In 2020, during the pandemic's first year, suicides among white residents decreased compared with previous years, while they increased among Black residents.

This article was published on Monday, August 23, 2021 in Kaiser Health News.

By Aneri Pattani   

This story is a collaboration between KHN and "Science Friday." Listen to the conversation between KHN national correspondent Aneri Pattani and John Dankosky, Science Friday's director of news and radio projects.

Rafiah Maxie has been a licensed clinical social worker in the Chicago area for a decade. Throughout that time, she'd viewed suicide as a problem most prevalent among middle-aged white men.

Until May 27, 2020.

That day, Maxie's 19-year-old son, Jamal Clay — who loved playing the trumpet and participating in theater, who would help her unload groceries from the car and raise funds for the March of the Dimes — killed himself in their garage.

"Now I cannot blink without seeing my son hanging," said Maxie, who is Black.

Clay's death, along with the suicides of more than 100 other Black residents in Illinois last year, has led locals to call for new prevention efforts focused on Black communities. In 2020, during the pandemic's first year, suicides among white residents decreased compared with previous years, while they increased among Black residents, according to state data.

But this is not a local problem. Nor is it limited to the pandemic.

Interviews with a dozen suicide researchers, data collected from states across the country and a review of decades of research revealed that suicide is a growing crisis for communities of color — one that plagued them well before the pandemic and has only been exacerbated since.

Overall suicide rates in the U.S. decreased in 2019 and 2020. National and local studies attribute the trend to a drop among white Americans, who make up the majority of suicide deaths. Meanwhile, rates for Black, Hispanic and Asian Americans — though lower than their white peers — continued to climb in many states. (Suicide rates have been consistently high for Native Americans.)

"COVID created more transparency regarding what we already knew was happening," said Sonyia Richardson, a licensed clinical social worker who focuses on serving people of color and an assistant professor at the University of North Carolina-Charlotte, where she researches suicide. When you put the suicide rates of all communities in one bucket, "that bucket says it's getting better and what we're doing is working," she said. "But that's not the case for communities of color."

Losing Generations

Although the suicide rate is highest among middle-aged white men, young people of color are emerging as particularly at risk.

Research shows Black kids younger than 13 die by suicide at nearly twice the rate of white kids and, over time, their suicide rates have grown even as rates have decreased for white children. Among teenagers and young adults, suicide deaths have increased more than 45% for Black Americans and about 40% for Asian Americans in the seven years ending in 2019. Other concerning trends in suicide attempts date to the '90s.

"We're losing generations," said Sean Joe, a national expert on Black suicide and a professor at Washington University in St. Louis. "We have to pay attention now because if you're out of the first decade of life and think life is not worth pursuing, that's a signal to say something is going really wrong."

These statistics also refute traditional ideas that suicide doesn't happen in certain ethnic or minority populations because they're "protected" and "resilient" or the "model minority," said Kiara Alvarez, a researcher and psychologist at Massachusetts General Hospital who focuses on suicide among Hispanic and immigrant populations.

Although these groups may have had low suicide rates historically, that's changing, she said.

Paul Chin lost his 17-year-old brother, Chris, to suicide in 2009. A poem Chris wrote in high school about his heritage has left Chin, eight years his senior, wondering if his brother struggled to feel accepted in the U.S., despite being born and raised in New York.

Growing up, Asian Americans weren't represented in lessons at school or in pop culture, said Chin, now 37. Even in clinical research on suicide as well as other health topics, kids like Chris are underrepresented, with less than 1% of federal research funding focused on Asian Americans.

It wasn't until the pandemic, and the concurrent rise in hate crimes against Asian Americans, that Chin saw national attention on the community's mental health. He hopes the interest is not short-lived.

Suicide is the leading cause of death for Asian Americans ages 15 to 24, yet "that doesn't get enough attention," Chin said. "It's important to continue to share these stories."

Kathy Williams, who is Black, has been on a similar mission since her 15-year-old son, Torian Graves, died by suicide in 1996. People didn't talk about suicide in the Black community then, she said. So she started raising the topic at her church in Durham, North Carolina, and in local schools. She wanted Black families to know the warning signs and society at large to recognize the seriousness of the problem.

The pandemic may have highlighted this, Williams said, but "it has always happened. Always."

Pandemic Sheds Light on the Triggers

Pinpointing the root causes of rising suicide within communities of color has proven difficult. How much stems from mental illness? How much from socioeconomic changes like job losses or social isolation? Now, COVID may offer some clues.

Recent decades have been marked by growing economic instability, a widening racial wealth gap and more public attention on police killings of unarmed Black and brown people, said Michael Lindsey, executive director of the New York University McSilver Institute for Poverty Policy and Research.

With social media, youths face racism on more fronts than their parents did, said Leslie Adams, an assistant professor in the department of mental health at Johns Hopkins Bloomberg School of Public Health.

Each of these factors has been shown to affect suicide risk. For example, experiencing racism and sexism together is linked to a threefold increase in suicidal thoughts for Asian American women, said Brian Keum, an assistant professor at UCLA, based on preliminary research findings.

COVID intensified these hardships among communities of color, with disproportionate numbers of lost loved ones, lost jobs and lost housing. The murder of George Floyd prompted widespread racial unrest, and Asian Americans saw an increase in hate crimes.

At the same time, studies in Connecticut and Maryland found that suicide rates rose within these populations and dropped for their white counterparts.

"It's not just a problem within the person, but societal issues that need to be addressed," said Shari Jager-Hyman, an assistant professor of psychiatry at the University of Pennsylvania's school of medicine.

Lessons From Texas

In Texas, COVID hit Hispanics especially hard. As of July 2021, they accounted for 45% of all COVID deaths and disproportionately lost jobs. Individuals living in the U.S. without authorization were generally not eligible for unemployment benefits or federal stimulus checks.

During this time, suicide deaths among Hispanic Texans climbed from 847 deaths in 2019 to 962 deaths in 2020, according to preliminary state data. Suicide deaths rose for Black Texans and residents classified as "other" races or ethnicities, but decreased for white Texans.

The numbers didn't surprise Marc Mendiola. The 20-year-old grew up in a majority-Hispanic community on the south side of San Antonio. Even before the pandemic, he often heard classmates say they were suicidal. Many faced dire finances at home, sometimes living without electricity, food or water. Those who sought mental health treatment often found services prohibitively expensive or inaccessible because they weren't offered in Spanish.

"These are conditions the community has always been in," Mendiola said. "But with the pandemic, it's even worse."

Four years ago, Mendiola and his classmates at South San High School began advocating for mental health services. In late 2019, just months before COVID struck, their vision became reality. Six community agencies partnered to offer free services to students and their families across three school districts.

Richard Davidson, chief operating officer of Family Service, one of the groups in the collaborative, said the number of students discussing economic stressors has been on the rise since April 2020. More than 90% of the students who received services in the first half of 2021 were Hispanic, and nearly 10% reported thoughts of suicide or self-harm, program data shows. None died by suicide.

Many students are so worried about what's for dinner the next day that they're not able to see a future beyond that, Davidson said. That's when suicide can feel like a viable option.

"One of the things we do is help them see … that despite this situation now, you can create a vision for your future," Davidson said.

A Good Future

Researchers say the promise of a good future is often overlooked in suicide prevention, perhaps because achieving it is so challenging. It requires economic and social growth and breaking systemic barriers.

Tevis Simon works to address all those fronts. As a child in West Baltimore, Simon, who is Black, faced poverty and trauma. As an adult, she attempted suicide three times. But now she shares her story with youths across the city to inspire them to overcome challenges. She also talks to politicians, law enforcement agencies and public policy officials about their responsibilities.

"We can't not talk about race," said Simon, 43. "We can't not talk about systematic oppression. We cannot not talk about these conditions that affect our mental well-being and our feeling and desire to live."

For Jamal Clay in Illinois, the systemic barriers started early. Before his suicide last year, he had tried to harm himself when he was 12 and the victim of bullies. At that time, he was hospitalized for a few days and told to follow up with outpatient therapy, said his mother, Maxie.

But it was difficult to find therapists who accepted Medicaid, she said. When Maxie finally found one, there was a 60-day wait. Other therapists canceled appointments, she said.

"So we worked on our own," Maxie said, relying on church and community. Her son seemed to improve. "We thought we closed that chapter in our lives."

But when the pandemic hit, everything got worse, she said. Clay came home from college and worked at an Amazon warehouse. On drives to and from work, he was frequently pulled over by police. He stopped wearing hats so officers would consider him less intimidating, Maxie said.

"He felt uncomfortable being out in the street," she said.

Maxie is still trying to make sense of what happened the day Clay died. But she's found meaning in starting a nonprofit called Soul Survivors of Chicago. Through the organization, she provides education, scholarships and shoes — including Jamal's old ones — to those impacted by violence, suicide and trauma.

"My son won't be able to have a first interview in [those] shoes. He won't be able to have a nice jump shot or go to church or even meet his wife," Maxie said.

But she hopes his shoes will carry someone else to a good future.

If you or someone you know is in crisis, call the National Suicide Prevention Lifeline at 1-800-273-8255 or text HOME to the Crisis Text Line at 741741.

KHN senior correspondent JoNel Aleccia contributed to this report.

[Editor's note: For the purposes of this story, "people of color" or "communities of color" refers to any racial or ethnic populations whose members do not identify as white, including those who are multiracial. Hispanics can be of any race or combination of races.]

Aneri Pattani: apattani@kff.org, @aneripattani

Some scientists see the announcement is rash and based on weak evidence, and they worry it could undercut confidence in vaccines with no clear benefit of controlling the pandemic.

This article was published on Friday, August 20, 2021 in Kaiser Health News.

By Rachana Pradhan 

The Biden administration's plans to make COVID-19 booster shots available next month has drawn a collective scream of protest from the scientific community.

As some scientists see it, the announcement is rash and based on weak evidence, and they worry it could undercut confidence in vaccines with no clear benefit of controlling the pandemic. Meanwhile, more information is needed on potential side effects or adverse effects from a booster shot, they say.

Perhaps even worse, the announcement has fueled deeper confusion about what Americans need to do to protect themselves from COVID.

"I think we've scared people," said Dr. Paul Offit, director of the Vaccine Education Center at Children's Hospital of Philadelphia and an adviser to the National Institutes of Health and the Food and Drug Administration.

"We sent a terrible message," he said. "We just sent a message out there that people who consider themselves fully vaccinated were not fully vaccinated. And that's the wrong message, because you are protected against serious illness."

As of Thursday, 51% of the U.S. population was fully vaccinated, Centers for Disease Control and Prevention data shows. Biden administration officials ― citing data from Israel, a study from the Mayo Clinic that is not yet peer-reviewed and new CDC studies ― say it's necessary to plan for boosters to prevent a worsening of the pandemic as the delta variant powers a surge in cases and overwhelms hospital intensive care units.

In essence, officials are caught between a rock and a hard place ― trying to be prepared while simultaneously not undermining messaging about how well the existing vaccines work.

Officials must weigh two unknowns: the risks of moving ahead aggressively with booster shots versus the risks of waiting to learn much more about the virus and the power of the vaccines. The government's normal path to regulatory approval is, by design, slow and deliberate. The virus has its own schedule, fast and unpredictable.

"Arguably, I think that the federal government is simply trying to stay ahead of the curve," said Dr. Joshua Barocas, associate professor of medicine at the University of Colorado. But, he said, "I have not seen robust data yet to suggest that it is better to boost Americans who have gotten two vaccines than invest resources and time in getting unvaccinated people across the world vaccinated."

Beginning in late September, boosters would be made available to adults (age 18 and up) eight months after they received the second dose of a Pfizer-BioNTech or Moderna COVID vaccine, President Joe Biden said. But his plan comes with big caveats: It does not yet have the blessing of a CDC advisory panel, and the FDA has not authorized boosters for all adults.

The urgent question is whether the vaccines are losing their power against COVID.

"We are concerned that this pattern of decline we are seeing will continue in the months ahead, which could lead to reduced protection against severe disease, hospitalization and death," Surgeon General Vivek Murthy said.

But many scientists and public health experts say the data doesn't demonstrate a clear benefit to the public in making booster shots widely available, and the Biden administration's message confuses people about what the COVID vaccines were designed to do.

"They're not a force field. They don't repel the virus from your body. They train your immune system to respond when you become infected … with the goal of keeping you out of the hospital," said Jennifer Nuzzo, an epidemiologist and associate professor at the Johns Hopkins Bloomberg School of Public Health.

Meanwhile, questions abound. Will boosters for fully vaccinated adults make the virus less transmissible ― that is, slower or less likely to spread to others?

"I certainly hope that's the case … but the bottom line, with full transparency, we don't know that right now," Dr. Anthony Fauci, Biden's chief medical adviser, said Wednesday.

What about side effects? "It would be nice to understand what side effects people have after their third dose," Nuzzo said.

"We don't have any reason to believe, based on the safety profile of the vaccine itself, that we're going to see significant adverse events with booster shots," Barocas said. However, those things are "just now being studied."

The concerns are real. While serious side effects from COVID vaccines have been rare, some have caused alarm ― including mRNA vaccines being linked to cases of myocarditis, or inflammation of the heart.

"At the individual level, we need to know the side effect profile of a 3rd dose, especially in younger people. Until now, the benefits of vaccination have far outweighed the potential side effects," Dr. Jeremy Faust, an emergency medicine physician at Brigham and Women's Hospital in Boston, wrote in a blog post outlining why he was skeptical about a plan to give boosters to everyone.

Even in light of the new CDC studies published Wednesday, experts say one thing is clear: The vaccines still work very well at what they were meant to do, which is to protect people against the worst outcomes of getting infected with the virus.

One study, relying on data from 21 hospitals in 18 states, found no significant change in the vaccines' effectiveness against hospitalization between March and July, which coincides with delta becoming the prevalent COVID strain. Another, using data from New York, also found the vaccines highly effective in preventing hospitalization, even as there was a decline in effectiveness against new infections. The third, evaluating the Pfizer and Moderna vaccines in nursing home residents, saw a drop in how effective they were at preventing infection ― but the research didn't distinguish between symptomatic and asymptomatic cases.

"It's like we're engaged in friendly fire against these vaccines," Nuzzo said. "What are we trying to do here? Are we just trying to reduce overall transmission? Because there's no evidence that this is going to do it."

Fauci, in outlining the case for boosters, highlighted data showing that antibody levels decline over time and higher levels of antibodies are associated with higher vaccine efficacy. But antibodies are only one component of the body's defense mechanisms against a COVID infection.

When the antibodies decrease, the body compensates with a cellular immune response. "A person who has lost antibodies isn't necessarily completely susceptible to infection, because that person has T-cell immunity that we can't measure easily," said Dr. Cody Meissner, a specialist in pediatric infectious diseases who sits on the FDA's vaccine advisory panel.

John Wherry, director of the Penn Institute of Immunology at the University of Pennsylvania, recently published a study finding that the mRNA vaccines provoked a strong response by the immune system's T cells, which researchers said could be a more durable source of protection. Wherry is working on a second study based on six months of data.

"We're seeing very good durability for at least some components of the non-antibody responses generated by the vaccines," he said.

For protection against serious disease, "really all you need is immunological memory, and these vaccines induce immunological memory and immunological memory tends to be longer-lived," Offit said. Federal scientists also are studying T-cell response, Fauci said.

Pfizer and Moderna have said they think boosters for COVID will be necessary. But it's up to the government to authorize them. Federal officials say they are sifting through new data from the companies and elsewhere as it becomes available.

There's not a deep playbook for this: Emergency use authorization, or EUA, of vaccines has been sparingly used. The FDA has already amended Pfizer's prior EUA clearance twice, first in May to expand the vaccines to adolescents 12 to 15 years old and, again, this month to allow immunocompromised people to obtain a third dose. The FDA did not respond to questions about the process for authorizing widespread booster shots.

Pfizer announced in July that it expects $33.5 billion in COVID vaccine revenue this year. Its stock has risen 33% this year, closing at $48.80 Thursday. Moderna reported sales of $5.9 billion through June 30 for 302 million doses of its vaccine. The company's stock has skyrocketed 236% year-to-date, closing at $375.53 Thursday.

In applying for emergency authorization, the FDA requires vaccine manufacturers to submit clinical efficacy data and all safety data from phase 1 and phase 2 clinical trials as well as two months of safety data from phase 3 studies. For full approval, the FDA requires manufacturers to submit six months of data.

Pfizer this week announced it has submitted phase 1 clinical trial data to the FDA as part of an evaluation for future approval of a third dose. The company said phase 3 results are "expected shortly."

Pfizer said its preliminary trial results showed a third dose was safe and increased antibody levels against the original virus and the delta variant. Moderna found a third dose had safety results similar to a second dose and produced a strong antibody response. 

Typically, any distribution of shots would occur after the CDC's Advisory Committee on Immunization Practices also developed recommendations. But with the Biden administration's announcement about boosters, public health experts worry the message suggests the outcome is preordained.

"They have completely and unfairly jammed FDA and ACIP. They've left them no choice. If there's no booster program, FDA gets blamed and that's not appropriate," said Dr. Nicole Lurie, a former senior Health and Human Services official in the Obama administration and U.S. director of the Coalition for Epidemic Preparedness Innovations, the global epidemic vaccines partnership.

KHN senior correspondent Sarah Jane Tribble and editor Arthur Allen contributed to this report.

Rachana Pradhan: rpradhan@kff.org, @rachanadixit

White House officials emphasized that the rollout of boosters was pending review of evidence by the FDA and the CDC. 

This article was published on Wednesday, August 17, 2021 in Kaiser Health News.

By Sarah Jane Tribble  

The Biden administration announced plans Wednesday to offer boosters to all U.S. adults as soon as next month, saying that recent data, including some made available only in the past few days, played a role in that decision.

"If you wait for something bad to happen before you respond to it, you find yourselves considerably behind," Dr. Anthony Fauci said during a White House briefing. "You want to stay ahead of the virus."

White House officials emphasized that the rollout of boosters was pending review of evidence by officials at the Food and Drug Administration as well as the advisory committee to the Centers for Disease Control and Prevention.

The rollout would begin the week of Sept. 20. U.S. residents 18 and older who received the Moderna or Pfizer-BioNTech vaccines would be eligible for a third shot eight months after their second dose. The timing would mean that healthcare workers, long-term care residents and older residents would be first in line for boosters.

"If you are fully vaccinated, you still have a high degree of protection from the worst outcomes — we are not recommending you go out and get a booster today," U.S. Surgeon General Vivek Murthy said. Johnson & Johnson vaccines were not distributed until March and a plan for those booster shots will come later, officials said.

Political and corporate pressure to offer a booster to U.S. citizens has been mounting over the summer months, as the highly contagious delta variant has spread nationally and filled hospital beds. On Wednesday, Biden officials offered slides filled with charts of recent data, talked about antibody response, and noted that research showing waning vaccine strength in Israel played a key role in their decision as did a study from Mayo Clinic that is not yet peer-reviewed.

"Stick to the advice from the CDC and the FDA, because they are doing their very best to ensure maximum protection and safety," said Dr. Cody Meissner, a specialist in pediatric infectious diseases who sits on the FDA's vaccine advisory panel. "People have to be very careful about statements that come from Big Pharma. They have a very different goal."

Dr. Sadiya Khan, an epidemiologist and cardiologist at Northwestern University's Feinberg School of Medicine, said that taking any medication has risks and that adding an additional dose of vaccine might cause unnecessary side effects. "What we need is data," she said.

There was no discussion Wednesday of any potential side effects of a third dose.

So what do we know about whether healthy, fully vaccinated people should get a booster? Here are answers to seven key questions.

1. What evidence are vaccine makers giving federal regulators to support the idea that an additional shot is needed?

It's unclear how the booster may be authorized by regulators. On Tuesday, FDA spokesperson Abby Capobianco said federal agencies are reviewing laboratory and clinical trial data as well as data from the real world. Some data will come from specific pharmaceutical companies, but the agency's analysis "does not rely on those data exclusively," she said.

The companies, for their part, are racing to produce data. On Monday, Pfizer and BioNTech submitted initial but promising results from a phase 1 study of the safety and immune response from a booster dose given at least six months after the second dose. Late-stage trial results that evaluate the effectiveness of a third dose are "expected shortly," Pfizer spokesperson Jerica Pitts confirmed this week.

Moderna President Stephen Hoge said during his company's earnings call this month that a third dose is "likely to be necessary" this fall because of the highly contagious delta variant. Moderna spokesperson Ray Jordan said Tuesday the company is in talks with regulators but hasn't provided an estimated timeline.

Johnson & Johnson, whose vaccine is administered in a single shot, hopes to share results soon from a late-stage clinical trial studying the safety and efficacy of a two-dose regimen in 30,000 adults. The study is looking at "potential incremental benefits" with a second dose, company spokesperson Richard Ferreira wrote in a Tuesday email.

2. Why might healthy people not need a booster yet?

Dr. Paul Offit, director of the Vaccine Education Center at Children's Hospital of Philadelphia and an adviser to the National Institutes of Health and FDA, said current federal guidance does not recommend a booster and there's no "science-based" reason to get an additional shot at this time — even after receiving the J&J vaccine.

The current mRNA vaccines work by inducing a certain level of neutralizing, virus-specific antibodies with the first dose. Then the second dose brings on an exponential increase in the measurable level of specific neutralizing antibodies — and, more important, there's evidence that the second dose of mRNA vaccine also gives cellular immunity, Offit said.

"That predicts relatively longer-term protection against severe critical disease," he said. A single dose of the J&J vaccine — which uses a different technology, called an adenovirus vector — has been shown to provide the equivalent response to the second dose of an mRNA vaccine, he said.

3. How do the three vaccines authorized in the U.S. compare?

A recent preprint — a paper that has not been peer-reviewed — from the Mayo Clinic suggests that the Moderna vaccine may be more protective against the delta variant than the Pfizer-BioNTech vaccine. However, that research is based on examining the vaccination history of thousands of people who got COVID, rather than a direct comparison of the vaccines, said Dr. Catherine Blish, a specialist in infectious diseases at Stanford Medicine.

"I would be hesitant to alter any practices or change behavior in any way based on that data," she said.

The Moderna and Pfizer-BioNTech vaccines are administered differently, which could factor into how much mRNA the body receives to code into protein, said Dr. Monica Gandhi, a specialist in infectious diseases at the University of California-San Francisco. Moderna's dosing is two shots of 100 micrograms delivered four weeks apart, while the Pfizer-BioNTech vaccine's two 30-microgram doses are delivered three weeks apart.

At the end of July, Pfizer and BioNTech announced findings that four to six months after a second dose their vaccine's efficacy dropped from a peak of 96% to about 84%. With its own data of fading efficacy, the Israeli government launched a vaccination campaign this month encouraging more than 1 million residents over age 50 to get a third shot.

As for J&J's one-shot vaccine, there's no evidence that recipients are being hospitalized with breakthrough infections at a higher rate than if they had received other vaccines, said Dr. Amesh Adalja, a specialist in infectious diseases at Johns Hopkins Center for Health Security.

4. Could a booster harm a healthy, fully vaccinated person?

It's unclear. Offit said he believes a booster is safe and may well become important — but "it's just not where we should be in this country right now." The best defense against delta and other variants, he said, is to first vaccinate as many people as possible.

Others, though, said the available research signaled that caution is warranted. During a media briefing reported by Reuters last month, Jay Butler, the CDC's deputy director for infectious diseases, said the agency was "keenly interested in knowing whether or not a third dose may be associated with any higher risk of adverse reactions, particularly some of those more severe — although very rare — side effects."

The CDC did not respond to questions this week about its stance on potential risks. There have been reports of blood clots and allergic reactions after regular dosing. Khan, at Northwestern, said she is also concerned about reports of myocarditis, inflammation of the heart — which is more common after the second shot than the first. She said it's not clear that the benefit of taking a booster would outweigh the risk for young, healthy people.

5. Would a booster limit a vaccinated person's ability to spread the virus?

Dr. William Moss, a professor of epidemiology at Johns Hopkins' Bloomberg School of Public Health, explained that the immune protection conferred by vaccines operates along a spectrum, from severely limiting initial virus replication to preventing widespread virus dissemination and replication within our bodies.

"Booster doses, by increasing antibody levels and enhancing other components of our immune responses, make it more likely virus replication will be rapidly prevented," Moss said. "This then makes it less likely a vaccinated individual will be able to transmit the virus."

Moss also said there are potential benefits to combinations of vaccines like those being administered in San Francisco and some European countries. German Chancellor Angela Merkel boosted her adenovirus-vectored AstraZeneca shot with Moderna in June.

Another possible step for pharmaceutical companies is to reformulate their COVID vaccines to more closely match newer variants. Pfizer has announced it could do so within 100 days of the discovery of a variant.

Hopefully, the regulatory process could be expedited for such reformulated vaccines, said Moss, who works within Johns Hopkins' International Vaccine Access Center.

6. Would we have to pay for the booster dose, or would it be free, like the previous shots?

It will be free regardless of immigration or health insurance status, according to White House officials. No identification or insurance will be required.

In July, White House press secretary Jen Psaki announced that the federal government bought an additional 200 million doses of the Pfizer-BioNTech vaccine for inoculating children under 12 and for possible boosters.

7. Is there a future in which we take an annual COVID shot?

Dr. Vincent Rajkumar, a hematologist at the Mayo Clinic who studies cancers involving the immune system, said a year ago he believed immune responses to COVID may be similar to those of the measles, which create "a very long memory that protects us."

Then COVID mutated. "India changed everything for me," he said, referring to its massive second wave after delta was discovered. Many of those who were infected had already had COVID, he said.

Rajkumar now believes "we might need annual boosters — and it would be nice if such boosters can be combined with the flu vaccine."

Sarah Jane Tribble: sjtribble@kff.org, @SJTribble

Employers, fearing a backlash, frame the policy as a choice, with both sides of the equation seen as effective in reducing the spread of COVID.

This article was published on Thursday, August 19, 2021 in Kaiser Health News.

By Julie Appleby  

With the delta variant surging, a growing number of employers are tiring of merely cajoling workers to get vaccinated against COVID-19 and are following President Joe Biden's protocol for federal workers: Either show proof of vaccination, or mask up and get regular testing if you want to work on-site.

The federal government — the nation's largest employer — will require unvaccinated employees to wear masks while working, get regular testing and take other precautions, like maintaining physical distance from co-workers and restricting work travel. Several states, including California, Hawaii, Maryland, Virginia and Washington, also say unvaccinated state workers must get regular tests.

On Wednesday, California Gov. Gavin Newsom broadly extended such a mandate to teachers and all school employees, the first state to do so.

Those programs, with their testing alternative, differ from outright mandates to get vaccinated, as some healthcare organizations — including the healthcare workforce of the Department of Health and Human Services, hospitals and the U.S. military — are requiring.

Employers, fearing a backlash, frame the policy as a choice, with both sides of the equation seen as effective in reducing the spread of COVID. Do public health experts think this approach will help?

All agreed the best solution is universal vaccination. Short of that, many said, the moves by employers will add a layer of protection — although how much remains to be seen.

Test results are "really only a snapshot in time," said Dr. Gigi Kwik Gronvall, an associate professor at Johns Hopkins' Bloomberg School of Public Health. Even testing every day, as was the standard in the Trump White House — without other measures like masking — didn't prevent staffers from falling ill last fall.

And daily testing is cumbersome and costly.

Employers hope the hassles required to remain unvaccinated in the workplace will encourage the reluctant to just get a vaccine. "It's a forceful nudge," said Dr. Georges Benjamin, executive director of the American Public Health Association.

But there are challenges, too. Here's what several experts had to say:

Universal Vaccination Remains the Gold Standard

Getting all eligible people vaccinated is "the perfect way out of this whole situation," said Dr. Marcus Plescia, chief medical officer at the Association of State and Territorial Health Officers. "But, given the realities of the current situation, I think it's reasonable that employers and others who are setting up vaccine requirements offer some accommodations."

But much depends, he and others said, on how well the rules are enforced.

"If [unvaccinated] people are wearing masks all day at work, even in the break room, that alone is pretty strong," he said. "When you add in the testing, it's an alternative that is going to have some value."

Some employers, he noted, are reluctant to set such edicts because they fear losing employees, particularly in areas already suffering shortages, such as nursing homes.

This Approach Relies Somewhat on the Honor System

Some states, healthcare organizations and New York City say they'll require proof of vaccination — a copy of an employee's vaccination certificate or a version uploaded into an app on a person's phone. But other employers say they will allow workers to self-attest that they've had the vaccine.

"There will be some folks who fib, no doubt about that," said Dr. William Schaffner, professor of medicine in the division of infectious diseases at Vanderbilt University School of Medicine, in Nashville.

"That will raise the issue of annoyance and concern by the vaccinated people," said Schaffner. "They will say, 'Wait a minute. Charlie is here and he's not wearing a mask and we know he's not vaccinated.' People know that sort of stuff about their co-workers."

There are other consequences.

There is online traffic in buying forged vaccination cards, designed to look like the real thing from the Centers for Disease Control and Prevention — even though that is illegal and can lead to fines or even jail time, the FBI has warned. Employers could also discipline workers who falsely state they've been vaccinated.

As for test results, it's less clear how the honor system will apply. Some workers — especially those in healthcare organizations — may well be able to get their tests done in-house. Other companies may allow workers to find (and pay for) outside testing. It isn't known whether employers will allow the use of self-administered home tests. And what kind of test companies require matters, since the rapid antigen tests are not as reliable as the standard PCR versions. To complicate matters, rising demand for tests during the surge has led to long lines for both kinds of tests in some parts of the country, and results for the more accurate PCR version may take days.

Frequency of Testing Will Vary and May Not Be Ideal

Many of the workplace edicts — including the one for federal workers — call for weekly or twice-a-week testing. Is that enough? It's hard to give an exact answer.

Dr. Robert Wachter, professor and chair of the department of medicine at the University of California-San Francisco, prefers tests be performed twice a week, especially given the explosion of cases in many parts of the country.

"If you're only testing once a week, there will be some cases that slip through," said Wachter. "You could get tested on a Monday, infected on Tuesday and could infect someone else that Friday or Saturday."

Who's Paying?

While some employers may pick up the cost, at least initially, not all will. And workers should not count on testing being fully covered by their health insurers, either. They may well have to pay out-of-pocket for employer-required tests.

"Generally, health insurance providers are covering COVID tests that are taken for diagnosing or treating a patient — if they are displaying symptoms or have had contact with someone who has been diagnosed with COVID," said Kristine Grow, a spokesperson for AHIP, the industry's lobbying group.

But, she noted, guidance issued last year by several federal agencies said insurers don't have to cover testing "conducted to screen for general workplace health and safety, for public health surveillance, or for any other purpose not primarily intended for diagnosis or treatment."

Bottom line: Employees could have to go through a lot of hoops to remain unvaccinated in the workplace. "That will get old very quickly for a lot of people," Schaffner said. "That will push a lot of people off the fence and onto the vaccination side."

Julie Appleby: jappleby@kff.org, @Julie_Appleby