President Joe Biden has promised enough COVID vaccine to immunize every willing adult by June 1. But right now, the gap between supply and demand is so dramatic that vaccinators are discovering ways to suck the final drops out of each vaccine vial — if federal regulators will let them.
Pharmacists involved in the COVID vaccination drive say it's common to have half a dose left in a Pfizer vial after five or even six doses have been administered — and to have half a dose left after 10 doses have been drawn out of a Moderna vial. Combining two half-doses could increase vaccinations by thousands at a time when 2 million or so doses are being administered every day in the country.
So, they want to use a single hypodermic needle to withdraw leftover vaccine from two vials from which all full doses already have been removed. The American Society of Health-System Pharmacists asked the Food and Drug Administration consider granting permission to do so in a recent letter. The governors of Colorado and Oregon also have sought permission to allow their pharmacists to pool COVID vaccine vials.
Federal health regulators, however, have long opposed the reuse of drug vials because of the risk of introducing a bacterial contaminant. From 1998 to 2014 more than 50 outbreaks of viral or bacterial disease were reported as a result of unsafe injection practices, including injecting multiple patients with a drug from the same vial.
The FDA wouldn't comment on the pharmacists' letter but restated to KHN its current policy that "doses not be pooled from different vaccine vials, especially for coronavirus vaccines, which are not formulated with a preservative." On its website, the Centers for Disease Control and Prevention explicitly tells vaccinators to discard vials "when there is not enough vaccine to obtain a complete dose. Do NOT combine residual vaccine from multiple vials to obtain a dose."
"It's a recipe for disaster," said Ann Marie Pettis, president of the Association for Professionals in Infection Control and Epidemiology. There is always a tiny chance that one of the two vials has previously been contaminated, which would contaminate a shot that combined their contents, she said. Spokespeople for both Moderna and Pfizer said excess portions of their vaccines must be discarded and never pooled. Johnson & Johnson had no comment on the issue.
Before the COVID vaccination program, public health officials generally frowned on giving multiple patients doses of medicine from a single vial, unless it contained an antibacterial preservative. Most children's vaccines, for example, have been shipped and stored in syringes or single-dose vials since 2001, when drug companies stopped using a preservative containing traces of mercury in some shots.
Rajesh Gupta, a biologics consultant who set up a sterility testing lab while serving at the FDA's Center for Biologics Evaluation and Research from 2006 to 2013, sees little risk in the COVID vaccination process, or even in using a single needle to combine vaccine from two vials.
The COVID vaccines are being used so quickly after removal from cold storage that there's no danger of contamination, he said. "I can say with some degree of confidence that it's scientifically sound," if vaccinators carefully wipe the rubber stopper atop the vial with disinfectant before each penetration with a syringe, he said.
While their plea for combining vial contents may fall on deaf ears at the FDA, pharmacists already are taking many other steps to maximize the yield of the mRNA vaccines, which have quite finicky shipment, handling and administration requirements.
Documents leaked through a cyberattack on the European drug regulatory agency suggest that Pfizer has had difficulty assuring the quality of the mRNA in its vaccine. The company said in a response that all the vaccine doses it has put on the market had been "double tested to ensure compliance" with regulatory specifications.
Michael Hogue, president of the American Pharmacists Association and dean of the Loma Linda University School of Pharmacy in California, runs a clinic at a university gymnasium that has been administering up to 10,000 vaccines each week since Jan. 28. It's nowhere near as simple as administering flu shots at a pharmacy, he said.
"The planning and procedures for these mRNA vaccines [made by Pfizer-BioNTech and Moderna] require a tremendous amount of focus," said Hogue. "You have to pay close attention to what's going on in the moment."
The Pfizer vaccine, which until recently was always stored in dry ice, is especially challenging. After Pfizer vials are removed from a freezer and thawed, saline solution is squirted into each vial. If the syringe preparer doesn't withdraw air from the vial after adding the saline, vaccine will shoot out.
After adding the solution, "you take the vial between thumb and forefinger and make a rainbow sweeping motion 10 times gently to mix the liquids together," Hogue said. Shaking the vaccine could render it ineffective.
Each Pfizer vaccination contains just a bead of liquid — about 1/16th of a teaspoon — and pharmacists must use tiny syringes in which air bubbles tend to form. But they can't tap on the syringe to get the bubble out, because that, too, could damage the vaccine, Hogue said.
To get six doses out of the Pfizer vials requires a type of plunger that pushes the last trace of vaccine out of the syringe. But about 15% of the syringes the federal government has been shipping to Loma Linda have larger needles that leave a bit of vaccine in the syringe, making it impossible to extract all six doses, he said. So, Loma Linda has been purchasing its own syringes to replace the inadequate ones.
U.S. Pharmacopeia, a nonprofit agency that issues standards for use of medical products, issued an 11-page guide on how to store, handle and administer the COVID vaccines. Among other things, it urges that vaccine sites set up clean rooms — separate from the areas where vaccines are being administered — to prepare the syringes, said Farah Towfic, CEO of operations for USP.
"That way we don't have clients breathing on it," not to mention the distraction of greeting old acquaintances who are bubbling over with enthusiasm about getting vaccinated, said Patricia Slattum, a retired Virginia Commonwealth University pharmacy school professor who has been volunteering at a mass vaccination site in Richmond, Virginia. "There's a lot of love to go around in there."
Another technique is to inject each needle into a different spot on the rubber vial stopper. If the syringe goes into the same location over and over, it can create a big hole that causes leakage. This tip is especially important now that Moderna is in talks with FDA to include up to 15 doses of vaccine in each vial, meaning 15 punctures of the stopper, noted Anna Legreid Dopp, director of clinical guidelines and quality improvement at the American Society of Health-System Pharmacists.
"To draw up the vaccine, you stick a needle through the rubber stopper, then turn the vial upside down," said Slattum. "If you stick it in the same place, drops will leak down the needle. So there's an art to not losing vaccine."
Slattum hopes the FDA will consider allowing vaccinators to draw the leftover vaccine from two vials. "We who are doing this work all feel this pressure, that our doing it well is one of the ways we're going to get out of this pandemic," said Slattum. "You just don't want to waste any vaccine!"
Since the start of the pandemic, the most terrifying task in healthcare was thought to be when a doctor put a breathing tube down the trachea of a critically ill COVID patient.
Those performing such "aerosol-generating" procedures, often in an intensive care unit, got the best protective gear even if there wasn't enough to go around, per Centers for Disease Control and Prevention guidelines. And for anyone else working with COVID patients, until a month ago, a surgical mask was considered sufficient.
A new wave of research now shows that several of those procedures were not the most hazardous. Recent studies have determined that a basic cough produces about 20 times more particles than intubation, a procedure one doctor likened to the risk of being next to a nuclear reactor.
Other new studies show that patients with COVID simply talking or breathing, even in a well-ventilated room, could make workers sick in the CDC-sanctioned surgical masks. The studies suggest that the highest overall risk of infection was among the front-line workers — many of them workers of color — who spent the most time with patients earlier in their illness and in sub-par protective gear, not those working in the COVID ICU.
"The whole thing is upside down the way it is currently framed," said Dr. Michael Klompas, a Harvard Medical School associate professor who called aerosol-generating procedures a "misnomer" in a recent paper in the Journal of the American Medical Association.
"It's a huge mistake," he said.
The growing body of studies showing aerosol spread of COVID-19 during choir practice, on a bus, in a restaurant and at gyms have caught the eye of the public and led to widespread interest in better masks and ventilation.
Yet the topic has been highly controversial within the healthcare industry. For over a year, international and U.S. nurse union leaders have called for health workers caring for possible or confirmed COVID patients to have the highest level of protection, including N95 masks.
But a widespread group of experts have long insisted that N95s be reserved for those performing aerosol-generating procedures and that it's safe for front-line workers to care for COVID patients wearing less-protective surgical masks.
Such skepticism about general aerosol exposure within the healthcare setting have driven CDC guidelines, supported by national and California hospital associations.
The guidelines still say a worker would not be considered "exposed" to COVID-19 after caring for a sick COVID patient while wearing a surgical mask. Yet in recent months, Klompas and researchers in Israel have documented that workers using a surgical mask and face shield have caught COVID during routine patient care.
The CDC said in an email that N95 "respirators have remained preferred over facemasks when caring for patients or residents with suspected or confirmed" COVID, "but unfortunately, respirators have not always been available to healthcare personnel due to supply shortages."
New research by Harvard and Tulane scientists found that people who tend to be super-spreaders of COVID — the 20% of people who emit 80% of the tiny particles — tend to be obese or older, a population more likely to live in elder care or be hospitalized.
When highly infectious, such patients emit three times more tiny aerosol particles (about a billion a day) than younger people. A sick super-spreader who is simply breathing can pose as much or more risk to health workers as a coughing patient, said David Edwards, a Harvard faculty associate in bioengineering and an author of the study.
Chad Roy, a co-author who studied primates with COVID, said the emitted aerosols shrink in size when the monkeys are most contagious at about Day Six of infection. Those particles are more likely to hang in the air longer and are easier to inhale deep into the lungs, said Roy, a professor of microbiology and immunology at Tulane University School of Medicine.
The study clarifies the grave risks faced by nursing home workers, of whom more than 546,000 have gotten COVID and 1,590 have died, per reports nursing homes filed to the Centers for Medicare & Medicaid since mid-May.
Taken together, the research suggests that healthcare workplace exposure was "much bigger" than what the CDC defined when it prioritized protecting those doing "aerosol-generating" procedures, said Dr. Donald Milton, who reviewed the studies but was not involved in any of them.
"The upshot is that it's inhalation" of tiny airborne particles that leads to infection, said Milton, a professor at the University of Maryland School of Public Health who studies how respiratory viruses are spread, "which means loose-fitting surgical masks are not sufficient."
On Feb. 10, the CDC updated its guidance to healthcare workers, deleting a suggestion that wearing a surgical mask while caring for COVID patients was acceptable and urging workers to wear an N95 or a "well-fitting face mask," which could include a snug cloth mask over a looser surgical mask.
Yet the update came after most of at least 3,500 U.S. healthcare workers had already died of COVID, as documented by KHN and The Guardian in the Lost on the Frontline project.
The project is more comprehensive than any U.S. government tally of health worker fatalities. Current CDC data shows 1,391 healthcare worker deaths, which is 200 fewer than the total staff COVID deaths nursing homes report to Medicare.
More than half of the deceased workers whose occupation was known were nurses or in healthcare support roles. Such staffers often have the most extensive patient contact, tending to their IVs and turning them in hospital beds; brushing their hair and sponge-bathing them in nursing homes. Many of them — 2 in 3 — were workers of color.
Two anesthetists in the United Kingdom — doctors who perform intubations in the ICU — saw data showing that non-ICU workers were dying at outsize rates and began to question the notion that "aerosol-generating" procedures were the riskiest.
Dr. Tim Cook, an anesthetist with the Royal United Hospitals Bath, said the guidelines singling out those procedures were based on research from the first SARS outbreak in 2003. That framework includes a widely cited 2012 study that warned that those earlier studies were "very low" quality and said there was a "significant research gap" that needed to be filled.
But the research never took place before COVID-19 emerged, Cook said, and key differences emerged between SARS and COVID-19. In the first SARS outbreak, patients were most contagious at the moment they arrived at a hospital needing intubation. Yet for this pandemic, he said, studies in early summer began to show that peak contagion occurred days earlier.
Cook and his colleagues dove in and discovered in October that the dreaded practice of intubation emitted about 20 times fewer aerosols than a cough, said Dr. Jules Brown, a U.K. anesthetist and another author of the study. Extubation, also considered an "aerosol-generating" procedure, generated slightly more aerosols but only because patients sometimes cough when the tube is removed.
Since then, researchers in Scotland and Australia have validated those findings in a paper pre-published on Feb. 10, showing that two other aerosol-generating procedures were not as hazardous as talking, heavy breathing or coughing.
Brown said initial supply shortages of PPE led to rationing and steered the best respiratory protection to anesthetists and intensivists like himself. Now that it is known emergency room and nursing home workers are also at extreme risk, he said, he can't understand why the old guidelines largely stand.
"It was all a big house of cards," he said. "The foundation was shaky and in my mind it's all fallen down."
Asked about the research, a CDC spokesperson said via email: "We are encouraged by the publication of new studies aiming to address this issue and better identify which procedures in healthcare settings may be aerosol generating. As studies accumulate and findings are replicated, CDC will update its list of which procedures are considered [aerosol-generating procedures]."
Cook also found that doctors who perform intubations and work in the ICU were at lower risk than those who worked on general medical floors and encountered patients at earlier stages of the disease.
In Israel, doctors at a children's hospital documented viral spread from the mother of a 3-year-old patient to six staff members, although everyone was masked and distanced. The mother was pre-symptomatic and the authors said in the Jan. 27 study that the case is possible "evidence of airborne transmission."
Klompas, of Harvard, made a similar finding after he led an in-depth investigation into a September outbreak among patients and staff at Brigham and Women's Hospital in Boston.
There, a patient who was tested for COVID two days in a row — with negative results — wound up developing the virus and infecting numerous staff members and patients. Among them were two patient care technicians who treated the patient while wearing surgical masks and face shields. Klompas and his team used genome sequencing to connect the sick workers and patients to the same outbreak.
CDC guidelines don't consider caring for a COVID patient in a surgical mask to be a source of "exposure," so the technicians' cases and others might have been dismissed as not work-related.
The guidelines' heavy focus on the hazards of "aerosol-generating" procedures has meant that hospital administrators assumed that those in the ICU got sick at work and those working elsewhere were exposed in the community, said Tyler Kissinger, an organizer with the National Union of Healthcare Workers in Northern California.
"What plays out there is there is this disparity in whose exposures get taken seriously," he said. "A phlebotomist or environmental services worker or nursing assistant who had patient contact — just wearing a surgical mask and not an N95 — weren't being treated as having been exposed. They had to keep coming to work."
Dr. Claire Rezba, an anesthesiologist, has scoured the web and tweeted out the accounts of healthcare workers who've died of COVID for nearly a year. Many were workers of color. And fortunately, she said, she's finding far fewer cases now that many workers have gotten the vaccine.
"I think it's pretty obvious that we did a very poor job of recommending adequate PPE standards for all healthcare workers," she said. "I think we missed the boat."
California Healthline politics correspondent Samantha Young contributed to this report.
Ana Guevara was determined to get a COVID vaccine for her mother, 85-year-old Adelina Coto, but she needed help. Guevara, a full-time nanny in Los Angeles, didn't have the time or knowledge to search for appointments online. Guevara's son, a school district employee, lacked the time to park himself in front of a computer waiting for new appointments to drop.
Then Guevara's boss connected her with a group that volunteers to help people like her mother get vaccinated.
Three days and one phone call later, Coto had a vaccine appointment. Now her daughter is telling everyone she knows about the group.
"I tell all my friends," said the 53-year-old immigrant from El Salvador. "They help, they're very nice, and they do everything."
Guevara is one of hundreds of people finding elusive vaccine appointment slots with the help of strangers. Grassroots volunteer corps — powered by people with time, tech savvy and a computer at their fingertips — are popping up in major metropolitan areas where thousands of people are competing for the same appointment slots. Their altruism offers an antidote to the actions of vaccine line jumpers.
"I would like to take away the stigma that appointments are not available and that they are impossible to get," said Rhea Hoffman, a 34-year-old former teacher in the Coachella Valley who has been helping people get vaccinated. "I can probably get you one within 48 hours if you qualify, and it's not a problem — just give me a second."
The volunteers reinforce local governments in helping disadvantaged people get vaccinated. In California, county officials are running hotlines, organizing mobile clinics, hiring community health workers and teaming up with faith communities and community organizations to get people signed up for an appointment or vaccinated on the spot.
Barbara Ferrer, Los Angeles County's public health director, gives big kudos to the "awesome" volunteer groups. "It makes my heart feel good that people are stepping up and helping people who really have been struggling to get those appointments," Ferrer told KHN at a news briefing.
The L.A. County neighborhoods hit hardest by the coronavirus are also the ones with the lowest vaccination rates. In poorer areas like Pacoima, San Fernando and Hawaiian Gardens, for example, 9% to 12% of the population had received at least one shot as of Feb. 20, while in wealthy Bel-Air, Century City and Beverly Hills, one-third of residents had been vaccinated. Statewide statistics show similar disparities.
The volunteer groups are vital to expanding vaccines to low-income, disabled and isolated people, said Louise McCarthy, president and CEO of the Community Clinic Association of Los Angeles County. Her group represents 64 community clinics and health centers that have all pivoted to getting people vaccinated in some way, either by directly administering shots or helping people navigate registration systems. (The clinics hope to eventually be compensated for this extra work.)
"We need all hands on deck to help people get access to this vaccine," McCarthy said. "Folks are getting left behind already, and it's projects like this that help us begin to catch up."
Volunteers have joined the effort after seeing how hard it was to book appointments for themselves, parents or grandparents. They get a kick out of helping people, and joining like-minded altruists on social media helps them get more efficient at the process.
It's an easy conversion from "caring about your parents and learning these skills, to caring about someone else's parents or grandparents," said Liz Schwandt, a 45-year-old early childhood program director at a Jewish preschool in Los Angeles. She co-founded Get Out the Shot: Los Angeles, the group that made Coto's appointment, and now has about 100 vetted volunteers who have booked at least 300 appointments directly through the group's system, and up to 4,000 through their individual efforts.
Schwandt said she didn't take on this mission out of anger and doesn't cast blame on the vaccine rollout or public health workers, who she said work diligently to protect people's health. It was simply that she saw a need and could fill it.
"These technology barriers are real, and every shot that gets into someone is potential protection for their life and their family," she said.
To get help from Schwandt's group, Los Angeles residents can leave a phone message or fill out their location, availability and other details on a Google form. Then a volunteer picks up the case, finds an appointment and calls to confirm.
The most skilled vaccine bookers have memorized the days and times certain sites release a new batch of appointments and stay up to date on new developments through Facebook groups or other social media.
Beverly Hills couple George and Cathi Rimalower, whose grandchild attends Schwandt's school, have been pulling late nights to get appointments for others. They were still in their pajamas at 11:30 a.m. on a recent day after waiting until 1 a.m. for a batch of appointments to drop.
"In my case, there's no excuse for me, as a retired person with the available resources to help people, to just sit around and do nothing," said George Rimalower, 69, who ran a translation company with his wife. Rimalower, born in Argentina, responds mostly to requests that come in from native Spanish speakers.
"It's nice to give money, and that's always helpful," said Cathi Rimalower, 67. "But it really feels good to give some time, too."
The couple are teasingly competitive about their work. So far, each has booked about 60 appointments.
Hoffman, the Coachella Valley booker, had spent most of the pandemic supervising her two kids' online schooling while volunteering as a Zoom moderator for a community college class for elderly people. When vaccines finally came online, it took her four days to make appointments for her parents. Seeing how tough the process was, she asked her class if they needed help; most students raised their hands.
Hoffman and a friend who worked in marketing and graphic design created a website to advertise their volunteer services. Hoffman estimates the two have booked 350 appointments. They've talked with a Coachella City Council member to strategize how they can expand and help in a more official way.
Many of these volunteer organizations are focusing on getting minorities or those from underserved communities into certain vaccine locations and appointment slots.
In Chicago, 26-year-old Brianna Wolin said the 45 "Chicago Vaccine Angels" on her Facebook group have scheduled over 750 vaccine appointments for seniors and others, while keeping equity in mind.
"We will not book people who live in a northern suburb to come down to the southwest side of Chicago, where they would have never stepped foot until there was an opening for a vaccine that they so desperately wanted," she said.
"After a year of caring so much about yourself and your own needs and your own safety, it feels darn good to do something for others," said Wolin, a graduate student studying prosthetics and orthotics.
Martha Gallagher, a 75-year-old retired school nurse, wanted to volunteer for the Delaware Medical Reserve Corps to administer COVID-19 vaccines.
She knew Delaware might need more vaccinators and thought, "Why not do something to help get the vaccine out?" Plus, Gallagher figured, it would be a good way for her to get vaccinated, too.
When the Ocean View resident initially filled out the paperwork for the program, run through the Delaware Division of Public Health, she said she was told she could get a vaccine as a volunteer. But then, after she turned in her paperwork, a medical reserve program coordinator said that wasn't the case.
Gallagher was surprised. "You want me at 75 to give vaccines, but I won't be able to get a vaccine?" she said.
The Delaware Division of Public Health said in a statement the agency "cannot guarantee vaccine to volunteers based on available supply at each event. Many volunteers have been able to receive vaccines if there have been doses remaining at the end of an event in order to utilize every single dose to avoid waste."
That was just one of many dead ends Gallagher encountered before she successfully got the coveted shot.
Gallagher launched her crusade on Jan. 20, when Delaware started vaccinating residents 65 and older and front-line essential workers.
She registered on the state's website and got a reply that when an event opened, she would be sent a notice to make a vaccine appointment. Gallagher never got any notification from the state. A couple of weeks later, she registered again but heard nothing. She then called the state's help line and was told the state had no vaccines and to check with commercial pharmacies.
The thing is, Gallagher had done that too.
She had made multiple phone calls and tried to make online appointments with Rite Aid, Walgreens, Walmart and Giant grocery stores.
No matter what nearby Delaware ZIP code Gallagher entered into the online form, the pharmacy websites gave her the same rejection message. "The only response I would get is 'There are no vaccines within 25 miles,'" she said.
"So, basically, it's an utter mess and I don't know when they're ever going to get this straightened out," said Gallagher in a Feb. 11 phone call.
She had even gone the extra mile. Gallagher became friendly with one Walmart pharmacist in her area, and he said he put her name on a list and would call her if he got a dose he could give. But he said if he called, she would have to "come down right away." Still, her phone never rang.
Gallagher's four daughters also tried to help their mom get appointments.
In early February, Gallagher started stalking the Walgreens website every hour to check for appointments. Finally, she saw something available for March 9 at 11 a.m.
"But, then, when I clicked on it the whole bloody site disappeared," said Gallagher. She couldn't get back on the webpage again. "It's like peeling my face on a daily basis," she exclaimed.
Finally, on Feb. 12, Gallagher reported to KHN that she had a change in luck.
"I got it!" she said in a phone call. "It's kind of a long story."
Back in January, when Gallagher's age group became eligible for the vaccine, she thought she had made an appointment at a Rite Aid in another town. That appointment was scheduled for Feb. 11. But she never received verification or confirmation from the pharmacy.
Fed up with everything else she had tried, Gallagher decided when that day came to drive the 40 minutes to the Rite Aid. If she wasn't booked, perhaps she could snag a shot because it had recently snowed and she thought maybe someone would have canceled an appointment.
"So, I went all that way, and then they said, 'Well if you didn't get a reply, then your name isn't on a list,'" said Gallagher. "And then I went on a long rant about what I had been through trying to get a vaccine."
One pharmacy staffer told Gallagher she would go back and look at the appointment list. The staff member came back and said the inclement weather did indeed cause a cancellation, but Gallagher would have to wait about an hour before her turn.
After 23 nonstop days of searching, Gallagher said, yes, she could certainly wait one more hour.
Now that the coronavirus has been in the United States for roughly a year, new numbers are revealing the scale of COVID-19's impact on American health: COVID has become the country's third-leading cause of death, and could be on its way to outpacing cancer.
"The toll of death is simply staggering — worse than I would have predicted," said Arthur Caplan, founding head of the division of medical ethics at the New York University School of Medicine. "COVID has been nothing short of the worst failure of public policy in modern memory."
With a year's worth of data, it's possible to look more precisely at how the coronavirus compares with the more routine causes of death in the U.S.
The takeaway is that the coronavirus killed more Americans in the past year than any cause of death in 2019, other than heart disease and cancer. And if the University of Washington model proves accurate, then by June, the 15-month toll from the coronavirus will be close to matching the annual number of deaths from cancer.
All other causes of death pale in comparison to the coronavirus death toll. So far, the coronavirus has killed roughly three times as many people as accidents, lung ailments, stroke or Alzheimer's disease did in 2019. And the coronavirus has outpaced the number of deaths from diabetes, kidney disease, pneumonia and suicide by even larger multiples.
Caution is warranted when comparing these causes of death. Most of the 10 leading causes of death are not primarily driven by infections, whereas the coronavirus is. So it's hard to imagine a scenario in which any of the other causes could spike the way coronavirus did.
Another way to look at the toll of the coronavirus pandemic is by considering "excess deaths," a statistic tracked by the CDC. This data takes the number of actual deaths in a given period and subtracts the average number of deaths from all causes during the comparable period in recent years.
The CDC data shows how excess deaths have risen with spikes in COVID infections. In some weeks over the past year, there were as many as 22,000 excess deaths.
The weekly excess deaths add up to 559,887 additional deaths since the pandemic began.
That's a bit higher than the 502,005 coronavirus deaths officially recorded. However, the additional 58,000 deaths could reflect a combination of coronavirus deaths that didn't get recorded as such; deaths caused by people unwilling or unable to go to the hospital for other serious illnesses during the pandemic; or from overdoses or suicides stemming from increased social isolation during the pandemic. (Because of reporting lags, the death certificates used to determine excess deaths tend to understate recent weeks' totals and are expected to increase in future weeks as more data rolls in.)
"There is nothing like these abstract statistics to illustrate the 'psychic numbing' we experience when dealing with large-scale loss of life," said David Ropeik, author of the book "How Risky Is it, Really? Why Our Fears Don't Always Match the Facts."
"It's unlikely that, as stark as these figures are, that they will evoke nearly as much emotion as the personal story of any one of these victims," Ropeik said. "A risk depicted as a face, or a name — that is, 'personified' — is one we can imagine happening to ourselves. Statistics are inhuman and far less moving."
In January, as Mississippi health officials planned for their incoming shipments of COVID-19 vaccine, they assessed the state's most vulnerable: healthcare workers, of course, and elderly people in nursing homes. But among those who needed urgent protection from the virus ripping across the Magnolia State were 1 million Mississippians with obesity.
Obesity and weight-related illnesses have been deadly liabilities in the COVID era. A report released this month by the World Obesity Federation found that increased body weight is the second-greatest predictor of COVID-related hospitalization and death across the globe, trailing only old age as a risk factor.
As a fixture of life in the American South — home to nine of the nation's 12 heaviest states — obesity is playing a role not only in COVID outcomes, but in the calculus of the vaccination rollout. Mississippi was one of the first states to add a body mass index of 30 or more (a rough gauge of obesity tied to height and weight) to the list of qualifying medical conditions for a shot. About 40% of the state's adults meet that definition, according to federal health survey data, and combined with the risk group already eligible for vaccination — residents 65 and older — that means fully half of Mississippi's adults are entitled to vie for a restricted allotment of shots.
At least 29 states have greenlighted obesity for inclusion in the first phases of the vaccine rollout, according to KFF — a vast widening of eligibility that has the potential to overwhelm government efforts and heighten competition for scarce doses.
"We have a lifesaving intervention, and we don't have enough of it," said Jen Kates, director of global health and HIV policy for KFF. "Hard choices are being made about who should go first, and there is no right answer."
The sheer prevalence of obesity in the nation — 2 in 3 Americans exceed what is considered a healthy weight — was a public health concern well before the pandemic. But COVID-19 dramatically fast-tracked the discussion from warnings about the long-term damage excess fat tissue can pose to heart, lung and metabolic functions to far more immediate threats.
In the United Kingdom, for example, overweight COVID patients were 67% more likely to require intensive care, and obese patients three times likelier, according to the World Obesity Federation report. A Centers for Disease Control and Prevention study released Monday found a similar trend among U.S. patients and noted that the risk of COVID-related hospitalization, ventilation and death increased with patients' obesity level.
The counties that hug the southern Mississippi River are home to some of the most concentrated pockets of extreme obesity in the United States. Coronavirus infections began surging in Southern states early last summer, and hospitalizations rose in step.
Deaths in rural stretches of Mississippi, Tennessee, Louisiana and Arkansas have been overshadowed by the sheer number of deaths in metropolitan areas like New York City, Los Angeles and Essex County, New Jersey. But as a share of the population, the coronavirus has been similarly unsparing in many Southern communities. In sparsely populated Claiborne County, Mississippi, on the floodplains of the Mississippi River, 30 residents — about 1 in 300 — had died as of early March. In East Feliciana Parish, Louisiana, north of Baton Rouge, with 106 deaths, about 1 in 180 had died by then.
"It's just math. If the population is more obese and obesity clearly contributes to worse outcomes, then neighborhoods, cities, states and countries that are more obese will have a greater toll from COVID," said Dr. James de Lemos, a professor of internal medicine at UT Southwestern Medical Center in Dallas who led a study of hospitalized COVID patients published in the medical journal Circulation.
And, because in the U.S. obesity rates tend to be relatively high among African Americans and Latinos who are poor, with diminished access to healthcare, "it's a triple whammy," de Lemos said. "All these things intersect."
Poverty and limited access to medical care are common features in the South, where residents like Michelle Antonyshyn, a former registered nurse and mother of seven in Salem, Arkansas, say they are afraid of the virus. Antonyshyn, 49, has obesity and debilitating pain in her knees and back, though she does not have high blood pressure or diabetes, two underlying conditions that federal health officials have determined are added risk factors for severe cases of COVID-19.
Still, she said, she "was very concerned just knowing that being obese puts you more at risk for bad outcomes such as being on a ventilator and death." As a precaution, Antonyshyn said, she and her large brood locked down early and stopped attending church services in person, watching online instead.
"It's not the same as having fellowship, but the risk for me was enough," said Antonyshyn.
Governors throughout the South seem to recognize that weight can contribute to COVID-19 complications and have pushed for vaccine eligibility rules that prioritize obesity. But on the ground, local health officials are girding for having to tell newly eligible people who qualify as obese that there aren't enough shots to go around.
In Port Gibson, Mississippi, Dr. Mheja Williams, medical director of the Claiborne County Family Health Center, has been receiving barely enough doses to inoculate the health workers and oldest seniors in her county of 9,600. One week in early February, she received 100 doses.
Obesity and extreme obesity are endemic in Claiborne County, and health officials say the "normalization" of obesity means people often don't register their weight as a risk factor, whether for COVID or other health issues. The risks are exacerbated by a general flouting of pandemic etiquette: Williams said that middle-aged and younger residents are not especially vigilant about physical distancing and that mask use is rare.
The rise of obesity in the U.S. is well documented over the past half-century, as the nation turned from a diet of fruits, vegetables and limited meats to one laden with ultra-processed foods and rich with salt, fat, sugar and flavorings, along with copious amounts of meat, fast food and soda. The U.S. has generally led the global obesity race, setting records as even toddlers and young children grew implausibly, dangerously overweight.
Well before COVID, obesity was a leading cause of preventable death in the U.S. The National Institutes of Health declared it a disease in 1998, one that fosters heart disease, stroke, Type 2 diabetes and breast, colon and other cancers.
Researchers say it is no coincidence that nations like the U.S., the U.K. and Italy, with relatively high obesity rates, have proved particularly vulnerable to the novel coronavirus.
They believe the virus may exploit underlying metabolic and physiological impairments that often exist in concert with obesity. Extra fat can lead to a cascade of metabolic disruptions, chronic systemic inflammation and hormonal dysregulation that may thwart the body's response to infection.
Other respiratory viruses, like influenza and SARS, which appeared in China in 2002, rely on cholesterol to spread enveloped RNA virus to neighboring cells, and researchers have proposed that a similar mechanism may play a role in the spread of the novel coronavirus.
There are also practical problems for coronavirus patients with obesity admitted to the hospital. They can be more difficult to intubate due to excess central weight pressing down on the diaphragm, making breathing with infected lungs even more difficult.
Physicians who specialize in treating patients with obesity say public health officials need to be more forthright and urgent in their messaging, telegraphing the risks of this COVID era.
"It should be explicit and direct," said Dr. Fatima Stanford, an obesity medicine specialist at Massachusetts General Hospital and a Harvard Medical School instructor.
Stanford denounces the fat-shaming and bullying that people with obesity often experience. But telling patients — and the public — that obesity increases the risk of hospitalization and death is crucial, she said.
"I don't think it's stigmatizing," she said. "If you tell them in that way, it's not to scare you, it's just giving information. Sometimes people are just unaware."
Vaccine hesitancy experts say the concerns some people have about the covid vaccines are not identical to those around childhood vaccines, so pockets of childhood vaccine refusal may not correspond to covid vaccine-hesitant pockets.
Polls show Americans are increasingly interested in getting vaccinated against covid-19, but such surveys are largely national, leaving a big question: When the vaccines become available to the general public, will enough people get it in your county, city or neighborhood to keep your community safe?
Data on childhood vaccines, such as the one that protects against measles, mumps and rubella, provide hints. They show that the collective protection known as herd immunity can break down in pockets where not enough people choose to be immunized. Experts say at least92% of the population must be vaccinated against measles to prevent it from spreading.
In the 2019-20 school year, for example, fewer than 5% of kindergartners in Colorado had an exemption from the MMR vaccine, a KHN analysis found. But the exemptions were not evenly distributed in the state: In schools with complete data, at least 15% had enough kindergartners with nonmedical exemptions — religious or personal — to leave them vulnerable to measles outbreaks.
Does childhood immunization data show us which communities will shun the covid vaccines? Maybe yes, maybe no. Vaccine hesitancy experts say the concerns some people have about the covid vaccines are not identical to those around childhood vaccines. So pockets of childhood vaccine refusal may not correspond to covid vaccine-hesitant pockets.
“The Venn diagram will have some overlap, but it wouldn’t tell us the whole story,” said Saad Omer, a vaccine researcher and infectious disease epidemiologist who directs the Yale Institute for Global Health. “It's not the same circle.”
Experts like Omer are worried, however, that the political divisions that arose during the pandemic, and are evident in attitudes toward the covid vaccines, could spread to other vaccination campaigns. Some of the same coalitions that, in recent years, fought expansion of childhood vaccination requirements in state legislatures around the country joined to fight covid lockdowns.
School immunization rates can shed light on how pockets of vaccine uncertainty work. Colorado is one of 15 states, according to the National Conference of State Legislatures, where parents can opt their children out of vaccines required for school entry for philosophical reasons. It stands to reason that, in those states, school immunization rates may provide a more unfiltered look at vaccine refusal than in others.
Research shows childhood immunization exemption rates tend to remain relatively stable within schools over time, according to Daniel Salmon, who directs the Institute for Vaccine Safety at the Johns Hopkins Bloomberg School of Public Health. A KHN analysis found that in Utah and Idaho, which have a decade of school-level MMR data, most schools with complete data had the same herd immunity status in 2018 as in 2009.
Such trends might be somewhat predictive of how covid vaccines will be accepted, because once a community resists vaccination it’s hard to undo.
But this measles immunization data doesn’t measure vaccine hesitancy — it measures “actual refusal,” said Salmon. He also noted that childhood vaccines are much more easily accessible than covid vaccines, so school immunization patterns won’t reflect the potentially large number of people who forgo the covid vaccines because they’re just too hard to get.
Also, school immunization exemption figures capture the opinion only of parents of school-age kids, who may not be representative of the general population.
And there’s another, more basic issue: Vaccine hesitancy is not monolithic, regardless of which vaccine or population you’re talking about.
“I saw families that give certain vaccines to one child and other vaccines to a different child based on their perceptions of necessity,” said Jennifer Reich, a sociologist with the University of Colorado-Denver who studied vaccine acceptance. "I could see a family deciding that they want to delay childhood vaccines, but they think the covid vaccine is really important for their grandmother."
Omer said only a tiny fraction of very vocal people oppose all vaccines.
“There’s a group of people who are gonna refuse the vaccine no matter what,” he said. “Even if you put mom and apple pie in a shot, they would refuse the vaccine.”
A somewhat larger segment of parents will refuse one or more — but not all — vaccines for their children. And then there’s a much larger group that expresses hesitation about vaccination but ultimately accepts it.
Outright refusers are likely to make up a small part of the very broad group of adults who hesitate to get a covid vaccine, too, Omer said. Many people are sitting on the fence and may still opt to be vaccinated.
Polls from KFF and the Pew Research Center show Americans’ opinions have shifted over the past few months, with a growing share saying either that they want to get a vaccine “as soon as possible” or that they’ve already gotten one. (KHN is an editorially independent program of KFF.)
Interestingly, despite lots of coverage about vaccine concerns among racial and ethnic minorities, the latest KFF numbers show a nearly equal share of white and Black respondents — 15% and 14%, respectively — said they would “definitely not” get the vaccine.
Such polls also highlight another difference between childhood vaccines and the covid vaccines: how political covid vaccines have become.
“So far, childhood vaccines have been a bipartisan issue, more or less,” said Omer. “Every few months, there’s a debate on Twitter about whether it’s a conservative issue or a liberal issue, or if it’s the crunchy granola crowd or the libertarian crowd that is driving it. It’s all of the above.”
Indeed, Colorado schools that lacked herd immunity against the measles in 2019 because of high rates of nonmedical exemptions are a motley crew, spanning everything from a private religious school in the state’s rural southwest to a private Waldorf school in affluent Boulder and a public high school in the Rockies.
Still, vaccination skepticism has trended Republican in recent years as mistrust of scientific authority has grown in the party. Following the measles outbreaks that sprang up across the United States in 2019, GOP legislators in several states opposed Democrat-led efforts to tighten vaccine exemption laws — a harbinger of GOP-led protests against lockdowns during the pandemic.
And attitudes toward covid vaccination largely fall along party lines. As the KFF survey shows, the percentage of Democrats who said they wanted to get the shots as soon as possible (or had already gotten them) rose 28 points between December and February. The percentage rose 13 points among Republican respondents.
An increasingly politicized covid vaccine landscape could threaten acceptance of other vaccines. Kristin Lunz Trujillo, a political scientist at Carleton College in Minnesota, said the pandemic teed up a situation in which vaccines could become a partisan issue.
“We've seen with the covid vaccine, more so than any vaccine previously, the politicization that's occurring,” she said.
And as Omer put it, when something leaves the realm of opinion and enters partisan identity, it calcifies.
“You become less persuadable — even in the face of a lot of evidence,” he said. “With masks and the current debates around lockdowns, etc., if vaccines get folded in as part of that level of political identity, or a sense of yourself or your ideological brand, then we are in deep trouble.”
Dr. Peter Hotez, a professor at Baylor College of Medicine in Houston, has watched the anti-vaccine campaign grow from a fringe movement in the early 2000s. It accelerated in 2015, when it linked to the political extreme on the right under a banner of “health freedom,” he said.
“Covid-19, actually, somewhat paradoxically made things worse in terms of energizing the anti-vaccine movement,” he said. “It’s now a full-on anti-science empire.”
On the other hand, said Reich, covid vaccines may create opportunities to improve the conversation around vaccines in general. Previously, she said, vaccine messaging tended to be one-way: billboards, brochures, public service announcements. Now, state and local governments are engaging much more with stakeholders and community leaders.
“This moment is creating an awareness that communication that is successful has to be two-directional,” she said. “That's an overdue change.”
People have questions about what are, as Reich pointed out, vaccines that remain unlicensed. Engaging them in conversations, rather than dismissing them as victims of misinformation or conspiracy theories, could increase childhood vaccine use, too, she said.
HOUSTON — When the big, red and extremely loud fire alarm went off in Maria Skladzien's apartment, the 74-year-old ventured into the hallway with fellow residents of her Houston-area senior living community. The brutal winter storm that swept through Texas had knocked out power, which, in turn, disrupted water to the four-story building. The blaring alarms raised fears of fire.
The building's elevators were unusable without power. Dependent on her wheelchair, Skladzien went back inside her second-floor apartment. She watched as residents gathered in the subfreezing temperatures outside, wondering if she would have to "throw herself out the window" to survive.
"It's a very uneasy feeling," she said, sitting in the living room of her small apartment a week later, packages of water brought by friends and volunteers tucked against walls and sitting on tables. No fire had occurred, but her fears continued because the elevators were still not functioning. "So many crazy things race through your mind in a situation like this."
Winter storm Uri brought power failure and burst water pipes to millions of homes and businesses throughout Texas. But the impact, as is often the case in emergencies, was most profound on the state's most vulnerable — including residents of senior living facilities.
Of the state's 1,200 nursing facilities, about 50% lost power or had burst pipes or water issues, and 23 had to be evacuated, said Patty Ducayet, long-term care ombudsman for Texas. Of 2,000 assisted living facilities, about 25% had storm-related issues and 47 were evacuated. Some facilities reported building temperatures in the 50s.
The federal government requires nursing homes to maintain safe ambient temperatures but does not stipulate how and does not require generators or other alternative energy sources to run heating and air conditioning systems. States can implement more stringent guidelines, but, to date, Texas has not. Several bills were introduced in the Texas legislature after Uri to do just that, said Ducayet.
Uri was the latest disaster to highlight an ongoing problem. Evacuations and nursing home deaths in Hurricane Katrina in 2005 led to calls for similar protections. In 2009, Hurricane Sandy forced the evacuation of more than 4,000 nursing home residents in New York when backup power systems failed and emergency plans buckled. And calls for stricter rules were renewed when Hurricane Irma tore into Florida in 2017 and left a dozen residents dead in a nursing home that lost air conditioning. Multiple blackouts and wildfires in California also have exposed lax adherence to federal requirements for backup power at skilled nursing facilities, as well as weak state enforcement of those rules, according to a 2019 report from the U.S. Department of Health and Human Services.
"Every time we come back around with a new disaster, you see that these facilities still aren't as prepared as, maybe, they can or should be," said Lori Smetanka, executive director of the National Consumer Voice for Quality Long-Term Care, an advocacy organization based in Washington, D.C. "And many of them still aren't following the requirements that are in place. So it's like: What's it going to take to actually get the plans in place and to get enforcement of those plans?"
In November 2016, the Centers for Medicare & Medicaid Services implemented a slate of new regulations, including rules on disaster planning and emergency backup power in the nation's nursing homes.
A month later, Mark Parkinson, president and CEO of the long-term care industry's trade group, the American Healthcare Association and National Center for Assisted Living, sent a letter to then-President-elect Donald Trump requesting new rules because the regulations were burdensome and financially onerous, according to reporting by ProPublica.
In 2019, CMS published final rules with revised emergency preparedness guidance, agency spokesperson William Polglase said, after feedback from the public that those requirements were "overly burdensome and duplicative." But, he added, the rules require such facilities to have emergency and standby power systems and emergency plans. "We did not remove or modify any requirements that would endanger patient health or safety," he said.
Advocates for older adults, however, decried the changes as watering down the protections.
"The facilities push back because of the expense, but what I think recent years have shown us is that we're not talking about once-in-a-century type of disasters," said Eric Carlson, directing attorney with Justice in Aging, a national legal advocacy nonprofit.
But it's not just nursing homes at risk.
Cristina Crawford, an AHCA spokesperson, said prioritizing long-term care facilities at all levels is important in emergencies. "Nursing homes and assisted living facilities should be prioritized for power restoration and supplies for resource delivery in emergency situations," she said. "Long-term care facilities should also be included in community-based exercises to help ensure successful coordination in actual emergencies."
Although nursing homes face federal oversight, the licensing and regulatory authority for assisted and senior independent living facilities lies with the states, meaning a patchwork of definitions and guidelines for the facilities. Given that assisted and independent living communities have been the fastest-growing sector in senior living for many years, the disparate definitions and rules often leave residents and their families without a clear understanding of a facility's offerings and safety guardrails.
"There's no transparency from a consumer perspective about what are these different options, what am I getting in each of them," said David Grabowski, professor of healthcare policy at Harvard Medical School.
Years ago, Grabowski and others said, independent and assisted living facilities were filled with a generally healthier population who didn't need much medical assistance and who could afford to pay out-of-pocket for enhanced lifestyle amenities such as restaurants or outings.
But as the population ages, residents are often less healthy and may not have the financial resources to afford the higher level of care they need. And unlike nursing homes, assisted and independent living facilities do not necessarily operate under regulations that require building codes to address the needs of elderly or disabled residents, or requirements for backup power or emergency systems. It depends on where they are.
In Texas, assisted living facilities are required to have emergency plans but not generators. The legislation introduced in the wake of winter storm Uri seeks to change that. Independent living facilities like the one Skladzien lives in might not be covered, though; they already have even fewer state guidelines to follow.
"We still don't have good emergency management planning and preparation ingrained within the regulations to make sure our loved ones are safe within these facilities, because it just comes down to the money," said Brian Lee, executive director of Families for Better Care, a nonprofit in Austin, Texas, focused on the nation's long-term care facilities.
The debate is analogous to previous efforts to require sprinkler systems in nursing homes, he said. "How many more people have to be injured, maybe even have to have suffered death, because of power failure negligence?"
Lee and others said there is a distinction to be made between staff members — some of whom stayed in their facilities throughout the winter storm to keep residents safe — and industry forces resisting regulatory efforts to beef up backup safety systems.
"We can't, and shouldn't, let the industry decide how this is going to work," said Ducayet. "There needs to be involvement and organization at government levels, so that there is clarity and information about how these different settings work."
With elevators still not working at Skladzien's independent living building a week after the storm, she was trying to figure out how she would get to her weekly post-cancer medical treatment.
Skladzien, who owned her own cleaning business for 25 years and drove a school bus for 15 years, moved into senior housing in 2019 when she could no longer handle the upkeep on her home. When she was looking for a place to live, though, it never occurred to her that apartments marketed toward older adults would not have a generator or plans to help residents in an emergency. And she never thought to ask.
"I had no experience," she said.
It may not have mattered: Medical bills had depleted her savings, leaving her only the choice of what was available in low-income housing. In her building, she was told, wheelchair-accessible apartments on the first floor were beyond her financial reach.
Data on childhood vaccines show that the collective protection known as herd immunity can break down in pockets where not enough people choose to be immunized.
This article was published on Wednesday, March 10, 2021 in Kaiser Health News.
Polls show Americans are increasingly interested in getting vaccinated against COVID-19, but such surveys are largely national, leaving a big question: When the vaccines become available to the general public, will enough people get it in your county, city or neighborhood to keep your community safe?
Data on childhood vaccines, such as the one that protects against measles, mumps and rubella, provide hints. They show that the collective protection known as herd immunity can break down in pockets where not enough people choose to be immunized. Experts say at least92% of the population must be vaccinated against measles to prevent it from spreading.
In the 2019-20 school year, for example, fewer than 5% of kindergartners in Colorado had an exemption from the MMR vaccine, a KHN analysis found. But the exemptions were not evenly distributed in the state: In schools with complete data, at least 15% had enough kindergartners with nonmedical exemptions — religious or personal — to leave them vulnerable to measles outbreaks.
Does childhood immunization data show us which communities will shun the COVID vaccines? Maybe yes, maybe no. Vaccine hesitancy experts say the concerns some people have about the COVID vaccines are not identical to those around childhood vaccines. So pockets of childhood vaccine refusal may not correspond to COVID vaccine-hesitant pockets.
"The Venn diagram will have some overlap, but it wouldn't tell us the whole story," said Saad Omer, a vaccine researcher and infectious disease epidemiologist who directs the Yale Institute for Global Health. "It's not the same circle."
Experts like Omer are worried, however, that the political divisions that arose during the pandemic, and are evident in attitudes toward the COVID vaccines, could spread to other vaccination campaigns. Some of the same coalitions that, in recent years, fought expansion of childhood vaccination requirements in state legislatures around the country joined to fight COVID lockdowns.
School immunization rates can shed light on how pockets of vaccine uncertainty work. Colorado is one of 15 states, according to the National Conference of State Legislatures, where parents can opt their children out of vaccines required for school entry for philosophical reasons. It stands to reason that, in those states, school immunization rates may provide a more unfiltered look at vaccine refusal than in others.
Research shows childhood immunization exemption rates tend to remain relatively stable within schools over time, according to Daniel Salmon, who directs the Institute for Vaccine Safety at the Johns Hopkins Bloomberg School of Public Health. A KHN analysis found that in Utah and Idaho, which have a decade of school-level MMR data, most schools with complete data had the same herd immunity status in 2018 as in 2009.
Such trends might be somewhat predictive of how COVID vaccines will be accepted, because once a community resists vaccination it's hard to undo.
But this measles immunization data doesn't measure vaccine hesitancy — it measures "actual refusal," said Salmon. He also noted that childhood vaccines are much more easily accessible than COVID vaccines, so school immunization patterns won't reflect the potentially large number of people who forgo the COVID vaccines because they're just too hard to get.
Also, school immunization exemption figures capture the opinion only of parents of school-age kids, who may not be representative of the general population.
And there's another, more basic issue: Vaccine hesitancy is not monolithic, regardless of which vaccine or population you're talking about.
"I saw families that give certain vaccines to one child and other vaccines to a different child based on their perceptions of necessity," said Jennifer Reich, a sociologist with the University of Colorado-Denver who studied vaccine acceptance. "I could see a family deciding that they want to delay childhood vaccines, but they think the COVID vaccine is really important for their grandmother."
Omer said only a tiny fraction of very vocal people oppose all vaccines.
"There's a group of people who are gonna refuse the vaccine no matter what," he said. "Even if you put mom and apple pie in a shot, they would refuse the vaccine."
A somewhat larger segment of parents will refuse one or more — but not all — vaccines for their children. And then there's a much larger group that expresses hesitation about vaccination but ultimately accepts it.
Outright refusers are likely to make up a small part of the very broad group of adults who hesitate to get a COVID vaccine, too, Omer said. Many people are sitting on the fence and may still opt to be vaccinated.
Polls from KFF and the Pew Research Center show Americans' opinions have shifted over the past few months, with a growing share saying either that they want to get a vaccine "as soon as possible" or that they've already gotten one. (KHN is an editorially independent program of KFF.)
Interestingly, despite lots of coverage about vaccine concerns among racial and ethnic minorities, the latest KFF numbers show a nearly equal share of white and Black respondents — 15% and 14%, respectively — said they would "definitely not" get the vaccine.
Such polls also highlight another difference between childhood vaccines and the COVID vaccines: how political COVID vaccines have become.
"So far, childhood vaccines have been a bipartisan issue, more or less," said Omer. "Every few months, there's a debate on Twitter about whether it's a conservative issue or a liberal issue, or if it's the crunchy granola crowd or the libertarian crowd that is driving it. It's all of the above."
Indeed, Colorado schools that lacked herd immunity against the measles in 2019 because of high rates of nonmedical exemptions are a motley crew, spanning everything from a private religious school in the state's rural southwest to a private Waldorf school in affluent Boulder and a public high school in the Rockies.
Still, vaccination skepticism has trended Republican in recent years as mistrust of scientific authority has grown in the party. Following the measles outbreaks that sprang up across the United States in 2019, GOP legislators in several states opposed Democrat-led efforts to tighten vaccine exemption laws — a harbinger of GOP-led protests against lockdowns during the pandemic.
And attitudes toward COVID vaccination largely fall along party lines. As the KFF survey shows, the percentage of Democrats who said they wanted to get the shots as soon as possible (or had already gotten them) rose 28 points between December and February. The percentage rose 13 points among Republican respondents.
An increasingly politicized COVID vaccine landscape could threaten acceptance of other vaccines. Kristin Lunz Trujillo, a political scientist at Carleton College in Minnesota, said the pandemic teed up a situation in which vaccines could become a partisan issue.
"We've seen with the COVID vaccine, more so than any vaccine previously, the politicization that's occurring," she said.
And as Omer put it, when something leaves the realm of opinion and enters partisan identity, it calcifies.
"You become less persuadable — even in the face of a lot of evidence," he said. "With masks and the current debates around lockdowns, etc., if vaccines get folded in as part of that level of political identity, or a sense of yourself or your ideological brand, then we are in deep trouble."
Dr. Peter Hotez, a professor at Baylor College of Medicine in Houston, has watched the anti-vaccine campaign grow from a fringe movement in the early 2000s. It accelerated in 2015, when it linked to the political extreme on the right under a banner of "health freedom," he said.
"COVID-19, actually, somewhat paradoxically made things worse in terms of energizing the anti-vaccine movement," he said. "It's now a full-on anti-science empire."
On the other hand, said Reich, COVID vaccines may create opportunities to improve the conversation around vaccines in general. Previously, she said, vaccine messaging tended to be one-way: billboards, brochures, public service announcements. Now, state and local governments are engaging much more with stakeholders and community leaders.
"This moment is creating an awareness that communication that is successful has to be two-directional," she said. "That's an overdue change."
People have questions about what are, as Reich pointed out, vaccines that remain unlicensed. Engaging them in conversations, rather than dismissing them as victims of misinformation or conspiracy theories, could increase childhood vaccine use, too, she said.
Many long haulers have found it impossible to fulfill their professional obligations and are making the tough decision to stop working and seek disability benefits.
This article was published on Wednesday, March 10, 2021 in Kaiser Health News.
Rickie Andersen took a brief break from work in March after she fell ill. Her cough, fever and chills were typical COVID-19 symptoms, but coronavirus tests were so scarce she could not obtain one to confirm the diagnosis.
After Andersen returned to her job as an information systems project manager in the San Francisco Bay Area, she struggled with profound fatigue, cognitive difficulties and other disabling complaints. For six months, she tried to keep awake during meetings and finish basic tasks that took much longer than before.
Finally, she decided to retain legal help so she could take advantage of the disability insurance coverage offered as an employee benefit. "I realized this is not going to be a short-term thing," Andersen said.
Hundreds of thousands of people around the world are experiencing what is being called "long COVID" — a pattern of prolonged symptoms following an acute bout of the disease. Many have managed to continue working through accommodations like telecommuting, cutting down on hours and delegating responsibilities.
Others have found it impossible to fulfill their professional obligations and are making the tough decision to stop working and seek disability benefits. But as they pursue the application process, they are discovering a particular set of challenges.
Given the lack of testing in the first months, many "long haulers," like Andersen, have no laboratory proof of infection. While antibody tests can provide such evidence, their accuracy varies. Moreover, many of the reported symptoms, including fatigue and cognitive impairment, are subjective and not clearly linked to specific organ damage.
Beyond that, compiling a thorough record for a disability application and navigating the bureaucratic hurdles require sustained brain power, something many long-haul patients can no longer muster. Barbara Comerford, a New Jersey disability lawyer, said she received dozens of inquiries starting last fall from long haulers seeking advice on filing for disability and often citing what is being called "brain fog" as their main complaint.
"Most are people calling to say, 'I thought I could do it. I can't. My mind doesn't function for more than really brief periods of time,'" Comerford said. She gave a presentation to the New Jersey State Bar Association in mid-February on how to develop evidence for such cases.
In the U.S., close to 30 million people have tested positive for the coronavirus, although many cases of infection are asymptomatic. What proportion might be affected by long-term illness isn't known. Scientific understanding of the phenomenon is in its infancy.
In January, The Lancet reported that around three-quarters of more than 1,700 COVID patients who had been hospitalized in Wuhan, China, reported at least one ongoing symptom six months later. More recently, investigators from the University of Washington reported in JAMA Network Open that around 30% of 177 patients who had tested positive for the coronavirus still reported symptoms when they were surveyed one to 10 months later.
The Social Security Administration provides long-term disability to American workers who qualify under its strict criteria, but applicants often get turned down on the first try. A few states, including California and New York, provide short-term disability benefits, in some cases for up to a year.
Tens of millions of Americans also have private disability coverage, most often as part of their employment benefit packages.
The maximum currently available to an individual through the Social Security Disability Insurance program is just over $3,000 a month. A typical private long-term disability plan might cover 60% of a beneficiary's base salary, with a much higher maximum amount.
Sandy Lewis, a pharmaceutical industry researcher, fell ill last March with what she assumed was COVID. She recovered but relapsed in April and again in May.
Through her employer-based insurance coverage, she received short-term disability for November and December, but the insurer, Prudential Financial, rejected her request for an extension. Soon after, she was diagnosed with myalgic encephalomyelitis/chronic fatigue syndrome, or ME/CFS, a debilitating illness that can be triggered by viral infections.
Lewis, who lives outside Philadelphia, is planning to appeal Prudential's rejection of the short-term extension and apply for long-term disability. But the matter is unlikely to be resolved before fall. The situation has left her feeling "devastated," she said, and in serious financial distress.
"This has been such an arduous journey," she said. "I have no income and I'm sick, and I'm continuing to need medical care. I am now in a position, at 49 years old, that I may have to sell my home during a pandemic and move in with family to stay afloat."
In Lewis' case, a Prudential reviewer noted that her symptoms were "subjective" and that there were "no physical exam findings to correlate with any ongoing functional limitations," according to Cassie Springer Ayeni, an Oakland disability lawyer who is representing her as well as Andersen.
Prudential would not comment on a specific case. Evan Scarponi, chief claims officer, said in a statement that "our collective understanding of COVID-19 and any associated long-term effects are still evolving" but that Prudential is "well-versed in evaluating both subjective and objective aspects of disability claims."
Lawyers and advocates in the field expect the numbers of COVID-related long-term disability applicants to rise this year. But it's still too soon to detect any such increase, said a spokesperson for the American Council of Life Insurers, a trade association. Workers typically must be unable to work for half a year before becoming eligible for long-term disability benefits, and applying can itself be a lengthy process.
Brian Vastag, a former Washington Post science and health reporter with ME/CFS, stopped working in 2014 and then sued Prudential after it rejected his long-term disability claim. Insurance companies, he said, can easily find reasons to dismiss applications from claimants with chronic illnesses characterized by symptoms like fatigue and cognitive impairment.
"The insurance companies will often say, 'There's no objective evidence, so we have nothing to support your claim,'" said Vastag, who won his case against Prudential in 2018. "I'm worried about the long-COVID patients who can't work anymore."
Claimants can appeal a rejection. If the insurer rejects the appeal, claimants have the right to sue, as Vastag did. However, most such cases fall under the Employee Retirement Income Security Act of 1974. Because this federal law requires a losing insurer to pay the unpaid claims but does not provide for punitive or compensatory damages, critics argue it incentivizes the denial of coverage.
In the event of litigation, the court's role is to assess the already existing evidentiary record. That means it is essential to present a robust case in the initial application or during the administrative appeal before any litigation begins, said Ayeni, the disability lawyer for Andersen and Lewis.
"It's the only shot to build a record for the courts, to develop a full body of evidence," she said.
However, a successful disability case ultimately depends on documenting inability to work, not on obtaining a specific diagnosis. To augment the medical evidence, Ayeni often sends clients for neuropsychological testing, investigations of lung function and other specialist assessments. She also gathers affidavits from family members, professional colleagues and friends to confirm patients' accounts.
In Rickie Andersen's case, the strategy worked. Recognizing how complicated the application process was likely to be, she sought legal help early on. The insurer contracted by her employer approved her for short-term benefits late last year and granted her application for long-term benefits in February.
"I knew all of it was completely exhausting, so it wasn't something I thought I could do on my own," Andersen said.