chairs the American College of Radiology’s breast imaging commission, said the breast centers’ recommendations for more frequent screening predate the pandemic.

“What this study is telling us is that the experts in breast cancer in the U.S. do not support these recommendations,” Dr. Smetherman said in an interview, referring to the U.S. task force’s guidelines.

Indeed: Both the college of radiology and the American Society of Breast Surgeons recommend annual mammograms starting at age 40 (Dr. Redberg’s institution, the University of California, San Francisco, also recommends that schedule).

The American Cancer Society scaled back its recommendations recently, however, endorsing yearly scans starting at age 45, with the option of switching to every other year at age 54. The American College of Obstetricians and Gynecologists recommends women at average risk start mammography at 40, but “every one or two years.”

The debate over screening frequency for breast cancer — the second leading cause of cancer death for women after lung cancer — dates back to 2009. That is when the U.S. Preventive Services Task Force, an independent expert panel that reviews the evidence and provides guidance to doctors and insurers, rolled back its mammography recommendations for women who were deemed at average risk for breast cancer.

Screening can actually be harmful, especially for younger women, the panel found. False positive findings can trigger unnecessary procedures like biopsies, or lead to what experts call over-diagnosis — the aggressive treatment of slow-growing tumors that might never become life-threatening, but cannot be distinguished from fast-growing tumors.

When women had mammograms every other year, the harms of false positives and unnecessary treatment were reduced, the panel determined, while it found the life-saving benefits remained relatively unchanged.

But some experts believe the panel overstated the harms of more frequent screenings. The appropriate schedule for screenings can vary from doctor to doctor, and patient to patient, and has become quite confusing.

“Many women may not even be aware of the guidelines, or that there may be any downside to mammography, and that they have the option to begin screening at age 45 or 50,” Dr. Jennifer L. Marti, an assistant professor of surgery at Weill Cornell Medicine who led the new study, said in an interview. “In almost every other country, women start at 50.”

While many women might assume that “the pros of breast cancer screening outweigh the harms,” Dr. Marti said, that is not always the case for women who aren’t at elevated risk.

Dr. Marti and her co-authors, Mark Lee and Neal Patel, two Weill Cornell researchers, decided to examine the recommendations posted on the websites of some 606 breast cancer centers in the United States. They found that 376 centers — over half — made recommendations that differed from those of the U.S. task force, saying women at average risk for breast cancer should start imaging at age 40.

And 347 centers said women should not only start at 40, but continue annually.

More rigorous screening may be appropriate for some high risk groups, like Ashkenazi Jewish women, who are more likely to carry mutations that put them at risk for breast and ovarian cancer, and Black women, who were likely underrepresented in mammography screening trials, Dr. Marti said.

Women who want help assessing their individual risk to make screening decisions can use an online tool developed by Dr. Margaret Polaneczky, a gynecologist from Weill Cornell Medicine, and Elena Elkin, a research scientist at Memorial Sloan Kettering Cancer Center, Dr. Marti suggested.

As for myself, I’ve been on a two-year plan for a while. I do regular breast self-examinations, and have clinical breast exams too. So even though I felt a smidgen of irrational guilt after receiving the text messages, I politely asked a receptionist to please stop calling. I promised I’d be in touch.

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.”

In Search of a Vaccine, Some Tourists Find Luck in the Caribbean

Roughly 3 percent of vaccines in the U.S. Virgin Islands have gone to tourists, the governor said this week. “Nowhere else in the U.S. can you actually just walk in and get the vaccine,” he said.

When Lydia Todman booked a trip to St. Croix with her husband earlier this month, she was hoping only for a relaxing getaway. But when she arrived, she learned she could also get the Covid-19 vaccine.

Ms. Todman, 43, said that local residents she knew on the island encouraged her to book a vaccine appointment. At the time, she and her husband, who is 64 and has asthma, were not eligible for a shot in their home state, Georgia. But in St. Croix, every adult is eligible. So she visited the territory’s Department of Health website, saw they had appointments available for the next day, and signed up.

“We were in and out within a matter of a few minutes,” Ms. Todman said. “It was amazing.”

Nearly 106,000 people call the U.S. Virgin Islands home, and the territory has administered more than 33,000 Covid-19 vaccines to date, with about 10,600 people now fully protected with two doses. At a news briefing on Monday, the governor, Albert Bryan Jr., estimated that at most 3 percent, or approximately 1,000 of those vaccines, have gone to tourists.

“Have we become aware of the fact that people are seeking us out? Yes. And you know, we accommodate everyone,” said Angela East, the coordinator and director of the Covid-19 vaccine program at Plessen Healthcare, which has administered 44 percent of all Covid-19 vaccines in the territory. “We are going to give you the shot in the spirit of putting as many shots in arms as possible.”

Health authorities and ethicists don’t see a big problem with the vaccine tourism in the U.S. Virgin Islands, given the ample supply of the shots and high levels of vaccine hesitancy among residents there. And the trend may wane as more U.S. states open up their eligibility criteria. Still, wealthy Americans traveling to the Caribbean to secure Covid-19 vaccines is an example of the many ways in which vaccine access across the world is shaped by race, circumstance and privilege.

In St. Croix, St. John and St. Thomas, the three largest of the U.S. Virgin Islands, vaccines are readily available to tourists partly because of vaccine hesitancy, “which is very high in the Virgin Islands,” said Dr. Tai Hunte-Ceasar, the medical director of the territory’s Department of Health. This hesitancy seems most pronounced among residents of color, Mr. Bryan said at the news briefing. “Caucasians that live in the Virgin Islands are more apt to take the vaccine and take it quicker,” he said.

When Bridget Platten, 40, who works in sales in New York City, received her Covid-19 vaccine in St. Croix, she was encouraged to tell friends to get inoculated, too. “The doctor said: ‘Listen, I have all this vaccine. And people are afraid to get it here,’” Ms. Platten recalled. “‘If you have any friends, or there’s anyone you know who wants a vaccine, please have them call me.’”

A pop-up coronavirus testing site by the U.S. Virgin Islands Department of Health in a parking lot in Charlette Amalie on Saint Thomas last month.
A pop-up coronavirus testing site by the U.S. Virgin Islands Department of Health in a parking lot in Charlette Amalie on Saint Thomas last month.Gabby Jones for The New York Times

Some Americans have flown to the island specifically to be vaccinated. “My friends from New Jersey went, and the most probing question they faced was, ‘Will that be Pfizer or Moderna for you?’” said Rob DeRocker, a marketing consultant from Tarrytown, N.Y., who spends winters in St. Croix. “The result has been a mini boom of visitors on an island whose tourism economy, like most others, has been brutalized by the pandemic.”

This boom has been aided by the fact that since March 1, everyone over 16 has been eligible to get the vaccine in the Virgin Islands — so tourists don’t even have to worry about cutting in line. The territory accommodates about 100 walk-ins each day, too. “Nowhere else in the U.S. can you actually just walk in and get the vaccine, anybody over 16,” Mr. Bryan said on Monday. On March 1, the islands also opened two federally supported community vaccination centers on St. Thomas and St. Croix.

U.S. travelers also face less red tape when visiting the U.S. Virgin Islands compared with other Caribbean destinations. If they submit a negative coronavirus test within five days of leaving for the territory, or a positive antibody test taken within four months, they do not have to quarantine upon arrival. Travelers to Jamaica and Barbados, in contrast, are asked to quarantine no matter what. And U.S. travelers can’t visit the Cayman Islands unless they conform to strict eligibility criteria.

Dr. Hunte-Ceasar said that, at this point, the Department of Health did not consider vaccine tourism to be a problem. “We definitely want to ensure the local residents get vaccinated,” she said. But “we have not had any shortages by serving both populations.” The Virgin Islands currently have 27,000 doses of the Pfizer vaccine, 18,900 doses of the Moderna vaccine, and 600 doses of the Johnson & Johnson vaccine available, said Monife Stout, the department’s immunization director.

Noreen Michael, a scientist at the University of the Virgin Islands who studies health disparities, agreed that it was crucial to ensure that vaccines are available to residents who want them, but said she had not seen evidence to suggest that tourists are taking vaccines away from residents who want them. “On the public health side, it’s a plus,” she said. “On the equity side, I don’t see it as significant issue.”

Perhaps, too, vaccine tourism could be used as a force for good — to secure doses for marginalized groups in other regions. Although the Virgin Islands provide free Covid-19 vaccines, the islands could charge tourists for their vaccines, and the funds could be used to send vaccines to regions that need them, said Felicia Knaul, an international health economist at the University of Miami. “Could we send those vaccines to Jamaica, or to the Dominican Republic or Haiti?” she asked. “Once you’ve gotten past the key welfare and human rights aspects, if you can use that funding to pay for people who right now have no access, I think it’s worth thinking about.”

For now, health authorities are focused on ways to reduce vaccine hesitancy in the territory. “People access misinformation and perpetuate lies and things that are harmful,” Dr. Hunte-Ceasar said in a news conference last week. As a result, the islands have been experiencing a surge in cases and hospitalizations that she said give her “chest pain and heartburn every night.” Although vaccine hesitancy does seem to be decreasing, residents will need to start widely embracing the vaccine if the islands are to meet their goal of vaccinating 50,000 Virgin Islanders by July 1.

In the meantime, visitors from the continental U.S. will continue to take advantage of the extra doses. Some have stayed longer than they planned, too — and have even contemplated moving to the islands for good.

“I started falling in love with the culture of St. Croix,” said Hemal Trivedi, a documentary filmmaker who lives in Weehawken, N.J., and was vaccinated in St. Croix in February. “Toward the end of the trip, we were actually looking for a place to buy.”

Vaccinated People Can Get Covid, but It’s Most Likely Very Rare

“Breakthrough” cases, though quite uncommon, are a sharp reminder that vaccinated people should wear masks while the virus is circulating widely.

More than two months after he was fully vaccinated against Covid, a doctor in New York woke up with a headache and a dull, heavy feeling of fatigue. A fever and chills soon followed, and his senses of taste and smell began to fade.

This, he thought, could not be happening. But it was: He tested positive for the coronavirus.

“It was a huge shock,” he said. He knew that no vaccine was perfect and that the Pfizer-BioNTech shots he received had been found 95 percent effective in a large clinical trial. “But somehow in my mind, it was 100 percent,” he said.

The doctor, who requested anonymity to protect his privacy, is among the few reported cases of people who have been infected after being partly or even fully vaccinated. Nearly 83 million Americans have received at least one dose of a Covid vaccine, and it’s unclear just how many of them will have a “breakthrough” infection, though two new reports suggest the number is very small.

One study found that just four out of 8,121 fully vaccinated employees at the Southwestern Medical Center in Dallas became infected. The other found that only seven out of 14,990 workers at UC San Diego Health and the David Geffen School of Medicine at the University of California, Los Angeles tested positive two or more weeks after receiving a second dose of either the Pfizer-BioNTech or Moderna vaccines. Both reports, published on Tuesday in the New England Journal of Medicine, show how well the vaccines work in the real world, and during a period of intense transmission.

But these breakthrough cases, though quite rare, are a sharp reminder that vaccinated people are not invincible, especially when the virus continues to circulate widely.

“We felt really strongly that this data should not lead people to say, ‘Let’s all get vaccinated and then we can all stop wearing masks,’” said Dr. Francesca J. Torriani, an infectious disease specialist at UC San Diego Health who led the California study. “These measures have to continue until a larger segment of the population is vaccinated.”

Only some of the Covid-positive health workers in the California study showed symptoms, she said, and they tended to be mild, suggesting that the vaccines were protective. That echoes data from the vaccine trials indicating that breakthrough infections were mild and did not require hospitalizations. Some people had no symptoms at all, and were discovered only through testing in studies or as part of their medical care.

For example, doctors at the University of North Carolina found a few asymptomatic cases in vaccinated patients who were tested for the coronavirus ahead of surgery or other medical procedures, according to Dr. David Wohl, the medical director of that center’s vaccine clinic.

He said the absence of symptoms may have meant that the vaccine was doing exactly what it is supposed to do: prevent people from getting sick, even if it does not fully block the virus from infecting them.

The Centers for Disease Control and Prevention has a small team studying breakthrough cases, said an agency spokeswoman, Kristen Nordlund. One question the researchers are considering is whether particular variants of the coronavirus might play a role in breakthrough cases.

“Currently, there is no evidence that Covid-19 after vaccination is occurring because of changes in the virus,” Ms. Nordlund said.

In the next few months, Pfizer and Moderna are expected to release data that should indicate how often vaccinated people become infected by the virus, even if they have no symptoms. The companies have been testing participants in their vaccine trials for antibodies to a protein called N that is part of the coronavirus but not part of the vaccine. Finding those antibodies means that a vaccinated person has been infected by the virus. Some volunteers from the studies are also having their noses swabbed regularly to test for an active viral infection.

Another question is how effective the vaccines are in people whose immune systems have been weakened by illness or medications, said Dr. William Schaffner, an infectious disease expert at Vanderbilt University. Breakthrough cases might occur in those people because their bodies cannot produce a robust reaction to a vaccine.

“And it is amazing how pervasive immunocompromise is,” Dr. Schaffner said. He called the condition “a testament to modern medicine,” because many patients with it are being treated successfully for conditions that not so long ago would have killed them.

The doctor who became ill in New York despite full vaccination stayed in isolation at home for nearly two weeks. He described his illness as relatively mild, and said he was treated with monoclonal antibodies to fight the virus. “If the worst flu is a 10, this was a four,” he said.

Without the vaccine, he said, he believes he would have been sicker.

“I would have been in fear for my mortality,” he said. “But I didn’t have a moment’s anxiety. I did not think I was going to die. Thinking you’re not going to die — that’s a pretty big thing.”

Apoorva Mandavilli contributed reporting.

Some Long Covid-19 Patients Feel Better After Vaccine Doses

It is too soon to tell whether the shots have a broad beneficial effect on patients with continuing issues, but scientists are intrigued and beginning to study the phenomenon.

Judy Dodd began struggling with long Covid symptoms last spring — shortness of breath, headaches, exhaustion. Then she got the vaccine.

After her first Pfizer-BioNTech shot in late January, she felt so physically miserable that she had to be persuaded to get the second. For three days after that one, she also felt awful. But the fourth day, everything changed.

“I woke up and it was like ‘Oh what a beautiful morning,’” said Ms. Dodd, a middle-school teacher who is also an actor and director. “It was like I’d been directing ‘Sweeney Todd’ for months, and now I’m directing Oklahoma.”

Ms. Dodd, who continues to feel good, is among a number of people who are reporting that the post-Covid symptoms they’ve experienced for months have begun improving, sometimes significantly, after they got the vaccine. It’s a phenomenon that doctors and scientists are watching closely, but as with much about the yearlong coronavirus pandemic, there are many uncertainties.

Scientists are only beginning to study any potential effect of vaccines on long Covid symptoms. Anecdotes run the gamut: Besides those who report feeling better after the shots, many people say they have experienced no change and a small number say they feel worse.

Reports from doctors vary too. Dr. Daniel Griffin, an infectious disease physician at Columbia University, said about 40 percent of the long Covid patients he’s been treating cite symptom improvement after the vaccine. “They notice, ‘Hey, over the days, I’m feeling better. The fatigue isn’t so bad, maybe smell is coming back,’” Dr. Griffin said.

Other doctors say it is too early to know.

“Too few of our participants have been vaccinated so far to really be able to provide insight into this question,” said Dr. Michael Peluso, an infectious disease specialist working on a study of long-term Covid patients at University of California, San Francisco. “I’ve heard anecdotes as well, but I’ve seen too little data so far.”

This month, a small study by British researchers that has not yet been peer reviewed found that eight months after people were hospitalized for Covid-19, those who were vaccinated experienced improvement in more long Covid symptoms than those who weren’t yet vaccinated. The 44 vaccinated patients in the study were older and had more underlying medical conditions, since people with those characteristics qualified for vaccines earlier.

One month after vaccination, those patients reported improvement in 23 percent of their long Covid symptoms like joint pain and breathing, while 5.6 percent of their symptoms had worsened. The 22 unvaccinated people questioned at that time said 15 percent of their symptoms were better, while 14 percent of their symptoms were worse. There was no difference in response between people who received the Pfizer-BioNTech and Oxford-AstraZeneca vaccines.

Additional information comes from two surveys of several hundred people with long Covid symptoms, many of whom were never hospitalized for the disease.

Jim Golen, a former hospice nurse in Saginaw, Minn. He said his long Covid symptoms have gotten worse since his vaccination, but he’s still glad he got the vaccine.
Jim Golen, a former hospice nurse in Saginaw, Minn. He said his long Covid symptoms have gotten worse since his vaccination, but he’s still glad he got the vaccine.Tim Gruber for The New York Times

One survey of 345 people, mostly women and mostly in the U.K., found that two weeks or more after their second vaccine dose, 93 felt slightly better and 18 felt back to normal — a total of 32 percent reporting improved long Covid symptoms.

In that survey, by Gez Medinger, a London-based filmmaker who has experienced post-Covid symptoms, 61 people, just under 18 percent, felt worse, most of them reporting only a slight decline in their condition. Nearly half — 172 people — reported feeling no different.

Another survey, by Survivor Corps, a group of over 150,000 Covid survivors, found that as of March 17, 225 of 577 respondents reported some improvement, while 270 felt no change and 82 felt worse.

Jim Golen, 55, of Saginaw, Minn., feels some long Covid symptoms have worsened since his vaccination. Mr. Golen, a former hospice nurse who also has a small farm, had experienced months of difficulty, including blood clots in his lungs, chest pain, brain fog, insomnia and shortness of breath with any exertion. Late last year, after seeing several doctors, “I was finally starting to get better,” he said.

Since receiving the second dose of the Pfizer vaccine in mid-January, he said, his chest burning and shortness of breath have returned with a vengeance, especially if he taxes himself with activities like collecting sap from the maple trees on his farm. Nonetheless, Mr. Golen said he was “very happy” to be vaccinated, emphasizing that the effects of Covid were worse and preventing it is crucial.

Some people shared stories of stark symptom improvements that took them by surprise.

Laura Gross, 72, of Fort Lee, N.J. rattled off a lengthy list of debilitating long Covid symptoms she’d experienced since April, including exhaustion, joint pain, muscle aches and a “zizzy-dizzy-weaky thing that was like an internal headachy all-over-body vibration.”

Her cognitive fuzziness and forgetfulness were so intense that “brain fog barely describes it,” she said. “It’s more like brain cyclone.”

She also felt uncharacteristically “hopeless, sad, lonely, unmotivated,” she said.

Three days after her first Moderna shot in late January, everything changed. “It was like a revelation,” she said. The brain fog cleared completely, muscle aches were gone, joint pains were less intense and she suddenly had much more energy. It felt, she said, “like the old me.”

That continued after the second dose. “It’s like my cells went kerflooey last year when they met Covid,” she said, and the “vaccine said, ‘Wait, you dopes, that isn’t how you fight this, do it this way.’”

Recently, she walked briskly for 23 minutes and even “ran a little bit because I was so happy,” she said. “I’m a very happy little chappy.”

Laura Gross of Fort Lee, N.J., said brain fog is inadequate in describing her symptoms: “It’s more like brain cyclone,” she said. She reports feeling much better since being vaccinated.Nancy Borowick for The New York Times

Scientists say that understanding whether vaccines help some long Covid patients but not others could help unravel the underlying causes of different symptoms and potential ways to treat them.

“They might be different disease processes and you manage them differently,” said Dr. Adam Lauring, a virologist and infectious disease physician at the University of Michigan. “It might be that there’s a subset of people who have a certain type of long Covid, who respond well to vaccines, but there might be other people who have a different subtype that we haven’t quite defined yet.”

Akiko Iwasaki, an immunologist at Yale, said that a vaccine, by generating antibodies to the coronavirus’s spike protein, could potentially eliminate vestiges of the virus or remnants of viral RNA that may linger in some patients.

If this is occurring, she said, it could suggest that the vaccine “might be like a permanent cure” for those patients.

Dr. Iwasaki said the vaccine might also help people whose long Covid symptoms may be caused by a post-viral response resembling an autoimmune disease if “the vaccine stimulates innate immune responses that dampen these kinds of autoreactive responses,” she said. But based on experiences of people with other autoimmune diseases, that relief would “not be very long-lasting and they would kind of revert back” to having symptoms like fatigue, she said.

Dr. Eric Topol, a professor of molecular medicine at the Scripps Research Institute in San Diego, said he is starting a study to measure physiological information like heart rate, respiratory rate, temperature and markers of immune system response in people with long Covid before they receive a vaccine and weeks afterward.

It’s plausible that “you have your immune system revved up when you’re fighting a reservoir” of virus or RNA remnants, he said, “and that could be an explanation of why you’re in overdrive with your heart rate.” He wants to see if these biological indicators improve post-vaccine.

“We’d really like objective metrics that show that you not just feel better,” Dr. Topol said. “You could feel better from the placebo effect, but it’s unlikely your heart rate’s going to go from 100 to 60 because of a placebo effect. And if we keep seeing that pattern, that would be like Eureka.”

He added, “I think there’s probably something there, but I just don’t know what is the magnitude, how many people are going to benefit.”

There are many other questions: Are there specific characteristics, like age, gender, type or duration of symptoms, that might make some long Covid patients more likely to feel better? Would a vaccine be less effective for people with more complex conditions: people whose symptoms are driven by multiple biological pathways (perhaps both an RNA remnant and autoimmune activation) or whose symptoms have changed or fluctuated over time? Are certain types of vaccines more likely to produce benefit?

“It was awful thinking it may never get better, like ‘Is this my new normal, am I now damaged this way?’” recalled Bridget Hayward of her symptoms, which she says have eased since her vaccination.Alyssa Schukar for The New York Times

Bridget Hayward, 51, an operating room nurse in Alexandria, Va., said that after contracting Covid a year ago, her body ached from her hands to her hips and she became so brain-fogged that instead of asking for a scalpel, she would say “Give me that sharp thing we cut with.”

Almost daily, she would briefly pass out while bending down to fix a patient’s intravenous line or plug in the cord of a hospital bed.

“It was horrifying,” she said. “It was awful thinking it may never get better, like ‘Is this my new normal, am I now damaged this way?’”

After several months, her worst symptoms improved, but she still tired easily, felt hot even in cool weather, and found it too taxing to do some ordinary tasks, she said.

One day after her first dose of the Pfizer vaccine in late December, “it was like click, everything is fine,” she said. Her body temperature has normalized and “it felt like a darkness lifted.”

While “it’s not 100 percent every day,” she said she has so much energy now that “I’m not just getting from A to B, I’m like leaping up.”

One recent day, she did several long-overdue errands. “This may not sound like much but it is a 180-turnaround from three months ago,” she said. “I’m back!”

Kim Leighton, 64, of Vancouver, Wash., has had a similar experience. She was hospitalized last March and had long Covid symptoms that included mini blackouts, shortness of breath, getting lost in her own neighborhood, depression and fatigue.

“It really has been hell,” she said.

When she started feeling better in late January, she didn’t even think to connect it to the vaccine, but later realized her stark improvement had started four days after receiving her first Moderna shot. She is delighted that she can now take walks in downtown Portland and has the desire to reconnect with friends.

“Every day, I feel like I’m feeling stronger,” Ms. Leighton said. “All the stuff I had to let go of, I’m trying to get it back.”

Ms. Dodd, like several others, said she wasn’t taking her improvement for granted. “I’m still sort of wary of what’s around the corner, this disease is so unpredictable,” she said.

But, she added, “even if, God forbid, I have a relapse, to have this time now when I feel better, it’s really amazing.”

Some Long Covid Patients Feel Better After Getting the Vaccine

It is too soon to tell whether the shots have a broad beneficial effect on patients with continuing issues, but scientists are intrigued and beginning to study the phenomenon.

Judy Dodd began struggling with long Covid symptoms last spring — shortness of breath, headaches, exhaustion. Then she got the vaccine.

After her first Pfizer-BioNTech shot in late January, she felt so physically miserable that she had to be persuaded to get the second. For three days after that one, she also felt awful. But the fourth day, everything changed.

“I woke up and it was like ‘Oh what a beautiful morning,’” said Ms. Dodd, a middle-school teacher who is also an actor and director. “It was like I’d been directing ‘Sweeney Todd’ for months, and now I’m directing Oklahoma.”

Ms. Dodd, who continues to feel good, is among a number of people who are reporting that the post-Covid symptoms they’ve experienced for months have begun improving, sometimes significantly, after they got the vaccine. It’s a phenomenon that doctors and scientists are watching closely, but as with much about the yearlong coronavirus pandemic, there are many uncertainties.

Scientists are only beginning to study any potential effect of vaccines on long Covid symptoms. Anecdotes run the gamut: Besides those who report feeling better after the shots, many people say they have experienced no change and a small number say they feel worse.

Reports from doctors vary too. Dr. Daniel Griffin, an infectious disease physician at Columbia University, said about 40 percent of the long Covid patients he’s been treating cite symptom improvement after the vaccine. “They notice, ‘Hey, over the days, I’m feeling better. The fatigue isn’t so bad, maybe smell is coming back,’” Dr. Griffin said.

Other doctors say it is too early to know.

“Too few of our participants have been vaccinated so far to really be able to provide insight into this question,” said Dr. Michael Peluso, an infectious disease specialist working on a study of long-term Covid patients at University of California, San Francisco. “I’ve heard anecdotes as well, but I’ve seen too little data so far.”

This month, a small study by British researchers that has not yet been peer reviewed found that eight months after people were hospitalized for Covid-19, those who were vaccinated experienced improvement in more long Covid symptoms than those who weren’t yet vaccinated. The 44 vaccinated patients in the study were older and had more underlying medical conditions, since people with those characteristics qualified for vaccines earlier.

One month after vaccination, those patients reported improvement in 23 percent of their long Covid symptoms like joint pain and breathing, while 5.6 percent of their symptoms had worsened. The 22 unvaccinated people questioned at that time said 15 percent of their symptoms were better, while 14 percent of their symptoms were worse. There was no difference in response between people who received the Pfizer-BioNTech and Oxford-AstraZeneca vaccines.

Additional information comes from two surveys of several hundred people with long Covid symptoms, many of whom were never hospitalized for the disease.

Jim Golen, a former hospice nurse in Saginaw, Minn. He said his long Covid symptoms have gotten worse since his vaccination, but he’s still glad he got the vaccine.
Jim Golen, a former hospice nurse in Saginaw, Minn. He said his long Covid symptoms have gotten worse since his vaccination, but he’s still glad he got the vaccine.Tim Gruber for The New York Times

One survey of 345 people, mostly women and mostly in the U.K., found that two weeks or more after their second vaccine dose, 93 felt slightly better and 18 felt back to normal — a total of 32 percent reporting improved long Covid symptoms.

In that survey, by Gez Medinger, a London-based filmmaker who has experienced post-Covid symptoms, 61 people, just under 18 percent, felt worse, most of them reporting only a slight decline in their condition. Nearly half — 172 people — reported feeling no different.

Another survey, by Survivor Corps, a group of over 150,000 Covid survivors, found that as of March 16, 207 of 508 respondents reported some improvement, while 231 felt no change and 70 felt worse.

Jim Golen, 55, of Saginaw, Minn., feels some long Covid symptoms have worsened since his vaccination. Mr. Golen, a former hospice nurse who also has a small farm, had experienced months of difficulty, including blood clots in his lungs, chest pain, brain fog, insomnia and shortness of breath with any exertion. Late last year, after seeing several doctors, “I was finally starting to get better,” he said.

Since receiving the second dose of the Pfizer vaccine in mid-January, he said, his chest burning and shortness of breath have returned with a vengeance, especially if he taxes himself with activities like collecting sap from the maple trees on his farm. Nonetheless, Mr. Golen said he was “very happy” to be vaccinated, emphasizing that the effects of Covid were worse and preventing it is crucial.

Some people shared stories of stark symptom improvements that took them by surprise.

Laura Gross, 72, of Fort Lee, N.J. rattled off a lengthy list of debilitating long Covid symptoms she’d experienced since April, including exhaustion, joint pain, muscle aches and a “zizzy-dizzy-weaky thing that was like an internal headachy all-over-body vibration.”

Her cognitive fuzziness and forgetfulness were so intense that “brain fog barely describes it,” she said. “It’s more like brain cyclone.”

She also felt uncharacteristically “hopeless, sad, lonely, unmotivated,” she said.

Three days after her first Moderna shot in late January, everything changed. “It was like a revelation,” she said. The brain fog cleared completely, muscle aches were gone, joint pains were less intense and she suddenly had much more energy. It felt, she said, “like the old me.”

That continued after the second dose. “It’s like my cells went kerflooey last year when they met Covid,” she said, and the “vaccine said, ‘Wait, you dopes, that isn’t how you fight this, do it this way.’”

Recently, she walked briskly for 23 minutes and even “ran a little bit because I was so happy,” she said. “I’m a very happy little chappy.”

Laura Gross of Fort Lee, N.J., said brain fog is inadequate in describing her symptoms: “It’s more like brain cyclone,” she said. She reports feeling much better since being vaccinated.Nancy Borowick for The New York Times

Scientists say that understanding whether vaccines help some long Covid patients but not others could help unravel the underlying causes of different symptoms and potential ways to treat them.

“They might be different disease processes and you manage them differently,” said Dr. Adam Lauring, a virologist and infectious disease physician at the University of Michigan. “It might be that there’s a subset of people who have a certain type of long Covid, who respond well to vaccines, but there might be other people who have a different subtype that we haven’t quite defined yet.”

Akiko Iwasaki, an immunologist at Yale, said that a vaccine, by generating antibodies to the coronavirus’s spike protein, could potentially eliminate vestiges of the virus or remnants of viral RNA that may linger in some patients.

If this is occurring, she said, it could suggest that the vaccine “might be like a permanent cure” for those patients.

Dr. Iwasaki said the vaccine might also help people whose long Covid symptoms may be caused by a post-viral response resembling an autoimmune disease if “the vaccine stimulates innate immune responses that dampen these kinds of autoreactive responses,” she said. But based on experiences of people with other autoimmune diseases, that relief would “not be very long-lasting and they would kind of revert back” to having symptoms like fatigue, she said.

Dr. Eric Topol, a professor of molecular medicine at the Scripps Research Institute in San Diego, said he is starting a study to measure physiological information like heart rate, respiratory rate, temperature and markers of immune system response in people with long Covid before they receive a vaccine and weeks afterward.

It’s plausible that “you have your immune system revved up when you’re fighting a reservoir” of virus or RNA remnants, he said, “and that could be an explanation of why you’re in overdrive with your heart rate.” He wants to see if these biological indicators improve post-vaccine.

“We’d really like objective metrics that show that you not just feel better,” Dr. Topol said. “You could feel better from the placebo effect, but it’s unlikely your heart rate’s going to go from 100 to 60 because of a placebo effect. And if we keep seeing that pattern, that would be like Eureka.”

He added, “I think there’s probably something there, but I just don’t know what is the magnitude, how many people are going to benefit.”

There are many other questions: Are there specific characteristics, like age, gender, type or duration of symptoms, that might make some long Covid patients more likely to feel better? Would a vaccine be less effective for people with more complex conditions: people whose symptoms are driven by multiple biological pathways (perhaps both an RNA remnant and autoimmune activation) or whose symptoms have changed or fluctuated over time? Are certain types of vaccines more likely to produce benefit?

“It was awful thinking it may never get better, like ‘Is this my new normal, am I now damaged this way?’” recalled Bridget Hayward of her symptoms, which she says have eased since her vaccination.Alyssa Schukar for The New York Times

Bridget Hayward, 51, an operating room nurse in Alexandria, Va., said that after contracting Covid a year ago, her body ached from her hands to her hips and she became so brain-fogged that instead of asking for a scalpel, she would say “Give me that sharp thing we cut with.”

Almost daily, she would briefly pass out while bending down to fix a patient’s intravenous line or plug in the cord of a hospital bed.

“It was horrifying,” she said. “It was awful thinking it may never get better, like ‘Is this my new normal, am I now damaged this way?’”

After several months, her worst symptoms improved, but she still tired easily, felt hot even in cool weather, and found it too taxing to do some ordinary tasks, she said.

One day after her first dose of the Pfizer vaccine in late December, “it was like click, everything is fine,” she said. Her body temperature has normalized and “it felt like a darkness lifted.”

While “it’s not 100 percent every day,” she said she has so much energy now that “I’m not just getting from A to B, I’m like leaping up.”

One recent day, she did several long-overdue errands. “This may not sound like much but it is a 180-turnaround from three months ago,” she said. “I’m back!”

Kim Leighton, 64, of Vancouver, Wash., has had a similar experience. She was hospitalized last March and had long Covid symptoms that included mini blackouts, shortness of breath, getting lost in her own neighborhood, depression and fatigue.

“It really has been hell,” she said.

When she started feeling better in late January, she didn’t even think to connect it to the vaccine, but later realized her stark improvement had started four days after receiving her first Moderna shot. She is delighted that she can now take walks in downtown Portland and has the desire to reconnect with friends.

“Every day, I feel like I’m feeling stronger,” Ms. Leighton said. “All the stuff I had to let go of, I’m trying to get it back.”

Ms. Dodd, like several others, said she wasn’t taking her improvement for granted. “I’m still sort of wary of what’s around the corner, this disease is so unpredictable,” she said.

But, she added, “even if, God forbid, I have a relapse, to have this time now when I feel better, it’s really amazing.”

Advanced Cancers Are Emerging, Doctors Warn, Citing Pandemic Drop in Screenings

People have skipped their cancer screenings and ignored possible symptoms as a result of the pandemic. In some cases, the delay has come at a great cost.

Yvette Lowery usually gets her annual mammogram around March. But last year, just as the pandemic was gaining a foothold and medical facilities were shutting down, the center where she goes canceled her appointment. No one could tell her when to reschedule.

“They just said keep calling back, keep calling back,” said Ms. Lowery, 59, who lives in Rock Hill, S.C.

In August, Ms. Lowery felt a lump under her arm but still couldn’t get an appointment until October.

Eventually, she received a diagnosis of Stage 2 breast cancer, started chemotherapy in November and had a double mastectomy this month.

“I’ve been seeing a lot of patients at an advanced stage,” said Dr. Kashyap B. Patel, one of Ms. Lowery’s doctors and the chief executive of Carolina Blood and Cancer Care Associates. If her cancer had been detected last May or June, it would have probably been caught before it had spread, Dr. Patel said.

Months of lockdowns and waves of surging Covid cases throughout last year shuttered clinics and testing labs, or reduced hours at other places, resulting in steep declines in the number of screenings, including for breast and colorectal cancers, experts have said.

Numerous studies showed that the number of patients screened or given a diagnosis of cancer fell during the early months of the pandemic. By mid-June, the rate of screenings for breast, colon and cervical cancers were still 29 percent to 36 percent lower than their prepandemic levels, according to an analysis of data by the Epic Health Research Network. Hundreds of thousands fewer screenings were performed last year than in 2019, according to the network data.

“We still haven’t caught up,” said Dr. Chris Mast, vice president of clinical informatics for Epic, which develops electronic health records for hospitals and clinics.

Another analysis of Medicare data suggested that as Covid cases spiked during certain periods in 2020, cancer screenings fell. The analysis — conducted by Avalere Health, a consulting firm, for Community Oncology Alliance, which represents independent cancer specialists — found that testing levels in November were about 25 percent lower than in 2019. The number of biopsies, used to diagnose cancer, decreased by about one-third.

While it is too early to assess the full impact of the delays in screenings, many cancer specialists say they are concerned that patients are coming in with more severe disease.

“There’s no question in practice that we are seeing patients with more advanced breast cancer and colorectal cancer,” said Dr. Lucio N. Gordan, the president of the Florida Cancer Specialists & Research Institute, one of the nation’s largest independent oncology groups. He is working on a study to see if, over all, these missed screenings resulted in more patients with later-stage cancers.

Yvette Lowery in Rock Hill, S.C. 
Yvette Lowery in Rock Hill, S.C. Travis Dove for The New York Times

And even though the numbers of mammograms and colonoscopies have rebounded in recent months, many people with cancer remain undiagnosed, doctors are reporting.

Some patients, like Ms. Lowery, could not easily get an appointment once clinics reopened because of pent-up demand. Others skipped regular testing or ignored worrisome symptoms because they were afraid of getting infected or after losing their jobs, they couldn’t afford the cost of a test.

“The fear of Covid was more tangible than the fear of missing a screen that detected cancer,” said Dr. Patrick I. Borgen, the chair of surgery at the Maimonides Medical Center in Brooklyn who also leads its breast center. His hospital treated such large numbers of coronavirus patients early on that “we’re now associated as the Covid hospital,” he said, and healthy people stayed away to avoid contagion.

Even patients at high risk because of their genetic makeup or because they previously had cancer have missed critical screenings. Dr. Ritu Salani, the director of gynecologic oncology at the UCLA Health Jonsson Comprehensive Cancer Center said one woman, who was at risk for colon cancer, had a negative test in 2019 but didn’t go for her usual screening last year because of the pandemic.

When she went to see her doctor, she had advanced cancer. “It’s just a devastating story,” Dr. Salani said. “Screening tests are really designed when patients aren’t feeling bad.”

Ryan Bellamy felt no hurry last spring to reschedule a canceled colonoscopy, even though the presence of blood in his stool had prompted him to look up symptoms. “I really didn’t want to go to the hospital,” Mr. Bellamy said. He decided it was unlikely he had cancer. “They’re not following up with me so I’m OK with Googling,” he told himself.

A resident of Palm Coast, Fla., Mr. Bellamy said that after his symptoms worsened, his wife insisted that he go for testing in December, and he had a colonoscopy in late January. With a new diagnosis of Stage 3 rectal cancer, Mr. Bellamy, 38, is undergoing radiation treatment and chemotherapy.

Colon screening remained significantly lower in 2020, declining about 15 percent from 2019 levels, according to the Epic network data, although overall screenings were down 6 percent. The analysis looked at screenings for more than 600 hospitals in 41 states.

Eric Prieto holding a picture of his family. His wife, Sandy Prieto, died after receiving a diagnosis of Stage 4 pancreatic cancer.Salgu Wissmath for The New York Times

Lung cancer patients have also delayed seeking appropriate care, said Dr. Michael J. Liptay, chairman of cardiovascular and thoracic surgery at Rush University Medical Center in Chicago. One patient had imaging that showed a spot on his lung, and he was supposed to follow up, just as the pandemic hit. “Additional work-up and care was deferred,” Dr. Liptay said. By the time the patient was fully evaluated, the cancer had increased in size. “It wasn’t a good thing to wait 10 months,” Dr. Liptay said, although he was uncertain whether earlier treatment would have changed the patient’s prognosis.

Just as previous economic recessions led people to forgo medical care, the downturn in the economy during the pandemic has also discouraged many people from seeking help or treatment.

“We know cancers are out there,” said Dr. Barbara L. McAneny, the chief executive of New Mexico Oncology Hematology Consultants. Many of her patients are staying away, even if they have insurance, because they cannot afford the deductibles or co-payments. “We’re seeing that, particularly with our poorer folks who are living on the edge anyway, living paycheck to paycheck,” she said.

Some patients ignored their symptoms as long as they could. Last March, Sandy Prieto, a school librarian who lived in Fowler, Calif., had stomach pain. But she refused to go to the doctor because she didn’t want to get Covid. After having a telehealth visit with her primary care doctor, she tried over-the-counter medications, but they didn’t help with the pain and nausea. She continued to decline.

“It got to the point where we didn’t have a choice,” said her husband, Eric, who had repeatedly urged her to go to the doctor. Jaundiced and in severe discomfort, she went to the emergency room at the end of May and was given a diagnosis of Stage 4 pancreatic cancer. She died in September.

“If it wasn’t for Covid and we could have gotten her some place earlier, she would still be with us today,” said her sister, Carolann Meme, who had tried to persuade Ms. Prieto to go to an academic medical center where she might have gotten into a clinical trial.

Mr. Prieto, left, with his son, Ethan, outside their home in Fowler, Calif. He repeatedly urged his wife to seek treatment.Salgu Wissmath for The New York Times

When patients like Ms. Prieto are not seen in person but treated virtually, doctors may easily miss important symptoms or recommend medication rather than tell them to come in, said Dr. Ravi D. Rao, the oncologist who treated Ms. Prieto. Patients may downplay how sick they feel or neglect to mention the pain in their hip, he said.

“In my mind, telemedicine and cancer don’t travel together,” Dr. Rao said. While he also made use of telemedicine during the height of the pandemic, he says he worked to keep his offices open.

Other doctors defended the use of virtual visits as a critical tool when office visits were too hazardous for most patients and staff. “We were grateful to have a robust telemedicine effort when people simply couldn’t come into the center,” said Dr. Borgen of Maimonides. But he acknowledged that patients were frequently reluctant to discuss their symptoms during a telehealth session, especially a mother whose young children could be listening to what they were saying. “It’s not private,” he noted.

Some health networks say they took aggressive steps to try to counteract the effects of the pandemic. During the initial stay-at-home order last year, Kaiser Permanente, the large California-based managed care outfit, spotted a declining number of breast cancer screenings and diagnoses in the northern part of the state. “Doctors immediately got together” to begin contacting patients, said Dr. Tatjana Kolevska, medical director for the Kaiser Permanente National Cancer Excellence Program.

Kaiser also relies on its electronic health records to make appointments for women who are overdue for their mammograms when they book an appointment with their primary care doctor or even want to get a prescription for new glasses.

While Dr. Kolevska says she is waiting to see data for the system as a whole, she has been encouraged by the number of patients in her practice who are now up to date with their mammograms.

“All of those things put in place have helped tremendously,” she said.

Moderna Starts Testing Its Covid Vaccine in Babies and Young Children

The company will study its vaccine in children ages six months through 11 in the United States and Canada.

The drug company Moderna has begun a study that will test its Covid vaccine in children under 12, including babies as young as six months, the company said on Tuesday.

The study is expected to enroll 6,750 healthy children in the United States and Canada. Moderna declined to say how many had already signed up or received the first shots, according to a spokeswoman, Colleen Hussey.

“There’s a huge demand to find out about vaccinating kids and what it does,” said Dr. David Wohl, the medical director of the vaccine clinic at the University of North Carolina, who is not involved the study.

In a separate study, Moderna is testing its vaccine in 3,000 children ages 12 to 17, and may have results for that age group by summer. The vaccine would then have to be authorized for use in children, so it would not be immediately available.

Many parents want protection for their children, and vaccinating children should help to produce the herd immunity considered crucial to stopping the pandemic. The American Academy of Pediatrics has called for expansion of vaccine trials to include children.

Vaccine side effects like fever, sore arms, fatigue and achy joints and muscles can be more intense in children than in adults, and doctors say it is important for parents to know what to expect after their children are inoculated.

Each child in Moderna’s study will receive two shots, 28 days apart. The study will have two parts. In the first, children aged 2 years to less than 12 may receive two doses of 50 or 100 micrograms each. Those under 2 years may receive two shots of 25, 50 or 100 micrograms.

In each group, the first children inoculated will receive the lowest doses and will be monitored for reactions before later participants are given higher doses.

Then, researchers will perform an interim analysis to determine which dose is safest and most likely to be protective for each age group.

Children in part 2 of the study will receive the doses selected by the analysis — or placebo shots consisting of salt water.

Moderna developed its vaccine in collaboration with the National Institute of Allergy and Infectious Diseases. The company and the institute are also working together on the study, along with the federal Biomedical Advanced Research and Development Authority.

The children will be followed for a year, to look for side effects and measure antibody levels that will help researchers determine whether the vaccine appears to provide protection. The antibody levels will be the main indicator, but the researchers will also look for coronavirus infections, with or without symptoms.

Dr. Wohl said the study appeared well designed and likely to be efficient, but he questioned why the children were to be followed for only one year, when adults in Moderna’s study are followed for two years. He also said he was somewhat surprised to see the vaccine being tested in children so young this soon.

“Should we learn first what happens in the older kids before we go to the really young kids?” Dr. Wohl asked. Most young children do not become very ill from Covid, he said, though some develop a severe inflammatory syndrome that can be life threatening.

Johnson & Johnson has also said it would test its coronavirus vaccine in babies and young children after testing it first in older children.

Pfizer-BioNTech is testing its vaccine in children ages 12 to 15, and has said it plans to move to younger groups; the product is already authorized for use in those 16 and up in the United States.

Last month, AstraZeneca began testing its vaccine in Britain in children 6 years and older.

Health Care Workers on the Frontline Face a Year of Risk, Fear and Loss

Gabrielle Dawn Luna followed her father into emergency nursing. She was the last person to hold his hand when he died of Covid in April at her hospital in Teaneck, N.J.
Gabrielle Dawn Luna followed her father into emergency nursing. She was the last person to hold his hand when he died of Covid in April at her hospital in Teaneck, N.J.Credit…Calla Kessler for The New York Times

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A Year of Risk, Fear and Loss for Families in Medicine

For many nurses and doctors, medicine was an inherited calling and one that bound couples. Then the virus threatened the ones they love.

Gabrielle Dawn Luna followed her father into emergency nursing. She was the last person to hold his hand when he died of Covid in April at her hospital in Teaneck, N.J.Credit…Calla Kessler for The New York Times

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  • March 12, 2021, 9:42 a.m. ET

Gabrielle Dawn Luna sees her father in every patient she treats.

As an emergency room nurse in the same hospital where her father lay dying of Covid last March, Ms. Luna knows firsthand what it’s like for a family to hang on to every new piece of information. She’s become acutely aware of the need to take extra time in explaining developments to a patient’s relatives who are often desperate for updates.

And Ms. Luna has been willing to share her personal loss if it helps, as she did recently with a patient whose husband died. But she has also learned to withhold it to respect each person’s distinct grief, as she did when a colleague’s father also succumbed to the disease.

It’s challenging, she said, to allow herself to grieve enough to help patients without feeling overwhelmed herself.

“Sometimes I think that’s too big a responsibility,” she said. “But that’s the job that I signed up for, right?”

The Lunas are a nursing family. Her father, Tom Omaña Luna, was also an emergency nurse and was proud when Ms. Luna joined him in the field. When he died on April 9, Ms. Luna, who also had mild symptoms of Covid-19, took about a week off work. Her mother, a nurse at a long-term-care facility, spent about six weeks at home afterward.

“She didn’t want me to go back to work for fear that something would happen to me, too,” Ms. Luna said. “But I had to go back. They needed me.”

When her hospital in Teaneck, N.J. swelled with virus patients, she struggled with stress, burnout and a nagging fear that left her grief an open wound: “Did I give it to him? I don’t want to think about that, but it’s a possibility.”

Like the Lunas, many who have been treating the millions of coronavirus patients in the United States over the past year come from families defined by medicine. It is a calling passed through generations, one that binds spouses and connects siblings who are states apart.

It’s a bond that brings the succor of shared experience, but for many, the pandemic has also introduced a host of fears and stresses. Many have worried about the risks they’re taking and those their loved ones face every day, too. They worry about the unseen scars left behind.

And for those like Ms. Luna, the care they give to coronavirus patients has come to be shaped by the beloved healer they lost to the virus.

Working through grief

Dr. Shawki Zuabi, right, who was from Nazareth, Israel, loved painting, fishing and rich conversation.Credit…Gabriella Angotti-Jones for The New York Times
“He believed in me so much,” Dr. Nadia Zuabi said. They had talked about working together one day.Credit…Gabriella Angotti-Jones for The New York Times

For Dr. Nadia Zuabi, the loss is so new that she still refers to her father, a fellow emergency department physician, in the present tense.

Her father, Dr. Shawki Zuabi, spent his last days in her hospital, UCI Health in Orange County, Calif., before dying of Covid on Jan. 8. The younger Dr. Zuabi almost immediately returned to work, hoping to keep going through purpose and her colleagues’ camaraderie.

She had expected that working alongside the people who had cared for her father would deepen her commitment to her own patients, and to some extent it has. But mainly, she came to realize how important it is to balance that taxing emotional availability with her own well-being.

“I try to always be as empathetic and compassionate as I can,” Dr. Zuabi said. “There’s a part of you that maybe as a survival mechanism has to build a wall because to feel that all the time, I don’t think it’s sustainable.”

Work is filled with reminders. When she saw a patient’s fingertips, she recalled how her colleagues had also pricked her father’s to check insulin levels.

“He had all these bruises on his fingertips,” she said. “It just broke my heart.”

The two had always been close, but they found a special connection when she went to medical school. Physicians often descend from physicians. About 20 percent in Sweden have parents with medical degrees, and researchers believe the rate is similar in the United States.

The older Dr. Zuabi had a gift for conversation and loved talking about medicine with his daughter as he sat in his living room chair with his feet propped up. She is still in her residency training, and throughout last year she would go to him for advice on the challenging Covid cases she was working on and he’d bat away her doubts. “You need to trust yourself,” he’d tell her.

When he caught the virus, she took time off to be at his bedside every day, and continued their conversations. Even when he was intubated, she pretended they were still talking.

She still does. After difficult shifts, she turns to her memories, the part of him that stays with her. “He really thought that I was going to be a great doctor,” she said. “If my dad thought that of me, then it has to be true. I can do it, even if sometimes it doesn’t feel like it.”

Love tempered by risk and horror

“We definitely have cathartic moments together where we just let it all out,” said Dr. Fred E. Kency Jr., who met his wife in medical school.Credit…Rory Doyle for The New York Times

In the same way that medicine is often a passion grown from a set of values passed from one generation to the next, it’s also one shared by siblings and one that draws healers together in marriage.

About 14 percent of physicians in the United States have siblings who also earned medical degrees, according to an estimate provided by Maria Polyakova, a health policy professor at Stanford University. And a fourth of them are married to another physician, according to a study published in the Annals of Internal Medicine.

In interviews with a dozen doctors and nurses, they described how it has long been helpful to have a loved one who knows the rigors of the job. But the pandemic has also revealed how frightening it can be to have a loved one in harm’s way.

A nurse’s brother tended to her when she had the virus before volunteering in another virus hot spot. A doctor had a bracing talk with her children about what would happen if she and her husband both died from the virus. And others described quietly weeping during a conversation about wills after putting their children to bed.

Dr. Fred E. Kency Jr., a physician at two emergency departments in Jackson, Miss., understood that he was surrounded by danger when he served in the Navy. He never expected that he would face such a threat in civilian life, or that his wife, an internist and pediatrician, would also face the same hazards.

“It is scary to know that my wife, each and every day, has to walk into rooms of patients that have Covid,” Dr. Kency said, before he and his wife were vaccinated. “But it’s rewarding in knowing that not just one of us, both of us, are doing everything we possibly can to save lives in this pandemic.”

The vaccine has eased fears about getting infected at work for those medical workers who have been inoculated, but some express deep concerns about the toll that working through a year of horrors has taken on their closest relatives.

“I worry about the amount of suffering and death she’s seeing,” Dr. Adesuwa I. Akhetuamhen, an emergency medicine physician at Northwestern Medicine in Chicago, said of her sister, who is a doctor at the Mayo Clinic in Rochester, Minn. “I feel like it’s something I’ve learned to cope with, working in the emergency department before Covid started, but it’s not something that’s supposed to happen in her specialty as a neurologist.”

“Of all my family members, I worry about her the most,” Dr. Adesuwa I. Akhetuamhen said.Credit…Sebastian Hidalgo for The New York Times
“We keep each other safe,” Dr. Eseosa T. Ighodaro said.Credit…Caroline Yang for The New York Times

She and her sister, Dr. Eseosa T. Ighodaro, have regularly talked on the phone to compare notes about precautions they’re taking, provide updates on their family and offer each other support. “She completely understands what I am going through and gives me encouragement,” Dr. Ighodaro said.

The seemingly endless intensity of work, the mounting deaths and the cavalier attitudes some Americans display toward safety precautions have caused anxiety, fatigue and burnout for a growing number of health care workers. Nearly 25 percent of them most likely have PTSD, according to a survey that the Yale School of Medicine published in February. And many have left the field or are considering doing so.

Donna Quinn, a midwife at N.Y.U. Health in Manhattan, has worried that her son’s experience as an emergency room physician in Chicago will lead him to leave the field he only recently joined. He was in his last year of residency when the pandemic began, and he volunteered to serve on the intubation team.

“I worry about the toll it’s taking on him emotionally,” she said. “There have been nights where we are in tears talking about what we’ve encountered.”

She still has nightmares that are sometimes so terrifying that she falls out of bed. Some are about her son or patients she can’t help. In one, a patient’s bed linens transform into a towering monster that chases her out of the room.

A nurse’s purpose

When Ms. Luna first returned to her emergency room at Holy Name Medical Center in Teaneck, N.J., after her father died, she felt as though something was missing. She had gotten used to having him there. It had been nerve-racking as every urgent intercom call for a resuscitation made her wonder, “Is that my dad?” But she could at least stop by every now and again to see how he was doing.

More than that though, she had never known what it was like to be a nurse without him. She remembered him studying to enter the field when she was in elementary school, coloring over nearly every line in his big textbooks with yellow highlighter.

Over breakfast last March, Ms. Luna told her father how shaken she was after holding an iPad for a dying patient to say goodbye to a family who couldn’t get into the hospital.

“This is our profession,” she recalled Mr. Luna saying. “We are here to act as family when family can’t be there. It’s a hard role. It’s going to be hard, and there will be more times where you’ll have to do it.”

Tom Omaña Luna, who was from the Philippines, had warm humor, deep faith and a funny way of shuffling his feet as he walked through the family home in Woodbridge, N.J. “I just miss it,” his daughter said.Credit…Calla Kessler for The New York Times

Kitty Bennett contributed research.

Lung Cancer Scans Are Recommended for People 50 and Older With Shorter Smoking Histories

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Yearly Lung Cancer Scans Are Advised for People 50 and Over With Shorter Smoking Histories

New advice from an influential panel will make more women and African-Americans eligible for CT scans, but some who need them most may not be able to afford them.

A computed tomography scan of the lungs of a healthy adult man. The panel recommended low-dose CT scans, so-called because they involve a relatively small amount of radiation, and cost about $300.
A computed tomography scan of the lungs of a healthy adult man. The panel recommended low-dose CT scans, so-called because they involve a relatively small amount of radiation, and cost about $300.Credit…Alamy Stock Photo

  • March 9, 2021, 11:00 a.m. ET

New guidelines from medical experts will nearly double the number of people in the United States who are advised to have yearly CT scans to screen for lung cancer, and will include many more African-Americans and women than in the past.

The disease is the leading cause of U.S. cancer deaths, and the goal of the expanded screening is to find it early enough to cure it in more people at high risk because of smoking. In those individuals, annual CT scans can reduce the risk of death from the cancer by 20 to 25 percent, large studies have found.

The new recommendations, by the U.S. Preventive Services Task Force, include people ages 50 to 80 who have smoked at least a pack a day for 20 years or more, and who still smoke or have quit within the past 15 years.

The advice, published on Tuesday in the medical journal JAMA, differs in two major ways from the task force’s previous guidelines, issued in 2013: It lowers the age when screening should start, to 50 from 55, and it reduces the smoking history to 20 years, from 30.

Those changes will add more women and African-Americans to the pool eligible for screening, because they tend to smoke less heavily than the white male study participants on whom earlier guidelines were based. Women and Black Americans also tend to develop lung cancer earlier and from less tobacco exposure than do white men, experts said.

Why the risk appears to differ by race and gender is not known.

“Some studies have alluded to some hormonal influences in women,” Dr. Mara Antonoff, a lung surgeon at the M.D. Anderson Cancer Center in Houston, said in an interview. “In terms of racial differences, we don’t have an answer. We have population-based data to show they have a tendency to develop lung cancer younger and with less exposure to tobacco, but we don’t have a mechanism.”

Under the new criteria, 14.5 million people in the United States will qualify for the screening, an increase of 6.4 million.

The task force includes 16 physicians, scientists and public health experts who periodically evaluate screening tests and preventive treatments. Members are appointed by the director of the federal Agency for Healthcare Research and Quality, but the group is independent and its recommendations often help shape U.S. medical practice.

The use of chest X-rays to detect lung cancer was largely abandoned decades ago because they could not find the disease early enough to be useful.

The CT scans, called low-dose CT — because they involve a relatively small amount of radiation — cost about $300. Patients are advised to stop the screening once they have not smoked for 15 years, or if they develop health problems that would substantially shorten their life expectancy or make them unable to have lung surgery if needed.

Patients have not flocked to clinics for this screening. Researchers estimate that only 6 to 18 percent of those who qualify and could be helped by the screening have taken advantage of it. Some cannot afford it.

“Part of the low uptake is simply lack of access to care,” said Dr. Robert Smith, a screening expert at the American Cancer Society. “Smoking in general is increasingly concentrated in lower-income populations.”

The Affordable Care Act does require that insurers cover any screening broadly recommended by the task force, with no out-of-pocket costs.

Bettye Givens, right, of south Kansas City, reviewing lung scans with her doctor in 2017. She received a low-dose CT scan that detected her lung cancer at its earliest stage and was successfully treated.
Bettye Givens, right, of south Kansas City, reviewing lung scans with her doctor in 2017. She received a low-dose CT scan that detected her lung cancer at its earliest stage and was successfully treated.Credit…Andy Marso/Kansas City Star/TNS/Alamy Live News

But researchers have found that half the population eligible for lung-cancer screening had either no insurance, or Medicaid, Dr. Smith said. Not all Medicaid plans have covered the screening, according to an editorial in JAMA.

“There could be a 15-year period when you might quality for screening and not have any insurance,” Dr. Smith said.

He and other researchers also said that patients may be missing out on lung-cancer screening because they just don’t know about it. It has not received as much attention as other cancer screenings, like mammograms, colonoscopies and Pap tests. Some doctors may not encourage it as strongly, and especially with former smokers, may not take the time to calculate a patient’s smoking history to see if it matches the guidelines.

The changes in the criteria for smoking history and screening age were based on new data from multiple studies, Dr. Alex H. Krist, the task force chairman and a professor of family medicine and population health at Virginia Commonwealth University, said in an interview.

“Lung cancer is the No. 1 cancer killer in America,” Dr. Krist said, adding that with the new data, “we have even more confidence that screening does save lives.”

Like other kinds of screenings affected by the pandemic, those for lung cancer remain below 2019 levels, according to an analysis of Medicare data by Avalere Health, a consulting firm, conducted for Community Oncology Alliance, which represents independent cancer specialists.

While the number of screenings had started to rebound in the summer, the fresh spike in Covid cases later in the year caused them to fall again. In November, screenings were down by 30 percent, compared to 2019, and the number of lung biopsies had also dropped, indicating cases were not being diagnosed.

Using its own grading system, the task force gave its recommendation a B, saying there was “moderate certainty” that annual screening was of “moderate net benefit.”

That may not sound like a ringing endorsement, given that a grade of A means “high certainty that the net benefit is substantial.” But anything with an A or B grade should be offered to patients, according to task force rules.

“There is building evidence that a pretty simple, five-minute, low-dose, low radiation scan can really save a lot of people’s lives,” said Dr. Bernard J. Park, a lung surgeon and the clinical director of the lung-screening service at Memorial Sloan Kettering Cancer Center in New York. About 75 to 85 percent of the cancers found with this screening are Stage 1, and curable with just surgery or radiation, he estimated.

Dr. Park said that many people who signed up for the screening had quit smoking or were trying to stop, but that a few regarded clear scans as a sign that they could keep smoking.

Dr. Smith said that the American Cancer Society was due to revise its own guidelines for lung-cancer screening, and that its advice would probably be similar to that of the task force.

In 2013, the American Academy of Family Physicians declined to recommend for or against CT screening for lung cancer, saying there was insufficient evidence. But the president, Dr. Ada Stewart, said in an emailed statement on Monday that the academy would review the new task force evidence and decide whether to update its own recommendation to its members.

There were 228,820 new cases of lung cancer in the United States in 2020, and 135,720 people died from it, according to the National Cancer Institute. About 90 percent of cases occur in people who smoke, and current smokers’ risk of developing the disease is about 20 times that of nonsmokers.

Only about 20.5 percent of patients survive five years after the diagnosis. Most cases are diagnosed late, after the cancer has begun to spread. But if it can be found and treated early, cure is possible, doctors say.

CT screening has risks, and doctors say those must be explained to patients, who may decide to decline the testing. The scans detect tiny nodules in the lungs that may be early cancers — or maybe not. A suspicious-looking spot could be just a minor infection, inflammation or a benign growth, Dr. Park said.

Often, the nodules can just be monitored with repeat scans, but it can be nerve-racking for patients to spend months waiting for the next test, knowing there is something in their lung that might be malignant.

False positive rates, when something harmless is mistaken for cancer, have ranged from 3.9 to 25 percent and higher in studies, but tend to decrease over time, as the patient has more annual scans.

A major concern about false positives is that they can lead to invasive procedures like lung biopsies. One large study found that invasive procedures were performed needlessly in 1.7 percent of the patients who were screened. The task force report said that standards created by radiology societies for evaluating the scans could help to prevent some unnecessary procedures spurred by false positives.

Another possible risk from screening is the chance that the cumulative radiation exposure could cause cancer. But the dose is low, and the risk is thought to be small, especially when compared with the risk of lung cancer caused by smoking.

In theory, screening could also lead to unneeded invasive tests and treatment for a cancer that would not have progressed or harmed the patient. How often that might occur is not known, but it is considered rare.

Reed Abelson contributed to this article.

Hunting for a Leftover Vaccine? This Site Will Match You With a Clinic.

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Hunting for a Leftover Vaccine? This Site Will Match You With a Clinic.

More than half a million people have signed up for Dr. B, a service that promises to match them with clinics struggling to equitably dole out extra doses before they expire.

Allison Ingram, a pharmacist, administered the Moderna Covid vaccine to Thomas Black at Cornerstone Pharmacy - Rodney Parham in Little Rock, Ark., on Monday.
Allison Ingram, a pharmacist, administered the Moderna Covid vaccine to Thomas Black at Cornerstone Pharmacy – Rodney Parham in Little Rock, Ark., on Monday.Credit…Rory Doyle for The New York Times

  • March 9, 2021, 7:00 a.m. ET

In the hustle to score an elusive vaccine appointment, the leftover dose has become the stuff of pandemic lore.

Extra shots — which must be used within hours once taken out of cold storage — have been doled out to drugstore customers buying midnight snacks, people who are friends with nurses and those who show up at closing time at certain grocery stores and pharmacies. At some larger vaccination sites, the race to use every dose sets off a flurry of end-of-the-day phone calls.

In every case, if the leftover dose does not find an available arm, it must go into the trash.

Now, a New York-based start-up is aiming to add some order to the rush for leftover doses. Dr. B, as the company is known, is matching vaccine providers who find themselves with extra vaccines to people who are willing to get one at a moment’s notice.

Since the service began last month, more than 500,000 people have submitted a host of personal information to sign up for the service, which is free to join and is also free to providers. Two vaccine sites have begun testing the program, and the company said about 200 other providers had applied to participate.

Dr. B is just one attempt at coordinating the chaotic patchwork of public and private websites that allow eligible people to find vaccine appointments. Critics have said the current system is confusing, unreliable and often requires access to the internet, as well as the time to prowl websites for the rare appointment. In many places, it also largely ignores people who aren’t yet eligible for a shot, wasting the opportunity to get them on a formal waiting list.

While Dr. B does not solve all of those broader problems, if it scales up the way some hope that it will, it could serve as a model for a better, more equitable way of scheduling vaccinations.

“I think that’s a great idea,” said Sharon Whisenand, the administrator of the Randolph County Health Department in rural Missouri.

Ms. Whisenand said that 60 to 80 people failed to show up to the county’s first mass vaccination event in late January, prompting her staff to make dozens of calls at the end of the day to people on a waiting list. “We sounded a little like a call center for a bit,” she said. The workers eventually found enough takers to administer most of the extra doses, but some shots were thrown out.

Dr. B is a for-profit effort, set up as a public-benefit corporation that includes efficient and equitable vaccine distribution in its mission. But its founder, Cyrus Massoumi, a tech entrepreneur, hasn’t yet described Dr. B’s business model. He said he was financing the project out of his own pocket and had no plans to collect revenue. The company is named after his grandfather, who was nicknamed Dr. Bubba and became a doctor during the 1918 influenza pandemic.

Mr. Massoumi is a founder and former chief executive of ZocDoc, which helps patients find available doctor’s appointments, and the founder of Shadow, a company that reunites lost pets with their owners using technology and local volunteers. Like both of those efforts, Dr. B seeks to make connections between groups that need something from each other.

“Ultimately, patients need this vaccine, and there’s providers who need help getting it to the people of priority,” Mr. Massoumi said in an interview. “That’s my motivation.”

Brittany Marsh, pharmacist and owner of Cornerstone Pharmacy – Rodney Parham, with vials of the Pfizer-BioNTech vaccine.Credit…Rory Doyle for The New York Times
More than 500,000 people have signed up with Dr. B since it began last month, and the company said about 200 vaccine providers had applied to participate.Credit…Rory Doyle for The New York Times

After coming up with the idea for Dr. B in January, Mr. Massoumi recruited several engineers from Haven, a now-defunct health care collaboration among Amazon, Berkshire Hathaway and J.P. Morgan, to build its website and underlying database. Amazon also donated web services, Mr. Massoumi said.

The half a million people who have signed up for the service entered basic biographical information, such as their date of birth, address, underlying health conditions and the type of work they do. If vaccine providers near them have extra doses, they will get notified via text message and have 15 minutes to respond. Then they must be willing to quickly travel to the vaccination site.

The company’s database sorts people by local rules about vaccine priority, giving providers better odds of administering their leftover shots to those in the greatest need.

For many providers, that orderly procedure would be a welcome change from the haphazard systems they are using now. At some pharmacies and supermarket chains, workers have resorted to combing the shopping aisles to find people willing to get a last-minute vaccine. At other locations, vaccine hopefuls wait in line at the end of every shift, which could pose an infection risk, particularly to the most vulnerable.

Despite some grumbling about younger, healthier people skipping the line by snapping up leftover doses, public health experts and many ethicists say the most important thing is that the vaccines don’t go to waste. Earlier in the vaccine rollout, some politicians, such as Gov. Andrew M. Cuomo of New York, threatened sanctions against providers for not precisely following priority rules, and a doctor in Texas lost his job after he gave expiring doses to people with medical conditions, including his wife.

Vaccines ready to be administered at Cornerstone Pharmacy - Rodney Parham.
Vaccines ready to be administered at Cornerstone Pharmacy – Rodney Parham.Credit…Rory Doyle for The New York Times
Ms. Marsh said that the pharmacy had been testing the Dr. B service for a few weeks.Credit…Rory Doyle for The New York Times

For those who are offered a last-minute vaccine, “that person should not say no because they want it to go to someone else,” said Dr. Shikha Jain, an assistant professor of medicine at the University of Illinois Chicago, and a co-founder of IMPACT, a group that has been working to improve the equitable distribution of vaccines. However, “it’s really important to be intentional and to be equitable,” she said.

Mr. Massoumi said he had taken several steps to ensure that the service will be equitable. That has included turning down early media requests from mainstream publications and instead promoting Dr. B on Zoom calls with representatives for groups like Black churches and Native American community groups, given that the pandemic has disproportionately affected nonwhite groups.

“It was really important for him to let these communities have potentially a place at the front of the line, or to get the information early,” said Brooke Williams, who is Black and a member of the Resistance Revival Chorus in New York. She joined one of the early Zoom calls and began spreading the word.

“Hearing about shots that were getting thrown out was just heartbreaking and infuriating,” she said.

The service suffers, however, from some of the same barriers that have marred vaccination efforts so far. Although signing up is simple, doing so requires an internet connection as well as ready access to a cellphone. Because of the last-minute nature of leftover doses, participants must have flexible schedules and access to transportation.

“It’s still heavily internet dependent, so it will depend on who hears about it,” said Arthur Caplan, a medical ethicist at New York University’s Grossman School of Medicine. “It seems he’s trying to solve a problem and do some good, but I’m sad that governments — counties, cities, national organizations — didn’t prepare for this and then didn’t react more quickly to give advice and guidance.”

Volunteers registered patients for vaccines at Cornerstone Pharmacy – Rodney Parham.Credit…Rory Doyle for The New York Times
Daron Nelson got his shot at Cornerstone. Dr. B has said that providers in 30 states have shown interest in the platform, from doctors’ offices and pharmacies to medical departments at large academic institutions.Credit…Rory Doyle for The New York Times

Mr. Massoumi noted that the site allowed for people such as community volunteers to sign up on others’ behalf. The site is also available in Spanish.

He noted that the program’s setup, which allows people to sign up, then wait for a notification based on priority, is better than other sites that require hours of refreshing websites in the odds they may luck into a rare opening.

Some local health authorities, including Washington, D.C., and West Virginia, are shifting to a similar preregistration system, which can help to level the playing field.

“There is this feeling where you don’t know where you stand, and the only way to secure your place is by refreshing a browser,” said John Brownstein, a Boston Children’s Hospital researcher who runs VaccineFinder.org, an online portal that helps people book vaccine appointments.

For Brittany Marsh, who owns a pharmacy in Little Rock, Ark., figuring out what to do with leftover doses was a daily headache.

She said the number of no-shows had increased as vaccines have become more available, and others have had to cancel at the last minute because they developed Covid-19 or were exposed to someone who did. Although sometimes people do call, she said, “more times than not, we just have a no-show.”

Ms. Marsh has been testing Dr. B’s service for a few weeks and said it saved her workers the hassle of calling a waiting list of other customers to quickly fill the open slots. With Dr. B, she said, “I know that they’re calling at least what we think is the right group of people to come get those shots, so that we don’t have to ever waste any.”

Dr. B has revealed few details about which providers have expressed interest in using its platform, other than to say the providers are based in 30 states and include doctors’ offices, pharmacies and the medical departments at large academic institutions.

The company collects sensitive personal information that it vows to closely safeguard, even though, because the company is not itself a medical provider, the data is not protected by the federal health care privacy law known as HIPAA.

When asked about his long-term plans for the company, Mr. Massoumi demurred, noting that the race to vaccinate was not going to end anytime soon.

“Right now, we just want to get the vaccines allocated in the best possible way,” he said. “I can’t think of a better use of money to help solve the pandemic, so we’re just heads down, focused on that.”

See How the Vaccine Rollout Is Going in Your State

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Women Report Worse Side Effects After a Covid Vaccine

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Women Report Worse Side Effects After a Covid Vaccine

Men and women tend to respond differently to many kinds of vaccines. That’s probably because of a mix of factors, including hormones, genes and the dosing of the shots.

C.D.C. researchers analyzed safety data from 13.7 million Covid-19 vaccinations, finding 79.1 percent of reported side effects came from women, though only 61.2 percent of the vaccines had been administered to women.
C.D.C. researchers analyzed safety data from 13.7 million Covid-19 vaccinations, finding 79.1 percent of reported side effects came from women, though only 61.2 percent of the vaccines had been administered to women.Credit…Mike Kai Chen for The New York Times

  • March 8, 2021, 11:44 a.m. ET

On the morning that Shelly Kendeffy received her second dose of the Moderna Covid-19 vaccine, she felt fine. By afternoon, she noticed a sore arm and body aches, and by evening, it felt like the flu.

“My teeth were chattering, but I was sweating — like soaked, but frozen,” said Ms. Kendeffy, 44, a medical technician in State College, Pa.

The next day, she went to work and surveyed her colleagues — eight men and seven women — about their vaccine experiences. Six of the women had body aches, chills and fatigue. The one woman who didn’t have flu symptoms was up much of the night vomiting.

The eight men gave drastically different reports. One had mild arm pain, a headache and body aches. Two described mild fatigue and a bit of achiness. One got a headache. And four had no symptoms at all.

“I work with some very tough women,” Ms. Kendeffy said. But “clearly, us women suffered a severity of the side effects.” She felt better after 24 hours, and is thrilled she got the vaccine. “I wouldn’t change a thing, because it sure beats the alternative,” she said. “But I also didn’t know what to expect.”

The differences Ms. Kendeffy observed among her co-workers are playing out across the country. In a study published last month, researchers from the Centers for Disease Control and Prevention analyzed safety data from the first 13.7 million Covid-19 vaccine doses given to Americans. Among the side effects reported to the agency, 79.1 percent came from women, even though only 61.2 percent of the vaccines had been administered to women.

Nearly all of the rare anaphylactic reactions to Covid-19 vaccines have occurred among women, too. C.D.C. researchers reported that all 19 of the individuals who had experienced such a reaction to the Moderna vaccine have been female, and that women made up 44 of the 47 who have had anaphylactic reactions to the Pfizer vaccine.

“I am not at all surprised,” said Sabra Klein, a microbiologist and immunologist at the Johns Hopkins Bloomberg School of Public Health. “This sex difference is completely consistent with past reports of other vaccines.”

In a 2013 study, scientists with the C.D.C. and other institutions found that four times as many women as men between the ages of 20 and 59 reported allergic reactions after receiving the 2009 pandemic flu vaccine, even though more men than women got those shots. Another study found that between 1990 and 2016, women accounted for 80 percent of all adult anaphylactic reactions to vaccines.

In general, women “have more reactions to a variety of vaccines,” said Julianne Gee, a medical officer in the C.D.C.’s Immunization Safety Office. That includes influenza vaccines given to adults, as well as some given in infancy, such as the hepatitis B and measles, mumps and rubella (M.M.R.) vaccines.

The news isn’t all bad for women, though. Side effects are usually mild and short-lived. And these physical reactions are a sign that a vaccine is working — that “you are mounting a very robust immune response, and you will likely be protected as a result,” Dr. Klein said.

See How the Vaccine Rollout Is Going in Your State

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But why do these sex differences happen? Part of the answer could be behavioral. It’s possible that women are more likely than men to report side effects even when their symptoms are the same, said Rosemary Morgan, an international health researcher at the Johns Hopkins Bloomberg School of Public Health. There’s no vaccine-specific research to support this claim, but men are less likely than women to see doctors when they are sick, so they may also be less likely to report side effects, she said.

Still, there’s no question that biology plays an important role. “The female immune response is distinct, in many ways, from the male immune response,” said Eleanor Fish, an immunologist at the University of Toronto.

Research has shown that, compared with their male counterparts, women and girls produce more — sometimes twice as many — infection-fighting antibodies in response to the vaccines for influenza, M.M.R., yellow fever, rabies, and hepatitis A and B. They often mount stronger responses from immune fighters called T cells, too, Ms. Gee noted. These differences are often most robust among younger adults, which “suggests a biological effect, possibly associated with reproductive hormones,” she said.

Sex hormones including estrogen, progesterone and testosterone can bind to the surface of immune cells and influence how they work. Exposure to estrogen causes immune cells to produce more antibodies in response to the flu vaccine, for example.

And testosterone, Dr. Klein said, “is kind of beautifully immunosuppressive.” The flu vaccine tends to be less protective in men with lots of testosterone compared with men with less of the sex hormone. Among other things, testosterone suppresses the body’s production of immune chemicals known as cytokines.

Genetic differences between men and women may also influence immunity. Many immune-related genes are on the X chromosome, of which women have two copies and men have only one. Historically, immunologists believed that only one X chromosome in women was turned on, and that the other was inactivated. But research now shows that 15 percent of genes escape this inactivation and are more highly expressed in women.

These robust immune responses help to explain why 80 percent of autoimmune diseases afflict women. “Women have greater immunity, whether it’s to ourselves, whether it’s to a vaccine antigen, whether it’s to a virus,” Dr. Klein said.

The size of a vaccine dose may also be important. Studies have shown that women absorb and metabolize drugs differently than men do, often needing lower doses for the same effect. But until the 1990s, drug and vaccine clinical trials largely excluded women. “The drug dosages that are recommended are historically based on clinical trials that involve male participants,” Dr. Morgan said.

Clinical trials today do include women. But in the trials for the new Covid vaccines, side effects were not sufficiently separated and analyzed by sex, Dr. Klein said. And they did not test whether lower doses might be just as effective for women but cause fewer side effects.

Until they do, Dr. Klein said, health care providers should talk to women about vaccine side effects so they are not scared by them. “I think that there is value to preparing women that they may experience more adverse reactions,” she said. “That is normal, and likely reflective of their immune system working.”

Answers to All Your Questions About Getting Vaccinated for Covid-19

Times reporters answered questions from readers about getting the vaccine, what to expect and what happens next.

Delayed Skin Reactions Appear After Vaccine Shots

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A Few People Report Delayed Skin Reactions to the Covid Vaccine

Doctors are reporting additional, minor symptoms that appear several days after people have received their shots.

By sharing the information about reactions, doctors said they wanted to help prevent the needless use of antibiotics and to ease patients’ worries about getting their second vaccine shot.
By sharing the information about reactions, doctors said they wanted to help prevent the needless use of antibiotics and to ease patients’ worries about getting their second vaccine shot.Credit…Mike Kai Chen for The New York Times

  • March 3, 2021, 6:27 p.m. ET

Some people are having delayed reactions to their first dose of a Covid vaccine, with their arms turning red, sore, itchy and swollen a week or so after the shot.

The reactions, though unpleasant, appear to be harmless. But the angry-looking skin condition can be mistaken for an infection, according to a letter published on Wednesday in The New England Journal of Medicine. The doctors said they wanted to share information about the cases to help prevent the needless use of antibiotics and to ease patients’ worries and reassure them that they can safely get their second vaccine shot.

“We modified our patient handout once we started seeing this,” Dr. Kimberly G. Blumenthal, an author of the letter and an allergist at Massachusetts General Hospital, said in an interview. “We had said it was normal to get redness, itching and swelling when you get the vaccine. We changed the wording to say it can also start seven to 10 days after you get the vaccine.”

The letter describes the experiences of 12 people who had “delayed large local reactions” that began four to 11 days after the first shot of the Moderna vaccine, within a median of eight days. The report is not a controlled study, but rather a series of cases that came to the doctors’ attention because the vaccine recipients were concerned and wanted to know whether they should get the second shot.

Most were vaccinated at Massachusetts General Hospital, where both the Moderna and Pfizer-BioNTech vaccines were administered. But the delayed reactions occurred only in people who had received the Moderna shot, Dr. Blumenthal said, adding, “I don’t understand why.”

Delayed skin reactions in various patients after receiving the mRNA Covid vaccines.
Delayed skin reactions in various patients after receiving the mRNA Covid vaccines.Credit…New England Journal of Medicine

Moderna reported delayed skin reactions in its large clinical trial in 0.8 percent of recipients after the first dose, and 0.2 percent after the second dose.

According to the letter by Dr. Blumenthal and 10 other physicians, all 12 people reported typical symptoms like a sore arm that often occur shortly after inoculation, and those initial symptoms had disappeared.

Then, a delayed reaction hit. In five people, big, raised skin lesions emerged that measured 10 or more centimeters in diameter near the injection site. Two had rashes in other spots, one near the elbow and one on the palm of the hand. Some also had systemic symptoms at the same time, like fatigue and achy muscles.

Most treated the skin symptoms with ice and antihistamines. But some needed steroids, in cream or pill form, and one was prescribed an antibiotic by a doctor who mistook the problem for an infection.

The symptoms lasted a median of six days, ranging from two to 11 days. All the patients went on to get the second shot. Half did not have another delayed reaction, but three developed the same symptoms again and three had milder reactions than after the first shot.

Dr. Blumenthal said there were many unanswered questions about the reactions. Ten of the 12 patients were women, but it is not clear whether women are more prone to the problem or whether the imbalance occurred because more of the vaccinated health workers were female.

Some had allergies to drugs, wasp stings or food, but others did not.

A skin biopsy on one patient indicated that the condition was a drug reaction. But what exactly the patient’s immune system was reacting to is not known.

“I’m hoping the companies will figure it out,” Dr. Blumenthal said.

She is aware of about 30 cases now, mostly among women and all recipients of the Moderna vaccine so far, she said, and the hospital has created a registry to track them.

High Turnover at Nursing Homes Threatens Residents' Care

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High Staff Turnover at U.S. Nursing Homes Poses Risks for Residents’ Care

A new study highlights the persistent problems caused by an unstable work force, an underlying threat that may have led to staggering death tolls in the pandemic.

Emergency medical technicians transported a patient from a nursing home to an emergency room bed at St. Joseph’s Hospital in Yonkers, N.Y., last year.
Emergency medical technicians transported a patient from a nursing home to an emergency room bed at St. Joseph’s Hospital in Yonkers, N.Y., last year.Credit…John Minchillo/Associated Press
Reed Abelson

  • March 1, 2021, 4:05 p.m. ET

Extraordinarily high turnover among staffs at nursing homes likely contributed to the shocking number of deaths at the facilities during the pandemic, the authors of a new study suggested.

The study, which was published Monday in Health Affairs, a health policy journal, represents a comprehensive look at the turnover rates in 15,645 nursing homes across the country, accounting for nearly all of the facilities certified by the federal government. The researchers found the average annual rate was 128 percent, with some facilities experiencing turnover that exceeded 300 percent.

“It was really staggering,” said David Grabowski, a professor of health care policy at Harvard Medical School and one of the study’s authors. Researchers pointed to the findings to urge Medicare to publish the turnover rates at individual nursing home sites, as a way of putting a spotlight on substandard conditions and pressuring owners to make improvements.

Inadequate staffing — and low pay — have long plagued nursing homes and quality-of-care for the more than one million residents who live in these facilities. But the pandemic has exposed these issues even more sharply, with investigations underway into some states’ oversight of the facilities as Covid cases spiraled unchecked and deaths skyrocketed.

The high turnover rate likely made it harder for nursing homes to put in place strong infection controls during the pandemic, and led to rampant spread of the coronavirus, said Ashvin Ghandi, the lead author and a health economist and assistant professor at the University of California Los Angeles Anderson School of Management.

Nursing-home owners blame inadequate reimbursement from Medicaid, the federal-state program for elderly skilled nursing care.

“Workforce recruitment and retention is among the most pressing challenges confronting longterm care providers, and we have been calling for help for years,” Dr. David Gifford, the chief medical officer for the American Health Care Association and National Center for Assisted Living, a trade group, said in an emailed statement.

“It’s high past time that providers receive the proper resources to invest in our frontline caregivers in order to improve quality care,” he said.

At least 172,000 deaths from the virus had been reported among either residents or employees of nursing homes and other long-term care facilities by late February, according to a database compiled by The New York Times. The nursing home death toll alone has accounted for more than one-third of all Covid deaths in the United States, although death and case rates have begun to decline steeply as more than 70 percent of residents have received vaccinations.

Eleanor Garrison, a resident of Arbor Springs Health and Rehabilitation Center in Opelika, Ala., last month.
Eleanor Garrison, a resident of Arbor Springs Health and Rehabilitation Center in Opelika, Ala., last month.Credit…Julie Bennett/Associated Press

Industry criticism has also focused on decades of ownership of nursing homes by private equity and other private investment firms, which prioritized profits for investors above the well-being of residents. These owners have long been accused of insufficiently staffing their facilities and underpaying workers.

Labor is one of the main expenses in the operation of a nursing home, Dr. Gandhi said. “It’s not a very high margin industry, in general,” he said. “Any facility trying to maximize profits is going to be thinking carefully about its staffing costs.”

Nursing home staffs have also shown resistance to getting vaccinated against the coronavirus, complicating efforts by public health officials and nursing homes to provide blanket immunization protection for an individual facility. If a nurse who was immunized leaves and is replaced, the facility will need to ensure the new employee is also vaccinated, especially given the reluctance of some workers to getting a coronavirus shot.

“Trying to do a one-shot vaccination push isn’t enough,” Dr. Gandhi said. “You need continued vaccination outreach.”

Registered nurses, who are the most skilled workers, had the highest rates of turnover, and turnover varied widely across facilities. Among the states with the highest rates were Oklahoma, Montana and Kansas. Facilities that had low-star ratings on Medicare’s website comparing nursing homes had the highest median turnover, and nursing homes with high ratings had the lowest turnover. Turnover was also higher at for-profit institutions, owned by chains and those serving Medicaid beneficiaries, according to the study.

Melissa Unger, the executive director at S.E.I.U. 503, an Oregon division of the Service Employees International Union, said nurses struggle to work at facilities with too few staff members to adequately care for the residents.

“You don’t feel great about the job you’re doing,” Ms. Unger said, noting that many staff members are women and people of color. “You’re doing all of that for crappy benefits and low pay.”

Summer Trosko, a union member working at an Oregon nursing home, said she was used to colleagues leaving from burnout because of inadequate staffing and a lack of money. “They get tired and just can’t take it anymore and quit,” she said. Many are replaced by people who have just graduated from high school with little training, she said.

In addition to making the turnover rates available to the public, the authors point to a number of steps lawmakers could take to improve retention. Medicare could incorporate turnover into its star-rating system, and Medicare and Medicaid could reward nursing homes with higher rates if they had lower turnover. “If we’re going to change nursing homes, we have to start with the staff,” Dr. Grabowski said.

The researchers used newly available payroll-based data collected by the Centers for Medicare and Medicaid Services for registered nurses, licensed practical nurses and certified nursing assistants to calculate turnover rates in 2017 and 2018. They looked at the percentage of hours worked by a nursing employee in a given year and calculated higher rates if the person leaving had provided more care.

A Covid Vaccine Side Effect, Enlarged Lymph Nodes, Can Be Mistaken for Cancer

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A Covid Vaccine Side Effect, Enlarged Lymph Nodes, Can Be Mistaken for Cancer

The condition is becoming more common as immunization rates increase. Experts are suggesting ways to ease patients’ fears and avoid needless testing.

Covid-19 vaccinations at the Community Center in Rohnert Park, Calif. Swelling of lymph nodes in the armpit became a  recognized side effect in the trials of the Moderna and Pfizer-BioNTech vaccines.
Covid-19 vaccinations at the Community Center in Rohnert Park, Calif. Swelling of lymph nodes in the armpit became a  recognized side effect in the trials of the Moderna and Pfizer-BioNTech vaccines.Credit…Jim Wilson/The New York Times

  • March 1, 2021, 3:14 p.m. ET

Coronavirus vaccinations can cause enlarged lymph nodes in the armpit or near the collarbone, which may be mistaken for a sign of cancer.

As vaccines are rolled out across the country, doctors are seeing more and more of these swollen nodes in recently immunized people, and medical journals have begun publishing reports aimed at allaying fears and helping patients avoid needless testing for a harmless condition that will go away in a few weeks.

The swelling is a normal reaction by the immune system to the vaccine, and occurs on the same side as the arm where the shot was given. It can also occur after other vaccinations, including those for flu and the human papillomavirus (HPV). Patients may or may not notice it. But the enlarged lymph nodes show up as white blobs on mammograms and chest scans, resembling images that can indicate the spread of cancer from a tumor in the breast or elsewhere in the body.

“I am particularly eager to get the word out to all the patients undergoing surveillance after successful prior treatment of cancer,” said Dr. Constance D. Lehman, an author of two journal articles on the problem and the chief of breast imaging at the Massachusetts General Hospital. “I can’t imagine the anxiety of getting the scan and hearing, ‘We found a node that is large. We don’t think it’s cancer but can’t tell,’ or worse, ‘We think it might be cancer.’”

The swelling in the armpit was a recognized side effect in the large trials of the Moderna and Pfizer-BioNTech vaccines. In Moderna’s study, 11.6 percent of patients reported swollen lymph nodes after the first dose, and 16 percent after the second dose. Pfizer-BioNTech appeared to have a lower incidence, with 0.3 percent of patients reporting it. But those figures reflect only what patients and their doctors noticed, and radiologists say that the real rate is probably higher, and that many more cases are likely to show up on imaging like mammograms, or M.R.I.s or CT scans.

The condition was not listed among the reported side effects in a briefing document from the Food and Drug Administration about the Johnson & Johnson Covid vaccine. On Saturday, the agency authorized the company’s vaccine for emergency use.

The image on the left shows a 41-year old man’s right shoulder, with arrows pointing to normal-sized lymph nodes in the armpit. The image on the right shows swelling in his left arm (dashed yellow arrow) and enlarged lymph nodes (yellow arrows) in his armpit. He had received a Covid vaccination four days earlier. Although he previously had cancer, the swollen nodes were thought to be caused by the vaccine.
The image on the left shows a 41-year old man’s right shoulder, with arrows pointing to normal-sized lymph nodes in the armpit. The image on the right shows swelling in his left arm (dashed yellow arrow) and enlarged lymph nodes (yellow arrows) in his armpit. He had received a Covid vaccination four days earlier. Although he previously had cancer, the swollen nodes were thought to be caused by the vaccine.Credit…Özütemiz et al., Radiology 2021

Dr. Lehman said it was important for imaging centers to ask patients if they have had Covid inoculations and to record the date of the shot and the arm in which it was given.

Her clinic includes this advisory in a letter to patients whose screenings detect swelling but no other abnormalities: “The lymph nodes in your armpit area that we see on your mammogram are larger on the side where you had your recent Covid-19 vaccine. Enlarged lymph nodes are common after the Covid-19 vaccine and are your body’s normal reaction to the vaccine. However, if you feel a lump in your armpit that lasts for more than six weeks after your vaccination, you should let your health care provider know.”

One way people could avoid the problem would be to postpone routine mammograms and other imaging for at least six weeks after the last dose of vaccine, according to an article by an expert panel in the journal Radiology, published on Wednesday.

A professional group, the Society of Breast Imaging, offers similar advice: “If possible, and when it does not unduly delay care, consider scheduling screening exams prior to the first dose of a Covid-19 vaccination or 4-6 weeks following the second dose of a Covid-19 vaccination.”

But the expert panel also cautioned that nonroutine imaging, needed to help deal with an illness or other symptoms that might indicate cancer, should not be delayed. Nor should immunization.

People who have cancer are generally advised to be vaccinated against the coronavirus, particularly because they are at higher risk of dying from Covid than the general population. But some cancer treatments may interfere with the body’s ability to respond fully to the vaccine, and the American Cancer Society advises patients to consult with their oncologists about vaccination.

In recently vaccinated people who have cancer and develop enlarged lymph nodes, it may be necessary to perform more tests, including a biopsy of the nodes, Dr. Lehman said.

She described one patient with a newly diagnosed breast tumor who had swollen lymph nodes on the same side, and had recently received a Covid shot in the arm on that side.

A biopsy was performed, an important step to determine whether there were malignant cells in the nodes that would then help decide a course of treatment. It was negative for cancer. The vaccine had most likely caused the swelling.

In another case, a woman who previously had cancer in her right breast had a routine mammogram that showed an enlarged lymph node in her left armpit, and no other abnormality. She’d recently received a Covid vaccination in the left arm. Doctors determined that no more tests would be needed unless the swollen nodes lasted more than six weeks.

In a man with a history of bone cancer, a chest CT scan performed as part of a follow-up found swollen lymph nodes in one armpit — on the side where he’d recently had a Covid inoculation. Nothing else was wrong and no further tests were needed. The same decision was made for similar findings in a recently vaccinated man who had a chest CT to screen for lung cancer, and in a woman with a history of melanoma.

For patients undergoing treatment for cancer in one breast, Dr. Lehman said, the Covid shot should be given in the arm on the other side. The vaccine can also be injected into the thigh to prevent any issues with lymph node swelling.

“This could really impact a lot of people if we don’t start recording vaccination status immediately at imaging centers,” Dr. Lehman said. “I also want cancer patients to know they can get the vaccine on the opposite side or even the leg to avoid confusion.”

In Quest for Herd Immunity, Giant Vaccination Sites Proliferate

Thomas Hatcher Sr., 84, of Glastonbury, Conn., received a shot of the Pfizer-BioNTech Covid vaccine at a mass inoculation site set up at Rentschler Field in East Hartford this month.
Thomas Hatcher Sr., 84, of Glastonbury, Conn., received a shot of the Pfizer-BioNTech Covid vaccine at a mass inoculation site set up at Rentschler Field in East Hartford this month.

In Quest for Herd Immunity, Giant Vaccination Sites Proliferate

A day at one mass site in Connecticut shows both the promise and the shortcomings of the approach, which is at the center of President Biden’s plan to bring the pandemic to an end.

Thomas Hatcher Sr., 84, of Glastonbury, Conn., received a shot of the Pfizer-BioNTech Covid vaccine at a mass inoculation site set up at Rentschler Field in East Hartford this month.Credit…

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  • Feb. 28, 2021, 3:00 a.m. ET

EAST HARTFORD, Conn. — With the nation’s coronavirus vaccine supply expected to swell over the next few months, states and cities are rushing to open mass vaccination sites capable of injecting thousands of shots a day into the arms of Americans, an approach the Biden administration has seized on as crucial for reaching herd immunity in a nation of 330 million.

The Federal Emergency Management Agency has joined in too: It recently helped open seven mega-sites in California, New York and Texas, relying on active-duty troops to staff them and planning many more. Some mass sites, including at Dodger Stadium in Los Angeles and State Farm Stadium in suburban Phoenix, aim to inject at least 12,000 people a day once supply ramps up; the one in Phoenix already operates around the clock.

The sites are one sign of growing momentum toward vaccinating every willing American adult. Johnson & Johnson’s single-dose vaccine won emergency authorization from the Food and Drug Administration on Saturday, and both Moderna and Pfizer have promised much larger weekly shipments of vaccines by early spring. In addition to using mass sites, President Biden wants pharmacies, community clinics that serve the poor and mobile vaccination units to play major roles in increasing the vaccination rate.

With only about 9 percent of adults fully vaccinated to date, the kind of scale mass sites provide may be essential as more and more people become eligible for the vaccines and as more infectious variants of the virus proliferate in the United States.

But while the sites are accelerating vaccination to help meet the current overwhelming demand, there are clear signs they won’t be able to address a different challenge lying ahead: the many Americans who are more difficult to reach and who may be reluctant to get the shots.

The drive-through mass vaccination site on a defunct airstrip here in East Hartford, outside Connecticut’s capital, shows the promise and the drawbacks of the approach.

Run by a nonprofit health clinic, the site has become one of the state’s largest distributors of shots since it opened six weeks ago, and its efficiency has helped Connecticut become a success story. Only Alaska, New Mexico, West Virginia and the Dakotas have administered more doses per 100,000 residents.

The site, on a defunct runway owned by Pratt & Whitney, has become one of the Connecticut’s largest distributors of shots since it opened six weeks ago.
The site, on a defunct runway owned by Pratt & Whitney, has become one of the Connecticut’s largest distributors of shots since it opened six weeks ago.
Susan Bissonnette, a nurse manager for Community Health Center, delivered vaccine doses to be administered to frontline health workers.
Staff members and National Guard troops arrived for a day of giving vaccinations and performing other jobs at the site.

Most of the people running mass sites are learning on the fly. Finding enough vaccinators, already challenging for some sites, could become a broader problem as they multiply. Local health care providers or faith-based groups rooted in communities will likely be far more effective at reaching people who are wary of the shots. And many of the huge sites don’t work for people who lack cars or easy access to public transportation.

“Highly motivated people that have a vehicle — it works great for them,” said Dr. Rodney Hornbake, who serves as both a vaccinator and the East Hartford site’s medic, on call for adverse reactions. “You can’t get here on a city bus.”

Before dawn on a recent raw morning, Susan Bissonnette, the nurse in charge, prepared enough vials of the Pfizer vaccine and diluent for the first few hundred shots of the day. At 7:45 a.m., her team surrounded her in a semicircle, stamping the snow off their boots and warming their fingers for the hours of injections that lay ahead.

“We’re going to start with 40 vials, eight per trailer,” Ms. Bissonnette shouted to the group of 19 nurses, a doctor and an underemployed dentist who had volunteered to help. “OK, so remember it’s Pfizer, right? Point three milliliters, right?”

The site vaccinates about 1,700 people on a good day, partly because Connecticut is small and gets fewer doses than many other states. It is a well-oiled machine, with a few dozen National Guard troops directing cars into 10 lanes, checking in people, who have to make appointments in advance, and making sure they have filled out a medical questionnaire before moving down the runway to their shots.

Troops also supervise the area at the end of the runway where people wait after their shots for 15 minutes — or 30, if they have a history of allergies — in case of serious reactions.

In between are the vaccinators, two per car lane, trading on and off between jabbing arms. When they need to warm up, they retreat inside heated trailers to draw up doses and fill out vaccination cards.

“If you simply open up with 10 lanes, it will be chaos unless you have teams all along the way at checkpoints, executing on the plan you’ve laid out,” said Mark Masselli, the president and chief executive of Community Health Center, which opened the East Hartford site on Jan. 18 and has since opened two smaller versions, in Stamford and Middletown. “You’ve got to marry some groups together — folks with health care delivery sense and folks with logistics sense.”

Monica Torrenegra, 53, left, a health care worker, and her mother, Mariela Medina, 75, both of Waterbury, in a waiting area after receiving their vaccines.
A dose ready for delivery. Most sites say their main challenge is not having enough supply to meet demand, a problem experts say will fade as more vaccines become available.
Bernie Delgado, 42, a nurse supervisor for Community Health Center, drew diluent into a syringe in preparing a dose of the vaccine.

The site came together in six days, as Mr. Masselli’s staff worked frenetically with the state to install trailers, generators, lights, a wireless network, portable bathrooms, traffic signs and thousands of orange cones to mark the lanes. Every worker has two all-important pieces of equipment: a walkie-talkie to communicate with all the stations and supervisors, and an iPad to verify appointments or enter information about each patient into a database.

The vaccine they use is Pfizer’s, which adds complexity because it has to be stored at minus 70 degrees Fahrenheit. The supply is kept in an ultracold freezer that Community Health Center installed at the adjacent University of Connecticut football stadium. Ms. Bissonnette and other supervisors speed there in bumpy golf carts several times a day to grab more vials, which last for only two hours at room temperature.

The first cars roll in at 8:30, often driven by the adult children or grandchildren of those getting shots.

Drive-through clinics can be better for infection control, some experts say — people roll down their car windows only for the injection — and more comfortable than standing in line. But a month into the Connecticut site’s existence, its weaknesses are also clear.

Traffic can get snarled on the busy road leading to the site, and bad weather can shut it down, requiring hundreds of appointments to be rescheduled on short notice. Spotty vaccine supply, which forced sites in California to close for a few days recently, can also wreak havoc.

More significantly, you need a car, gas money and, for some elderly people, a driver to get to and from the site. At this point, white people comprise 82 percent of those seeking shots at the East Hartford site, down from 90 percent in early February; their overrepresentation is partly because the older population now eligible is less diverse than the state overall.

Dr. Rodney Hornbake took the blood pressure of Katherine Delventhal, 85, of West Hartford after she received the vaccine. 
Marilyn Coppola, 82, of Madison got the shot. Officials have been taking pains to keep the crowds moving and happy. “If it’s really a pain in the neck, why would you go wait in line again a few weeks later?” said one expert.
Ms. Delgado with a fresh batch of vaccines ferried via golf cart from the nearby University of Connecticut football stadium, where the vaccines are stored at minus 70 degrees Fahrenheit.

To address problems of access and equity, FEMA is opening many of its new mass sites in low-income, heavily Black and Latino neighborhoods where fear of the vaccine is higher, vaccination rates have been lower and many people lack cars. In addition to its mass sites, Community Health Center, which serves large numbers of poor and uninsured people in clinics around the state, is also planning to send small mobile teams into neighborhoods to extend its vaccination reach.

The East Hartford site has hired several dozen temporary nurses and trained its dentists and dental hygienists to help with the shots. Still, staffing the site with 22 vaccinators daily remains a challenge, one that will grow nationally as more people become eligible for the shots.

Dr. Marcus Plescia, the chief medical officer for the Association of State and Territorial Health Officials, said the need for mass vaccination sites might wane as more and more of the low-hanging fruit — Americans who are highly motivated to get vaccinated as soon as possible — is picked.

“I think they have worked well in the current setting of demand substantially exceeding supply, drawing on many people who are eager to be vaccinated,” Dr. Plescia said. “As supply increases, and we have vaccinated the eager, we may find that lower-volume settings are preferable.”

Mobile vaccination clinics will reach some of the vaccine hesitant. But Dr. Plescia said people who are uncertain and fearful would be best served by doctors’ offices or community health centers where they can talk it through with health care providers they know.

“They’re not there to counsel you,” he said of mass sites. “You go to get the shot, end of story.”

Lena Bryant, 76, of Middletown, waited her turn for a shot.
National Guard troops are helping to oversee the operation.
Alcohol swabs and bandages prepped for action.

Dr. Nicole Lurie, who was the assistant health secretary for preparedness and response under President Barack Obama, said that instead of just asking FEMA for help, state and local governments should seek input from private companies used to keeping large crowds moving — while keeping them safe and happy.

In one such example, the company running Boston’s mass vaccination sites contracted with the event management firm that runs the Boston Marathon to handle day-to-day logistics. Several companies that ran large coronavirus testing operations are also involved in mass vaccination.

“These sites need to be motivated to make this a good experience for the customer, especially since they’re working with a two-dose vaccine,” Dr. Lurie said. “If it’s really a pain in the neck, why would you go wait in line again a few weeks later?”

Most sites say their main challenge is not having enough supply to meet demand. But with 315 million more Pfizer and Moderna doses promised by the end of May, and Johnson & Johnson pledging to provide the United States with 100 million doses of its newly authorized vaccine by the end of June, that complaint may fade before long.

The biggest headache for the East Hartford site has been the system for booking appointments, a clunky online registry known as VAMS that is being used in about 10 states. Many people 65 and older have had such a hard time navigating it that most end up calling 211, the phone number for health and social services assistance, to make appointments instead.

As the hours pass, the eternally smiling vaccinators in East Hartford get tired — and sometimes bone cold. But sometimes there are unexpected boosts, such as when John Rudy, 65, pulled up with his mother, Antoinette, in the back seat.

“We’ve got a 100-year-old!” Jean Palin, a nurse practitioner, announced as she prepared Ms. Rudy’s shot.

Antoinette Rudy, 100, arrived for her shot.
The biggest headache for the East Hartford site has been the clunky online appointment registration system, which many people 65 and older have had trouble navigating.
On days when there are more no-shows than usual, workers must find ways to administer the remaining doses before the vaccines are ruined from too much time out of the freezer.

The site usually closes at 4 p.m., but there was a problem: There were more no-shows than usual that day, in the middle of a snowy week, and there were 30 unused doses. Word went out from nurses at the site, including to people working at a nearby big-box store, who were not all eligible but could qualify for a vaccine if the alternative was throwing it away.

“It’s just a precision game toward the end of the day,” Ms. Bissonnette said.

At 5:15, Greg Gaudet, 63, drove up, teary with excitement. He had learned from one of the nurses, a former high school classmate, that a shot was available.

“I have a luckily dormant cancer, but my immunity is low,” said Mr. Gaudet, an architect whose form of leukemia was diagnosed six years ago. “I’m so grateful.”

How much the site will cost over time remains “a question that we are eager to work through,” Mr. Masselli said. Community Health Center spent about $500,000 to set it up and is spending roughly $50,000 a week on labor and other costs. It receives a fee for each shot it can bill insurance for — the Medicare rate is $16.94 for the first dose and $28.39 for the second — but is also counting on reimbursement from the state and FEMA for start-up and other costs.

Still, the expense has not stopped Mr. Masselli from imagining an expansion.

“There’s another runway over there,” he said, gesturing behind him. “Between the two, with two shifts, we could do 10,000 a day. March 14 is Daylight Saving Time; we’re going to pick up warmer weather, more light. The timing is right.”

F.D.A. Expert Panel Endorses Johnson & Johnson’s Vaccine

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F.D.A. Expert Panel Endorses Johnson & Johnson’s Vaccine

With this last hurdle cleared, formal authorization of the one-dose vaccine is expected on Saturday and distribution within days.

Vaccinations at the Steve Biko Academic Hospital in Pretoria, South Africa, earlier this week. The shot showed 82 percent against severe Covid in South Africa and 86 percent efficacy in the U.S.
Vaccinations at the Steve Biko Academic Hospital in Pretoria, South Africa, earlier this week. The shot showed 82 percent against severe Covid in South Africa and 86 percent efficacy in the U.S.Credit…Phill Magakoe/Agence France-Presse — Getty Images
Carl ZimmerNoah Weiland

Carl Zimmer and

  • Feb. 26, 2021, 6:25 p.m. ET

Johnson & Johnson’s Covid-19 vaccine was endorsed on Friday by a panel of experts advising the Food and Drug Administration, clearing the last hurdle before a formal authorization expected on Saturday, according to two people familiar with the agency’s plans. The nation’s first shipments will go out in the days after that.

It will be the third shot made available to the United States in the year since the first surge of coronavirus cases began washing over the country, and it will be the first vaccine to require just one dose instead of two.

Johnson & Johnson’s formulation worked well in clinical trials, particularly against severe disease and hospitalizations, even though it did not match the sky-high efficacy rates of the first two vaccines made by Pfizer-BioNTech and Moderna.

The panel, made up of independent infectious disease experts, statisticians and epidemiologists, voted unanimously in favor of authorizing the vaccine.

“We’re dealing with a pandemic right now,” said Dr. Jay Portnoy, an allergist at Children’s Mercy Hospital in Kansas City, M.O. and a member of the board. “It’s great that we have this vaccine.”

During Johnson & Johnson’s presentation to the panel, Dr. Gregory Poland, a virologist at the Mayo Clinic and a paid external consultant for the company, noted the vaccine’s efficacy, ease of use and low rate of side effects. It “nearly checks all the boxes,” he said. “To me, it is clear that the known benefits vastly outweigh the known risks.”

The vaccine had an overall efficacy rate of 72 percent in the United States and 64 percent in South Africa, where a concerning variant emerged in the fall. The shot showed 86 percent efficacy against severe forms of Covid-19 in the United States, and 82 percent against severe disease in South Africa.

Those are strong numbers, but lower than the roughly 95 percent efficacy rates of Pfizer-BioNTech and Moderna’s vaccines against mild, moderate and severe cases of Covid.

Johnson & Johnson’s vaccine is a single dose and uses a different kind of technology than the authorized vaccines. And the scale and size of the Johnson & Johnson trial was vast, spanning eight countries, three continents and nearly 45,000 participants.

Johnson & Johnson’s vaccine will be the third shot made available to the U.S. since the pandemic began, and it will be the first vaccine to require just one dose instead of two.
Johnson & Johnson’s vaccine will be the third shot made available to the U.S. since the pandemic began, and it will be the first vaccine to require just one dose instead of two.Credit…Phill Magakoe/Agence France-Presse — Getty Images

Although the vaccine works with one shot, studies are underway to determine if a second dose would increase its protective effects.

Dr. Paul Offit, a pediatrician at the Children’s Hospital of Philadelphia and one of the panelists, pointed out on Friday that in early clinical trials that took place over the summer, Johnson & Johnson found that a second dose led to levels of coronavirus antibodies that were almost three times higher than those produced by one dose alone.

The results of Johnson & Johnson’s two-dose, late-stage clinical trial are not expected until July at the earliest. If those results turn out to be better than a single dose, Dr. Offit asked, “Does this then become a two-dose vaccine?”

Dr. Johan Van Hoof, the global head of vaccine research and development at Janssen Pharmaceuticals, the drug development arm of Johnson & Johnson, said that the company decided to pursue the one-shot strategy after its studies on monkeys last spring showed that a single dose was enough to provide strong protection against the disease.

“It’s clear that in a situation of an outbreak, in a raging epidemic, the big challenge is to get the epidemic under control,” he said. “The regimen is extremely well positioned to be used in outbreak situations.”

But Dr. Van Hoof also noted that it will be important to track volunteers who received a single dose to see if their immunity changes in the months to come. It might be necessary to deliver a booster shot for long-term protection. “The big question mark still is, how long does protection last?” he said.

After the vote, the F.D.A. told Johnson & Johnson that it “will rapidly work toward finalization and issuance of an emergency use authorization,” according to a statement. The F.D.A. also said that it had notified other government agencies “so they can execute their plans for timely vaccine distribution.”

Sharon LaFraniere contributed reporting.

How the Johnson & Johnson Vaccine Works

An adenovirus helps prime the immune system to fight the coronavirus.

Johnson & Johnson’s Vaccine Works Well and May Curb Virus Spread

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Johnson & Johnson’s Vaccine Works Well and May Curb Virus Spread

F.D.A. studies show the shot strongly protects against severe illness and may reduce spread of the virus. But the drugmaker has fallen short of initial production goals.

Jacqui Dallimore, a research nurse, delivering a shot to a volunteer in the Johnson & Johnson vaccine trial at the Desmond Tutu H.I.V. Foundation Youth Center in Masiphumelele, South Africa, in December.
Jacqui Dallimore, a research nurse, delivering a shot to a volunteer in the Johnson & Johnson vaccine trial at the Desmond Tutu H.I.V. Foundation Youth Center in Masiphumelele, South Africa, in December.Credit…Joao Silva/The New York Times
Carl ZimmerNoah WeilandSharon LaFraniere

Carl Zimmer, Noah Weiland and

  • Feb. 24, 2021, 5:36 p.m. ET

The coronavirus vaccine made by Johnson & Johnson provides strong protection against severe disease and death from Covid-19, and may reduce the spread of the virus by vaccinated people, according to new analyses posted online by the company and the Food and Drug Administration on Wednesday.

The reports provided an in-depth confirmation of the initial results announced by Johnson & Johnson late last month, indicating that the United States is likely to soon have access to a third coronavirus vaccine developed in under a year. The F.D.A. could authorize the vaccine as early as Saturday, depending on a vote by its vaccine advisory panel on Friday, and distribution could begin within days.

If cleared, the vaccine would reach a number of firsts for the U.S. pandemic. Unlike the authorized vaccines made by Pfizer-BioNTech and Moderna, which require two doses, Johnson & Johnson’s is just a single shot, allowing the number of fully vaccinated Americans to rapidly increase once it is deployed. More than 44 million Americans have received at least one dose of the Moderna and Pfizer vaccines, but only around 20 million have received a second dose.

Those earlier vaccines use a new technology called mRNA that needs freezers for long-term storage. Johnson & Johnson’s vaccine, which uses sturdier viruses to deliver genes into cells, can keep for three months at normal refrigeration temperatures, making it easier to distribute and easier for pharmacies and clinics to stock. The White House on Wednesday said around two million doses would be ready to allocate to states next week, with up to another two million for pharmacies and community health centers.

The documents published by the F.D.A. on Wednesday showed that the new vaccine had an overall efficacy rate of 72 percent in the United States and 64 percent in South Africa, where a concerning variant emerged in the fall that is now driving most cases. The efficacy in South Africa was seven percentage points higher than earlier data released by the company showed.

The vaccine also showed 86 percent efficacy against severe forms of Covid-19 in the United States, and 82 percent against severe disease in South Africa. That means that a vaccinated person has a far lower risk of being hospitalized or dying from Covid-19. None of the nearly 22,000 vaccinated people in the trial died of Covid-19.

“The vaccine has definitely met the bar of what’s worthy of rolling out and using. It’s performing well,” said Natalie Dean, a biostatistician at the University of Florida. Another authorized vaccine, and especially one that only requires one dose, could block the spread of the virus more effectively and drive down cases faster. “Having more products available is a huge advantage,” Dr. Dean said.

How the Johnson & Johnson Vaccine Works

An adenovirus helps prime the immune system to fight the coronavirus.

State health departments around the nation have been eager to take advantage of it. In North Dakota, which has one of the nation’s highest rates of vaccination, members of the state’s vaccine ethics committee met this week to discuss the allocation and distribution of the vaccine, anticipating the F.D.A.’s analysis, said Kylie Hall, a vaccine adviser for the state’s health department. The new data may help guide the state’s decisions on which people to prioritize for the small number of doses that may arrive next week, she said.

“It prevents severe disease and death from Covid,” she said. “That’s the best news we could have.”

But access to the new vaccine could be severely limited at first. Dr. Richard Nettles, the vice president of U.S. medical affairs at Janssen Pharmaceuticals, the drug development arm of Johnson & Johnson, told lawmakers on Tuesday that nearly four million doses would be ready for shipment if the F.D.A. authorizes the vaccine. That is far below the 12 million it had originally pledged to give the federal government by the end of February.

He said that a total of 20 million doses would be ready by the end of March, 17 million fewer doses than the firm’s federal contract envisioned. But he insisted that Johnson & Johnson would fulfill its promise of 100 million doses by the end of June.

Asked about the shortfall on Wednesday, Jeffrey D. Zients, the White House coordinator of the pandemic response, said that the Biden administration discovered when it took office five weeks ago that Johnson & Johnson was behind on manufacturing and needed federal help in obtaining equipment and raw materials.

“It was disappointing when we arrived,” he said, but “I think the progress is real.” He added: “Obviously the prospect of a potential third approved vaccine is very encouraging,” because lack of supply remains the biggest obstacle to the nation’s vaccination effort.

A lab technician worked on blood samples taken from participants in the Johnson & Johnson Covid-19 vaccine trial at a lab in Groblersdal, South Africa, earlier this month.
A lab technician worked on blood samples taken from participants in the Johnson & Johnson Covid-19 vaccine trial at a lab in Groblersdal, South Africa, earlier this month.Credit…Jerome Delay/Associated Press

Johnson & Johnson’s vaccine has a lower efficacy rate than the vaccines from Moderna and Pfizer-BioNTech, which are both around 95 percent.

But in South Africa, the Johnson & Johnson vaccine is so far the clear winner. Novavax’s shot had an efficacy of 49 percent in South Africa. And a small trial in South Africa of the AstraZeneca-Oxford vaccine found that it did not offer much protection at all. The negative results led the South African government to abandon its plan of giving a million doses of AstraZeneca vaccines to health care workers. Last week, the government started giving Johnson & Johnson’s vaccines instead, and has so far administered more than 32,000.

The newly released documents, which include the F.D.A.’s first technical analysis of the company’s 45,000-person clinical trial, presented evidence that the vaccine was safe, with noticeably milder side effects than the Pfizer and Moderna vaccines and without any reports of severe allergic reactions like anaphylaxis.

The vaccine’s protection was consistent across Black, Hispanic and white volunteers, and also across different ages. The trial estimated a lower efficacy, of 42.3 percent, for people over 60 who had risk factors like heart disease or diabetes, a figure that came with a large amount of statistical uncertainty, the F.D.A. noted.

Dr. James Burke, an expert on trial design at the University of Michigan School of Medicine, cautioned that the results found in small subgroups can turn out to be the result of chance. “We’re wrong more than we’re right,” he said. “So we should always tread very cautiously.”

He noted that the trial only recorded 41 cases of Covid-19 in 6,667 people over 60 with comorbidities. “Common sense makes it pretty clear that we can’t make very robust estimates with such a small number of outcomes,” Dr. Burke said.

Preliminary data suggests that the vaccine’s protective effects grow in the weeks after vaccination. After 42 days, for example, only one vaccinated person got Covid-19, whereas 13 people in the placebo group did, which translates to a 92.4 percent efficacy rate. It’s not clear how long the vaccine’s protection will last before it wanes, an uncertainty that hovers over all the coronavirus vaccines, since they have only gone into testing in recent months.

Although several vaccines can protect people from getting sick with Covid-19, it is unclear whether the shots can also prevent people from getting infected and passing the virus to others, leading to a debate about how quickly society can return to normal after inoculations begin.

Moderna’s trial found some hints that vaccinated people were less likely to develop an infection without symptoms. And AstraZeneca found that its vaccine reduced asymptomatic infections by about half.

Johnson & Johnson looked for asymptomatic infections by checking for coronavirus antibodies 71 days after volunteers got a vaccine or a placebo. The new analyses estimate that the vaccine has an efficacy rate of 74 percent against asymptomatic infections. But that calculation was based on a relatively small number of volunteers, and the F.D.A. noted that “There is uncertainty about the interpretation of these data and definitive conclusions cannot be drawn at this time.”

Still, Dr. Dean said the results, while preliminary, were encouraging, especially when combined with other studies suggesting that vaccinated people who did get infected have a lower viral load, potentially making them less infectious.

“I think there’s a lot of good reasons to be optimistic,” she said.

Vaccines Adapted for Variants Will Not Need Lengthy Testing, F.D.A. Says

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Vaccines Adapted for Variants Will Not Need Lengthy Testing, F.D.A. Says

The agency’s new guidance will speed the development of vaccines that protect against more contagious variants of the coronavirus.

Nurses preparing doses of the Pfizer vaccine at a community center in Rohnert Park, Calif., last month.
Nurses preparing doses of the Pfizer vaccine at a community center in Rohnert Park, Calif., last month.Credit…Jim Wilson/The New York Times

Noah Weiland, Katie Thomas and

  • Feb. 22, 2021, 5:32 p.m. ET

The Food and Drug Administration said on Monday that vaccine developers would not need to conduct lengthy randomized controlled trials for vaccines that have been adapted to protect against concerning coronavirus variants.

The recommendations, which call for small trials more like those required for annual flu vaccines, would greatly accelerate the review process at a time when scientists are increasingly anxious about how the variants might slow or reverse progress made against the virus.

The guidance was part of a slate of new documents the agency released on Monday, including others addressing how antibody treatments and diagnostic tests might need to be retooled to respond to the virus variants.

Together, they amounted to the federal government’s most detailed acknowledgment of the threat the variants pose to existing vaccines, treatments and tests for the coronavirus, and came weeks after the F.D.A.’s acting commissioner, Dr. Janet Woodcock, said the agency was developing a plan.

“The emergence of the virus variants raises new concerns about the performance of these products,” Dr. Woodcock said in a statement Monday. “We want the American public to know that we are using every tool in our toolbox to fight this pandemic, including pivoting as the virus adapts.”

Most of the vaccine manufacturers with authorized vaccines or candidates in late-stage trials have already announced plans to adjust their products to address the vaccine variants. The Moderna and Pfizer-BioNTech vaccines use mRNA technology that the companies have said can be used to alter the existing vaccines within six weeks, although testing and manufacturing would take longer.

Moderna has already begun developing a new version of its vaccine that could be used as a booster shot against a virus variant that originated in South Africa, known as B.1.351, which seems to dampen the effectiveness of the existing vaccines.

A fast-spreading coronavirus variant first observed in Britain has also gained a worrisome mutation that could make it harder to control with vaccines. That variant with the mutation was found in the United States last week.

Still, the guidance did not appear to be written with the assumption that new vaccines were imminent, or would be needed at all. Despite the recent indications that some variants — and particularly B.1.351 — make the currently authorized vaccines less effective, the shots still offer protection and appear to greatly reduce the severity of the disease, preventing hospitalizations and death.

Asked at a news briefing on Monday afternoon how much the variants would need to spread before updated vaccines were necessary, Dr. Woodcock did not give any specific criteria. “We need to anticipate this and work on it so that we have something in our back pocket before the threshold is upon us,” she said.

An updated Covid-19 vaccine can skip the monthslong process of a randomized clinical trial that would compare it with a placebo, the agency said. But a tweaked vaccine will still need to go undergo some testing. In trials proposed by the F.D.A., researchers will draw blood from a relatively small group of volunteers who have been given the adapted vaccine. Scientists will then observe what percentage of volunteers’ samples produce an immune response to the variants in the lab, and how large that response is. The vaccines will be judged acceptable if they produce an immune response that is relatively close to the one prompted by the original vaccines.

Dr. Peter Marks, the top vaccine regulator at the F.D.A., said at the news briefing that studies would include a “few hundred” people and last several months.

Volunteers will also be monitored carefully for side effects. The agency said the testing could be done in a single age group and then extrapolated to other age groups.

The guidance also encouraged the use of animal studies to support the case for modified vaccines, in case immune response studies come up with ambiguous conclusions.

The F.D.A. acknowledged that many questions remained unanswered, such as what type of data would trigger the need for an adapted vaccine and who would make that decision. The agency also noted that scientists had not yet determined the minimum level of antibodies in a vaccinated person’s blood that would protect someone from the virus.

Some other vaccines are regularly updated in a similar way. Because the influenza virus evolves rapidly from one year to the next, vaccine developers have to come up with new recipes annually.

The newly tweaked Covid-19 vaccines would be authorized under an amendment to the emergency authorization granted to the original vaccine, regulators said.

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

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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
Carl ZimmerNoah Weiland

Carl Zimmer and

  • 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.”

Coronavirus Variants and Mutations

Tracking recent mutations, variants and lineages.

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.”

Some Teens Volunteer for Covid Vaccine Trials to Get Their Lives Back

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To Get Their Lives Back, Teens Volunteer for Vaccine Trials

Immunizing teenagers is a critical part of slowing the pandemic and reaching herd immunity. But enrolling them in clinical trials poses challenges that are very different than wrangling adults.

In Houston, Isabelle King, 14, gets her second dose of the Moderna vaccine from Jallesse Flores, as her twin sister,  Alexandra, looks on.
In Houston, Isabelle King, 14, gets her second dose of the Moderna vaccine from Jallesse Flores, as her twin sister,  Alexandra, looks on.Credit…Brandon Thibodeaux for The New York Times

  • Feb. 16, 2021, 1:55 p.m. ET

To get out of ninth-grade science period one recent Friday, the King twins had an excuse that is so very 2021.

Alexandra and Isabelle, 14, had to miss class — including a test — because they were participating in an actual science experiment: a clinical trial of Moderna’s Covid-19 vaccine to evaluate whether the shot is effective and safe in children ages 12 through 17.

“In science we’re learning about, like, genetics and stuff like that,” said Alexandra during the monitoring period after they’d gotten their shots at a Houston clinic. “So maybe the teacher will say, ‘Oh, you really shouldn’t have to take the test, because you’re contributing to science already.’”

Teenagers contract the novel coronavirus almost twice as often as younger children but vaccines authorized in the United States are mostly for adults — Moderna’s for 18 and older, Pfizer’s for 16 and up. While teenagers don’t become severely ill from the virus as often as adults, research suggests that because they are often asymptomatic and casual about social distancing, they can be efficient spreaders — to one another as well as to adults like parents, grandparents and teachers. Although vaccinating educators will be an important factor in keeping schools open, vaccinating students will also be a key element.

Bottom line: If widespread immunity to the coronavirus is to be achieved, adolescents are critical links. They need a Covid vaccine that works for them.

But teenagers are harder than adults to enroll and keep in clinical trials. They are difficult to wrangle and not so great with compliance, which includes keeping a symptom diary and keeping appointments, as many as six a year, that include blood draws (for some, an instant deal breaker).

To reach students, some researchers have tapped school connections, local pediatricians and social media campaigns. While waiting for appointments in the vaccine research clinics, some teenagers, ignoring advice to keep their vaccine volunteering off of social media, have posted TikTok videos, which have inspired friends to sign up. But the adolescent Covid vaccine trials will be much smaller than the adult trials — two or three thousand subjects instead of 30,000.

“You want to enroll as many kids as necessary but as few as possible, to expose as few as possible,” said Dr. Robert W. Frenck, director of the Vaccine Research Center at Cincinnati Children’s Hospital Medical Center.

To enroll in a trial, children must give “assent,” a legally required, age-appropriate version of “consent.” But researchers must also obtain the parent’s consent or permission. Information sessions for each can be protracted and painstaking. Objection by either child or parent terminates the application.

“Parents may be willing to put themselves in a study but not their children,” said Dr. James Campbell, a pediatric infectious disease expert at the University of Maryland School of Medicine who conducts vaccine trials. “Their key role in life, as parents, is to keep their children safe and they may choose to wait until a vaccine is licensed rather than enroll their child in a trial.”

Often researchers give young subjects an additional caution. Because vaccine disinformation and online personal attacks are so widespread, youth volunteers should avoid discussing their role in the trial on social media.

Audrey, 14, and Sam, 12, brother and sister, are participating in the Pfizer trial in Cincinnati.
Audrey, 14, and Sam, 12, brother and sister, are participating in the Pfizer trial in Cincinnati.Credit…Maddie McGarvey for The New York Times

Although the novel coronavirus has had far less impact on children than older adults, some 2.2 million pediatric cases in the United States have been reported and about 280 children have died, according to the Centers for Disease Control and Prevention. About 2,060 children have contracted a dangerous rare condition related to the coronavirus called multisystem inflammatory syndrome, which can shut down the heart and other organs.

And like anenemy occupation, the pandemic has taken over most children’s lives — shutting down in-person school, sports, socializing. That has prompted some teenagers, who otherwise feel so powerless, to fight back by volunteering for vaccine trials.

Sam, 12, who entered the Pfizer trial at Cincinnati Children’s hospital, said he wanted to participate “because it would be helping science and beat the pandemic. And it was my way of saying thank you to the frontline workers who are keeping us healthy.”

His sister, Audrey, 14, who is also in the study, said, “I thought this would be a really good story I could tell my children and grandchildren — that I tried to help create the vaccine.”

“And I also thought it is important to have people of different ages and races represented,” added Audrey, who, like her brother, is Asian. (Their mother, Rachel, a nurse researcher who volunteered for a vaccine trial, asked that their last names be withheld for privacy reasons.)

Overall, the teen trials may be less diverse, because results from adult trials showed no discernible difference in outcome by race. And because the adult trials were so successful, up to two-thirds of teenagers may be offered the actual vaccine rather than a placebo.

Pfizer, whose trial is fully enrolled, expects results from its trials for children ages 12 through 15 in the first quarter of this year, which it will then submit to the Food and Drug Administration for review. Moderna is still recruiting for its adolescent trials, with data anticipated sometime this summer. Other companies expect to start adolescent trials soon. Shortly after, researchers will open trials for children as young as 5, most likely with more modest doses.

As in any medical trial, investigators are evenhanded when discussing risks and benefits. Rather than lecturing young subjects, Dr. Campbell, whose clinic will conduct a Moderna trial for younger children, engages them in conversation.

“Do you remember your tetanus shot? Tell me about it,” he might say. And then, “Here’s how this is similar and how it’s different.” He wants to make sure the teenager is actively involved in decision-making. “We always say, ‘Don’t do this for your parents.’ ”

Dr. Sarah Hasan, lead recruiter for DM Clinical Research, which oversees the Houston Fights Covid campaign and most of the city’s vaccine trials, said that information sessions for adolescents and adults differ strikingly. She has more fun with the teenagers.

“Usually adults will skim the form, ask a few questions and they’re done,” she said. “But kids ask way more questions than adults and they’re actually listening, which is pretty nice.”

“Of course,” she added, “they also want to know if the doses will turn them into zombies.”

During adult trials, when participants were leery and results unknown, no-shows for appointments were common, Dr. Hasan said. But teenagers “come on time and are being super-compliant.”

Another issue in enrollment is compensation. Researchers typically offer volunteers money to cover time and travel expenses but the amount cannot be substantial enough to seem like an inducement. The going rate is about $15 an hour. The Cincinnati Pfizer trial compensates parents too, reasoning that they contribute time and money, as unofficial chauffeurs for the young subjects.

In Houston, the King sisters were already fantasizing about how they would spend the money.

Alexandra’s impulses were immediately generous. Now she could buy presents for others that her father typically paid for. “It’ll definitely be something nice to do, like, I earned it by getting a shot in the arm to help people. And now at least I can buy Christmas gifts for my mom,” she said.

Jonah Proctor, 15, awaits his shot at a Covid vaccine trial site in Houston.Credit…Brandon Thibodeaux for The New York Times

Her sister Isabelle hastily chimed in that, of course, she too would use the money for something selfless. Then she did allow, “Well, my closet could use an update.”

This summer, Monica Mitchell, a community health educator who works for Cincinnati Children’s, participated in a Pfizer vaccine trial. Her daughter Melanie, a high school junior, was deeply curious, but at that point, volunteers had to be at least 16 years old. On the day she turned 16, Melanie called to enroll.

Both mother and daughter have become ambassadors for the vaccine. “Someone said to me, ‘You’re doing the white man’s work,’ ” recounted Melanie, who is Black. “And I said, ‘No, it’s the opposite. I’m doing the work for my people.’ ”

Dr. Mitchell, who is also a pediatric psychologist and researcher, got some blowback for allowing her daughter to enter a vaccine trial. “Some relatives asked, “‘Why would you do that?’ But at least they understand that Melanie is fairly independent and they know she made her own decision,” Dr. Mitchell said.

Like most trial volunteers, children worry about side effects. Sure enough, after Sam got the second dose from Cincinnati Children’s hospital, he had a rough go of it.

In the middle of the night he woke with a throbbing headache. Then chills, a low-grade fever, muscle aches.

“He looked miserable,” said his mother, Rachel. “It’s one thing to talk theoretically about side effects but it was hard as a mom to see him feeling really bad.”

She felt guilty for having encouraged him to participate. “I’m so sorry,” she said.

Sam was mystified by her reaction. “I’m so happy,” he replied. “This means I got the real thing!”

Audrey, his sister, felt fine after her dose. “I’m jealous,” she said.

Scientists Are Trying to Spot New Viruses Before They Cause Pandemics

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Scientists Are Trying to Spot New Viruses Before They Cause Pandemics

Scientists want to build a weather system for viruses. It would require a big financial investment, plus buy-in from doctors, hospitals and blood banks.

Dr. Michael Mina, an epidemiologist at the Harvard T.H. Chan School of Public Health.
Dr. Michael Mina, an epidemiologist at the Harvard T.H. Chan School of Public Health.Credit…Kayana Szymczak for The New York Times

  • Feb. 15, 2021, 5:00 a.m. ET

Back in the summer, Dr. Michael Mina made a deal with a cold storage company. With many of its restaurant clients closed down, the firm had freezers to spare. And Dr. Mina, an epidemiologist at the Harvard T.H. Chan School of Public Health, had a half-million vials of plasma from human blood coming to his lab from across the country, samples dating back to the carefree days of January 2020.

The vials, now in three hulking freezers outside Dr. Mina’s lab, are at the center of a pilot project for what he and his collaborators call the Global Immunological Observatory. They envision an immense surveillance system that can check blood from all over the world for the presence of antibodies to hundreds of viruses at once. That way, when the next pandemic washes over us, scientists will have detailed, real-time information on how many people have been infected by the virus and how their bodies responded.

It might even offer some early notice, like a tornado warning. Although this monitoring system will not be able to detect new viruses or variants directly, it could show when large numbers of people start acquiring immunity to a particular kind of virus.

The human immune system keeps a record of pathogens it has met before, in the form of antibodies that fight against them and then stick around for life. By testing for these antibodies, scientists can get a snapshot of which flu viruses you have had, what that rhinovirus was that breezed through you last fall, even whether you had a respiratory syncytial virus as a child. Even if an infection never made you sick, it would still be picked up by this diagnostic method, called serological testing.

“We’re all like little recorders,” keeping track of viruses without realizing it, Dr. Mina said.

Spotting Patterns

This type of readout from the immune system is different from a test that looks for an active viral infection. The immune system starts to produce antibodies one to two weeks after an infection begins, so serology is retrospective, looking back at what you have caught. Also, closely related viruses may produce similar responses, provoking antibodies that bind to the same kinds of viral proteins. That means carefully designed assays are needed to distinguish between different coronaviruses, for example.

But serology uncovers things that virus testing does not, said Derek Cummings, an epidemiologist at the University of Florida. With a large database of samples and clinical details, scientists can begin to see patterns emerge in how the immune system responds in someone with no symptoms compared to someone struggling to clear the virus. Serology can also reveal before an outbreak starts whether a population has robust immunity to a given virus, or if it is dangerously low.

“You want to understand what has happened in a population, and how prepared that population is for future attacks of a particular pathogen,” Dr. Cummings said.

The approach could also detect events in the viral ecosystem that otherwise go unnoticed, Dr. Cummings said. For example, the 2015 Zika outbreak was detected by doctors in Brazil who noticed a cluster of babies with abnormally small heads, born seven to nine months after their mothers were infected. “A serological observatory could conceivably have picked this up before then,” he said.

Freezers containing a half-million vials of plasma outside Dr. Mina’s lab at the Harvard T.H. Chan School of Public Health.
Freezers containing a half-million vials of plasma outside Dr. Mina’s lab at the Harvard T.H. Chan School of Public Health.Credit…Kayana Szymczak for The New York Times

Serological surveys are often small and difficult to set up, since they require drawing blood from volunteers. But for several years Dr. Mina and his colleagues have been discussing the idea of a large and automated surveillance system using leftover samples from routine lab tests.

“Had we had it set up in 2019, then when this virus hit the U.S., we would have had ready access to data that would have allowed us to see it circulating in New York City, for example, without doing anything different,” Dr. Mina said.

Although the observatory would not have been able to identify the new coronavirus, it would have revealed an unusually high number of infections from the coronavirus family, which includes those that cause common colds. It might also have shown that the new coronavirus was interacting with patients’ immune systems in unexpected ways, resulting in telltale markers in the blood. That would have been a signal to start genetic sequencing of patient samples, to identify the culprit, and might have provided grounds to shut down the city earlier, Dr. Mina said. (Similarly, serology would not be able to spot the emergency of a new virus variant, like the contagious coronavirus variants that were discovered in South Africa and England before spreading elsewhere. For that, researchers must rely on standard genomic sequencing of virus test samples.)

A Powerful Investment

The observatory would require agreements with hospitals, blood banks and other sources of blood, as well as a system for acquiring consent from patients and donors. It also faces the problem of financing, noted Alex Greninger, a virologist at the University of Washington. Health insurance companies would be unlikely to foot the bill, since serology tests are usually not used by doctors to treat people.

Dr. Mina estimated that the observatory would cost about $100 million to get off the ground. He pointed out that, according to his calculations, the federal government has allocated more than twice that much to diagnostics company Ellume to produce enough rapid Covid tests to cover the American demand for only a handful of days. A pathogen observatory, he said, is like a weather forecasting system that draws on vast numbers of buoys and sensors around the globe, passively reporting on events where and when they arise. These systems have been funded by government grants and are widely valued.

The predictive power of serology is worth the investment, said Jessica Metcalf, an epidemiologist at Princeton and one of the observatory team members. A few years ago, she and her collaborators found in a smaller survey that immunity to measles was ominously low in Madagascar. Indeed, in 2018 an outbreak took hold, killing more than 10,000 children.

Now, the half-million plasma samples in Dr. Mina’s freezers, collected by the plasma donation company Octopharma from sites across the country last year, are starting to undergo serological tests focused on the new coronavirus, funded by a $2 million grant from Open Philanthropy. Testing had to wait for the researchers to set up a new robotic testing facility and process the samples, but now they are working through their first batches.

The team hopes to use this data to show how the virus flowed into the United States, week by week, and how immunity to Covid has grown and changed. They also hope it will spark interest in using serology to illuminate the movement of many more viruses.

“The big idea is to show the world that you don’t have to spend huge dollars to do this kind of work,” Dr. Mina said. “We should have this happening all the time.”

How Scientists Are Trying to Spot New Viruses Before They Cause Pandemics

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Scientists Are Trying to Spot New Viruses Before They Cause Pandemics

Scientists want to build a weather system for viruses. It would require a big financial investment, plus buy-in from doctors, hospitals and blood banks.

Dr. Michael Mina, an epidemiologist at the Harvard T.H. Chan School of Public Health.
Dr. Michael Mina, an epidemiologist at the Harvard T.H. Chan School of Public Health.Credit…Kayana Szymczak for The New York Times

  • Feb. 15, 2021, 5:00 a.m. ET

Back in the summer, Dr. Michael Mina made a deal with a cold storage company. With many of its restaurant clients closed down, the firm had freezers to spare. And Dr. Mina, an epidemiologist at the Harvard T.H. Chan School of Public Health, had a half-million vials of plasma from human blood coming to his lab from across the country, samples dating back to the carefree days of January 2020.

The vials, now in three hulking freezers outside Dr. Mina’s lab, are at the center of a pilot project for what he and his collaborators call the Global Immunological Observatory. They envision an immense surveillance system that can check blood from all over the world for the presence of antibodies to hundreds of viruses at once. That way, when the next pandemic washes over us, scientists will have detailed, real-time information on how many people have been infected by the virus and how their bodies responded.

It might even offer some early notice, like a tornado warning. Although this monitoring system will not be able to detect new viruses or variants directly, it could show when large numbers of people start acquiring immunity to a particular kind of virus.

The human immune system keeps a record of pathogens it has met before, in the form of antibodies that fight against them and then stick around for life. By testing for these antibodies, scientists can get a snapshot of which flu viruses you have had, what that rhinovirus was that breezed through you last fall, even whether you had a respiratory syncytial virus as a child. Even if an infection never made you sick, it would still be picked up by this diagnostic method, called serological testing.

“We’re all like little recorders,” keeping track of viruses without realizing it, Dr. Mina said.

Spotting Patterns

This type of readout from the immune system is different from a test that looks for an active viral infection. The immune system starts to produce antibodies one to two weeks after an infection begins, so serology is retrospective, looking back at what you have caught. Also, closely related viruses may produce similar responses, provoking antibodies that bind to the same kinds of viral proteins. That means carefully designed assays are needed to distinguish between different coronaviruses, for example.

But serology uncovers things that virus testing does not, said Derek Cummings, an epidemiologist at the University of Florida. With a large database of samples and clinical details, scientists can begin to see patterns emerge in how the immune system responds in someone with no symptoms compared to someone struggling to clear the virus. Serology can also reveal before an outbreak starts whether a population has robust immunity to a given virus, or if it is dangerously low.

“You want to understand what has happened in a population, and how prepared that population is for future attacks of a particular pathogen,” Dr. Cummings said.

The approach could also detect events in the viral ecosystem that otherwise go unnoticed, Dr. Cummings said. For example, the 2015 Zika outbreak was detected by doctors in Brazil who noticed a cluster of babies with abnormally small heads, born seven to nine months after their mothers were infected. “A serological observatory could conceivably have picked this up before then,” he said.

Freezers containing a half-million vials of plasma outside Dr. Mina’s lab at the Harvard T.H. Chan School of Public Health.
Freezers containing a half-million vials of plasma outside Dr. Mina’s lab at the Harvard T.H. Chan School of Public Health.Credit…Kayana Szymczak for The New York Times

Serological surveys are often small and difficult to set up, since they require drawing blood from volunteers. But for several years Dr. Mina and his colleagues have been discussing the idea of a large and automated surveillance system using leftover samples from routine lab tests.

“Had we had it set up in 2019, then when this virus hit the U.S., we would have had ready access to data that would have allowed us to see it circulating in New York City, for example, without doing anything different,” Dr. Mina said.

Although the observatory would not have been able to identify the new coronavirus, it would have revealed an unusually high number of infections from the coronavirus family, which includes those that cause common colds. It might also have shown that the new coronavirus was interacting with patients’ immune systems in unexpected ways, resulting in telltale markers in the blood. That would have been a signal to start genetic sequencing of patient samples, to identify the culprit, and might have provided grounds to shut down the city earlier, Dr. Mina said. (Similarly, serology would not be able to spot the emergency of a new virus variant, like the contagious coronavirus variants that were discovered in South Africa and England before spreading elsewhere. For that, researchers must rely on standard genomic sequencing of virus test samples.)

A Powerful Investment

The observatory would require agreements with hospitals, blood banks and other sources of blood, as well as a system for acquiring consent from patients and donors. It also faces the problem of financing, noted Alex Greninger, a virologist at the University of Washington. Health insurance companies would be unlikely to foot the bill, since serology tests are usually not used by doctors to treat people.

Dr. Mina estimated that the observatory would cost about $100 million to get off the ground. He pointed out that, according to his calculations, the federal government has allocated more than twice that much to diagnostics company Ellume to produce enough rapid Covid tests to cover the American demand for only a handful of days. A pathogen observatory, he said, is like a weather forecasting system that draws on vast numbers of buoys and sensors around the globe, passively reporting on events where and when they arise. These systems have been funded by government grants and are widely valued.

The predictive power of serology is worth the investment, said Jessica Metcalf, an epidemiologist at Princeton and one of the observatory team members. A few years ago, she and her collaborators found in a smaller survey that immunity to measles was ominously low in Madagascar. Indeed, in 2018 an outbreak took hold, killing more than 10,000 children.

Now, the half-million plasma samples in Dr. Mina’s freezers, collected by the plasma donation company Octopharma from sites across the country last year, are starting to undergo serological tests focused on the new coronavirus, funded by a $2 million grant from Open Philanthropy. Testing had to wait for the researchers to set up a new robotic testing facility and process the samples, but now they are working through their first batches.

The team hopes to use this data to show how the virus flowed into the United States, week by week, and how immunity to Covid has grown and changed. They also hope it will spark interest in using serology to illuminate the movement of many more viruses.

“The big idea is to show the world that you don’t have to spend huge dollars to do this kind of work,” Dr. Mina said. “We should have this happening all the time.”

7 Virus Variants Found in U.S. Carrying the Same Mutation

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7 Virus Variants Found in U.S. Carrying the Same Mutation

Scientists don’t know yet whether the mutation makes the variants more contagious, but they are concerned that it might.

Scientists at Duke University sequenced positive coronavirus tests to identify which strains are circulating in the community, on Feb. 3.
Scientists at Duke University sequenced positive coronavirus tests to identify which strains are circulating in the community, on Feb. 3.Credit…Pete Kiehart for The New York Times
Carl Zimmer

  • Feb. 14, 2021, 11:25 a.m. ET

As Americans anxiously watch variants first identified in the United Kingdom and South Africa spread in the United States, scientists are finding a number of new variants that originated here. More concerning, many of these variants seem to be evolving in the same direction — potentially becoming contagious threats of their own.

In a study posted on Sunday, a team of researchers reported seven growing lineages of the novel coronavirus, spotted in states across the country. All of them have evolved a mutation in the same genetic letter.

“There’s clearly something going on with this mutation,” said Jeremy Kamil, a virologist at Louisiana State University Health Sciences Center and a co-author of the new study.

It’s unclear whether it makes the variants more contagious. But because the mutation appears in a gene that influences how the virus enters human cells, the scientists are highly suspicious.

“I think there’s a clear signature of an evolutionary benefit,” Dr. Kamil said.

The history of life is full of examples of so-called convergent evolution, in which different lineages follow the same path. Birds gained wings as they evolved from feathered dinosaurs, for example, just as bats did when they evolved from furry, shrew-like mammals. In both cases, natural selection gave rise to a pair of flat surfaces that could be flapped to generate lift — enabling bats and birds alike to take to the sky and fill an ecological niche that other animals could not.

Charles Darwin first recognized convergent evolution by studying living animals. In recent years, virologists have found that viruses can evolve convergently, too. H.I.V., for example, arose when several species of viruses shifted from monkeys and apes to humans. Many of those lineages of H.I.V. gained the same mutations as they adapted to our species.

As the coronavirus now branches into new variants, researchers are observing Darwin’s theory of evolution in action, day in and day out.

Dr. Kamil stumbled across some of the new variants while he was sequencing samples from coronavirus tests in Louisiana. At the end of January, he observed an unfamiliar mutation in a number of samples.

The mutation altered the proteins that stud the surface of the coronavirus. Known as spike proteins, they are folded chains of more than 1,200 molecular building blocks called amino acids. Dr. Kamil’s viruses all shared a mutation that changed the 677th amino acid.

Investigating these mutant viruses, Dr. Kamil realized they all belonged to the same lineage. The earliest virus in the lineage dated back to Dec. 1. In later weeks, it grew more common.

On the evening of his discovery, Dr. Kamil uploaded the genomes of the viruses to an online database used by scientists across the world. The next morning, he got an email from Darrell Dinwiddie, a geneticist at the University of New Mexico. He and his colleagues had just found the same variant in their state, with the same 677 mutation. Their samples dated back to October.

The scientists wondered whether the lineage they had discovered was the only one to have a 677 mutation. Probing the database, Dr. Kamil and his colleagues found six other lineages that independently gained the same mutation on their own.

Coronavirus Variants and Mutations

Tracking recent mutations, variants and lineages.

It’s difficult to answer even basic questions about the prevalence of these seven lineages because the United States sequences genomes from less than 1 percent of coronavirus test samples. The researchers found samples from the lineages scattered across much of the country. But they can’t tell where the mutations first arose.

“I’d be quite hesitant to give an origin location for any of these lineages at the moment,” said Emma Hodcroft, an epidemiologist at the University of Bern and a co-author of the new study.

It’s also hard to say whether the increase in variants is actually the result of their being more contagious. They might have become more common simply because of all of the travel over the holiday season. Or they might have exploded during superspreader events at bars or factories.

Still, scientists are worried because the mutation could plausibly affect how easily the virus gets into human cells.

An infection begins when a coronavirus uses the tip of the spike protein to latch onto the surface of a human cell. It then unleashes harpoon-like arms from the spike’s base, pulling itself to the cell and delivering its genes.

Before the virus can carry out this invasion, however, the spike protein has to bump into a human protein on the surface of the cell. After that contact, the spike becomes free to twist, exposing its harpoon tips.

The 677 mutation alters the spike protein next to the spot where our proteins nick the virus, conceivably making it easier for the spike to be activated.

Jason McLellan, a structural biologist at the University of Texas at Austin who was not involved in the study, called it “an important advance.” But he cautioned that the way that the coronavirus unleashes its harpoons is still fairly mysterious.

“It’s tough to know what these substitutions are doing,” he said. “It really needs to be followed up with some additional experimental data.”

Dr. Kamil and his colleagues are starting those experiments, hoping to see whether the mutation does indeed make a difference to infections. If the experiments bear out their suspicions, the 677 mutation will join a small, dangerous club.

Convergent evolution has transformed a few other spots on the spike protein as well. The 501st amino acid has mutated in a number of lineages, for example, including the contagious variants first observed in the United Kingdom and South Africa. Experiments have revealed that the 501 mutation alters the very tip of the spike. That change allows the virus to latch onto cells more tightly, and infect them more effectively.

Scientists anticipate that coronaviruses will converge on more mutations that give them an advantage — against not only other viruses but also our own immune system. But Vaughn Cooper, an evolutionary biologist at the University of Pittsburgh and a co-author of the new study, said lab experiments alone wouldn’t be able to reveal the extent of the threat.

To really understand what the mutations are doing, he said, scientists will need to analyze a much bigger sampling of coronaviruses gathered from across the country. But right now, they can look at only a relatively meager number of genomes collected by a patchwork of state and university labs.

“It’s ridiculous that our country is not coming up with a national strategy for doing surveillance,” Dr. Cooper said.