When he became eligible for the coronavirus vaccine in Illinois, Tom Arnold, 68, said he didn't need any convincing. He raises cattle, hogs and chickens in Elizabeth, a small town in the state's northwestern corner.
After all, who better to understand why herd immunity matters than a herdsman?
"Being a livestock producer, I'm well aware of vaccinations and vaccines," he said. "That's how we develop immunity in our animals. We're always vaccinating the breeding stock to pass on immunity to the little ones."
Boosting COVID-19 vaccination rates in rural America is now less a problem of access and more an issue of trust. Only about 40% of people in Jo Daviess County, where Arnold lives, are fully vaccinated. Arnold said he doesn't get why people are acting as if the pandemic were over. Scientists say those under-vaccinated parts of the country like Jo Daviess are at serious risk, especially as the highly contagious delta variant spreads rapidly.
It's why farmers and ranchers need to speak openly about why they've chosen to be vaccinated, said Carrie Cochran-McClain, chief policy officer with the National Rural Health Association.
"One of the hardest things about the vaccination effort is that it really, at this point, is almost down to those one-on-one kinds of conversations," she said.
Cochran-McClain's association has teamed up with the National Farmers Union to try to get more farmers to promote the vaccine in their communities. They've created an online toolkit for farmers with information and talking points for starting conversations.
Ryan Goodman, 32, is giving it a try. He's a cattle rancher in Virginia and self-described "agriculture advocate." On Instagram and Twitter, he's known as "Beef Runner."
Goodman, who lived in Colorado until recently, has been using his social media accounts to promote the vaccine, as part of a paid content partnership with the Colorado Department of Public Health and Environment.
The agency provides him with information about the vaccines to share online, and he responds to questions with support from the department's public health experts.
He said he's not sure he's changed any minds, but he's encouraged when skeptics return to chat more.
"I'm a fan of saying no one conversation changes someone's mind, especially when you disagree on a topic that might be as hot or as political as vaccines," Goodman said.
He'd like to see more farmers speak up, because in rural towns farmers have long roots, extending back generations — making them more trusted than even health experts, he said.
"Everybody looks at Joe down the road and thinks, 'Hey, you know, what might be his experiences on this topic or this issue?'" Goodman said. "[And they] listen to what he or she may say."
Larry Lieb farms 92 acres of soybeans and timber in central Illinois and also raises a few cows and pigs.
He said he wondered whether the vaccine could be safe, given how quickly it came to market — and he got it for only one reason.
"My daughter's a respiratory therapist, and she told me I was gonna get it," Lieb said. "Plain and simple."
Unlike some of his relatives, Lieb said, he does not buy into conspiracy theories about the vaccine. But he said he avoids those conversations altogether.
"It's their own personal choice," he said. "On issues where they're set in their ways, you know, it's futile to try."
The pandemic has had a huge economic impact on farmers, said Mike Stranz, vice president of advocacy for the National Farmers Union.
"There's been so much upheaval in the agricultural economy and in our communities," Stranz said. "We need to start moving past that, and vaccines are the way towards that [goal]."
Vaccination rates have consistently lagged in rural communities, and an analysis from NPR and Johns Hopkins University in June found new COVID hot spots are cropping up in areas with dangerously low vaccination rates — especially in the South, Midwest and West.
Urban and rural areas have been seeing similar rates of new COVID cases lately, according to an analysis from the University of Iowa. But some states — including Illinois, Missouri and Utah — are seeing higher rates in nonmetropolitan areas.
But Cochran-McClain said she hopes farmers don't get discouraged, and she has this message for people like Lieb: "He may not feel like his voice is much, but we believe it's very strong and important."
Arnold said he believes the vaccine saves lives, but he doesn't think it's his job to try to convince his neighbors or friends. And, he said, he has limited capacity for new challenges.
"I'm already overworked and underpaid," Arnold said. The vaccine rollout, so far, has coincided with some of the busiest times of the year for farmers.
If he gets into a conversation with someone about the vaccine, he said, he'll express to them that he's a livestock producer and understands how they work.
"But I don't elaborate," Arnold said. "Unless people are asking me. And usually they don't."
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."
State and local health departments are trying to build back operations with depleted resources, as COVID fatigue among their workers and the public alike complicate those efforts.
This article was published on Thursday, August 19, 2021 in Kaiser Health News.
Health departments nationwide scaled back their contact tracing in late spring or early summer when COVID-19 cases started to decrease as vaccination efforts took center stage.
Then delta hit.
Now state and local health departments are trying to build back operations with depleted resources, as COVID fatigue among their workers and the public alike complicate those efforts.
"Contact tracing from the start of this pandemic provided us with really kind of invaluable information," said Dr. Amanda Castel, a professor of epidemiology at George Washington University. Castel said it's still "a fundamental part of our response." As is COVID testing, especially for those who are vulnerable or unvaccinated, such as children under age 12. Yet numerous departments now find themselves with fewer contact tracers and less robust programs. Like testing, contact tracing seems to have fallen by the wayside.
Contact tracing is a resource-intensive operation, requiring workers to quickly call people who test positive for a disease and offer medical advice, and then to identify and reach out to anyone with whom the infected people came in close contact. The hope during the pandemic is to prevent spread of the COVID virus, and to observe how the virus is changing. The process has been used for decades by public health officials to stop disease transmission.
But many public health departments were overwhelmed by the onslaught of COVID. Last winter — before vaccines provided relief — they were unable to stay ahead of the virus through contact tracing. And as case counts dropped by virtue of increased vaccination rates in the spring and early summer, more than a dozen state health departments scaled back the workforce, said Crystal Watson, a senior scholar and assistant professor at the Johns Hopkins Center for Health Security. The resources were needed for vaccination initiatives and to restart other public health programs.
The situation has grown critical in a number of states during the past month or so as local health officials find themselves once again behind the curve as the delta variant drives up case counts. Resources are already stretched, and the politicization of COVID-19 has left these local officials making tough calls regarding whom to trace in places like Missouri and Texas. And some states just don't have enough personnel to do the job. The army of disease detectives more often than not included temporary staff or civil servants from outside the health department. In Kentucky, the former contact-tracing director is now the aviation department commissioner. The state health department said he has a successor but declined to name them.
The highly contagious delta variant makes the job harder. Cases can stack up quickly. Public health departments, which are chronically understaffed and underfunded, must pick and choose which tools will serve them the best.
"Some places have done a good job at retaining a kind of reserve workforce that they could call back up. And I'm sure that's coming in handy right now. Other places did not. And they're probably going to be quickly overwhelmed," Watson said. "It's also hard to say because there's not a lot of public reporting."
Arkansas, where Republican Gov. Asa Hutchison now says it was an error to sign a law in April banning mask mandates, is averaging around 2,000 new cases a day, one of the steepest upsurges among states. But the state health department has significantly fewer contact tracers now — 192 compared with 840 in December, when case counts were at the same level, according to the department and data collected by Johns Hopkins.
Danyelle McNeill, an Arkansas health department public information officer, said contractors performing this work have been authorized to increase their staff size. She also said that the agency is triaging cases, prioritizing those who tested positive for or were diagnosed with COVID within six days of specimen collection or symptom onset, which the Centers for Disease Control and Prevention has recommended when capacity is limited, and that its vendors are not calling all positive cases the same day they receive lists when infections near 2,000.
In states that have opted to downplay contact tracing, county and city health officials are left to fend for themselves. In hard-hit southwestern Missouri, the flood of cases has overwhelmed a staff already stretched thin, said Springfield-Greene County Health Department Director Katie Towns, so the department pivoted to conducting contact tracing only in cases involving children younger than 12, who aren't eligible for vaccination, Towns said.
Lisa Cox, a spokesperson for the state health department, said that "local health departments will work to triage and prioritize case investigations and will work with them if assistance is needed." Her department expects financial support through the federal American Rescue Plan, but funds have yet to be appropriated. Ultimately, local strategies will come down to priorities. "We've made it clear that local jurisdictions need to make decisions locally based on their unique situation."
The Springfield-Greene County Health Department's surge capacity has diminished as team members have been redeployed to other health programs, which had been neglected during the pandemic. But even if Towns had unlimited resources, she said, she questions how effective investing it all in contact tracing would be: COVID is rampant and compliance with public health measures has waned. She would likely deploy more people to perform vaccine outreach and distribution.
Kelley Vollmar, executive director of the Jefferson County Health Department in eastern Missouri, said the delta surge is hitting a community polarized against public health efforts. "You have a public who is really not supportive of contact tracing and quarantine, as well as the funding for contact tracing and infrastructure is not there like it was last year," she said.
In Texas, the Department of State Health Services is "winding down" the contact-tracing program to meet the requirements of the budget. In the new budget, which takes effect Sept. 1, taxpayer dollars are expressly banned from being used for COVID contact tracing. "We will still be doing case investigations and other public health follow up," said Chris Van Deusen, the state health department's director of media relations, via email, "but won't be providing contact tracing for local health departments." The Texas Education Agency, which oversees primary and secondary education, also said earlier this month that schools are not required to conduct contact tracing.
Contact tracing has been clouded by controversy in Texas. Five legislators sued Republican Gov. Greg Abbott and the health department in August 2020 for awarding a contract to conduct the program. "The contract tracing policy has never been established as a policy accepted or supported by the Texas Legislature," the suit said. Another lawsuit filed the same month by dozens of Texans alleges that the adoption of contact tracing violates their constitutional right to privacy.
Williamson County turned to the state health department for help in contact tracing and case investigation as 50 to 100 new cases per day were being reported.
The county health department, which is separate from the county government, also trained more than half its staff to do contact tracing, everyone from clinical staff to press, said Allison Stewart, lead epidemiologist at Williamson County and Cities Health District, but the 65 people, including external staff and volunteers, couldn't keep up with cases. Some worked seven days a week or 12-hour days, but now the county relies on the state for that work. "We can't return to those days now, because all the people that we used actually are doing their real jobs," she said. "We're trying to figure out right now what the plan is come Sept 1. And it may mean the plan is that we don't do case investigation or contact tracing."
"Honestly, we don't know," she said.
San Antonio, one of the country's largest cities and located in Bexar County, has its own contact tracers but leans on the state whenever there is a surge, said Rita Espinoza, the city's chief of epidemiology. San Antonio is currently relying on the state and thus able to handle the load without backlogs, Espinoza said. She worries about what will happen in the fall, after school starts and there are more opportunities for transmission. The staff is already operating at a reduced capacity of 80 people.
"The specific impacts are unknown, but it may impact efforts to enhance other infectious disease investigations," said Espinoza.
Florida, where COVID has become a political buzzword, is another state where this tension is playing out. Broward County Mayor Steve Geller said he's asked about contact-tracing capabilities, including how many investigators the state health department has, but he said he's only ever told, "We're working on it. It's under control." Contact-tracing data is not publicly available, but Republican Gov. Ron DeSantis once told local reporters contact tracing "has just not worked."
Geller has not pushed health officials for information, given that "contact tracing doesn't work well when everyone has COVID" and that COVID data has become contentious in Florida. "I'm not looking to create any new martyrs," he said.
Midwest correspondent Lauren Weber contributed to this story.
Experts say it's more plausible that the annoyances of masking could distract from in-class lessons and make it harder to hear other students or the teacher.
This article was published on Wednesday, August 18, 2021 in Kaiser Health News.
Florida Gov. Ron DeSantis is one of a handful of Republican governors trying to block school districts from requiring masks in the classroom.
Under DeSantis' direction, the state health departmentadopted a rule that lets families opt out of locally ordered school mask mandates. The State Board of Education approved another rule that allows parents to secure vouchers for their children to attend a different school if they encounter pushback on their refusal to use masks. The DeSantis administration threatened to penalize school officials financially if they bucked the rules.
Much of DeSantis' argument was based on his belief that parents have a right to determine what's best for their child, as well as his doubts about whether mask mandates are effective at curbing the COVID virus in a school setting. (When PolitiFact looked into the latter argument, multiple experts pointed to research showing that mask-wearing is effective at protecting children from COVID-19 and preventing COVID transmission in schools.)
But DeSantis also cited specific negatives for mask wearers' health.
In an executive order, DeSantis wrote that "masking children may lead to negative health and societal ramifications" and that "forcing children to wear masks could inhibit breathing, lead to the collection of dangerous impurities including bacteria parasites, fungi, and other contaminants, and adversely affect communications in the classroom and student performance."
DeSantis' press secretary, Christina Pushaw, told PolitiFact that "there are potential downsides to masking children for eight hours per day, from a developmental, emotional, academic, and medical perspective. These potential downsides are largely unexplored."
She cited concerns raised in an op-ed by Dr. Marty Makary, a professor at the Johns Hopkins School of Medicine, and Dr. Cody Meissner, chief of pediatric infectious diseases at Tufts Children's Hospital, that said that "masks can lead to increased levels of carbon dioxide in the blood" and that they "can be vectors for pathogens if they become moist or are used for too long." Makary and Meissner also warned of impacts on verbal and nonverbal communication.
Other people aligned with DeSantis' view have put the harm of kids wearing masks in even starker terms.
During a panel discussion convened by DeSantis, clinical psychiatrist Dr. Mark McDonald said, "My position is simple: Masking children is child abuse," according to the Miami Herald. (Meissner was also on the panel.)
Rep. Madison Cawthorn (R-N.C.) spoke out against a proposed school mask mandate by the Buncombe County Board of Education, saying a mandate is "nothing short of psychological child abuse."
And on the July 27 edition of his Fox News show, Tucker Carlson asserted that it's a "scientifically established fact that masks pose a far greater threat to children than COVID does. So, strictly speaking as a scientific matter, this is lunacy."
What does science say about whether masks can harm the wearer?
Generally, we found that concerns about significant negative effects on breathing aren't well supported. Worries about masks interfering with communication and serving as a barrier to social connection in the classroom may be more reasonable, experts say.
Breathing Concerns
The first thing to note is that masks aren't recommended for everyone. The American Lung Association cautions people with lung disease, for instance, to consult their doctor before wearing a mask regularly. In addition, the CDC does not recommend that children under 2 years old wear masks. Masks are also generally not recommended during heavy exercise.
But what about people who do not fall into these categories? Could they be hurt by wearing a mask?
Some of the most common concerns raised involve a lack of oxygen, or a buildup in carbon dioxide. We have previously foundsuchconcerns to be oversold, as have otherfact-checkers.
The issue "has been convincingly debunked," said Babak Javid, a professor of medicine at the University of California-San Francisco.
We should note that studies specific to children have been rare, so most of the scientific literature has involved research on adults. Two studies on children used N95 masks, which are more sophisticated than the masks most schoolchildren will use, but even these found no significant effect on breathing. Other peer-reviewed studies of adults have produced similar results.
A mask "will add some resistance to the breathing process, meaning it may feel like it takes a bit more work to take a breath, but it won't materially change the makeup of air that comes through the mask," said Benjamin Neuman, a biology professor at Texas A&M University and chief virologist of the university's Global Health Research Complex.
A paper published in February looked at 10 previous studies of adults or children that addressed questions of breathing while wearing a mask. The authors expressed disappointment at how few studies looked specifically at the impacts on children, and they urged that more research is needed on that specific question.
However, the paper found little reason for worry.
"The eight adult studies, including four prompted by the pandemic and one on surgeons, reported that face masks commonly used during the pandemic did not impair gas exchange during rest or mild exercise," the authors wrote.
A June study that seemed to indicate breathing challenges for masked children was retracted by the journal JAMA Pediatrics 16 days after publication because of methodological shortcomings and other concerns.
Dr. David Hill, an American Lung Association board member, has written that masks "absolutely" do not cause low oxygen levels.
"We wear masks all day long in the hospital," Hill wrote. "The masks are designed to be breathed through and there is no evidence that low oxygen levels occur."
Another reason medical experts aren't too worried is that "the world has engaged in a massive study — observational, but literally billions of people — on mass mask-wearing, and people are not dropping dead left, right and center," Javid said.
Other Possible Risks
A few other complaints about masks sometimes surface, such as fear that they could concentrate toxins or harm the immune system. But these aren't well supported either, experts say.
As long as masks are regularly replaced or laundered, "there's no reason to worry about toxins,'' said Columbia University virologist Angela Rasmussen. And there's "no evidence that masks have any effect on the immune system or immune function," she said.
Dr. Amesh Adalja, a senior scholar at the Johns Hopkins Center for Health Security, told PolitiFact that swabbing a student's backpack would probably generate as many (or more) pathogens as swabbing their mask.
And Nicole Gatto, an associate professor of public health at Claremont Graduate University, said pathogens on masks may be evidence that they're being kept "out of the mouths and noses of those who wore them, preventing people from potentially getting ill."
While the scientific evidence for specific ills such as low oxygen or high carbon dioxide is weak, experts say it's more plausible that the annoyances of masking could distract from in-class lessons and make it harder to hear other students or the teacher.
In a September 2020 paper in the International Journal of Environmental Research and Public Health, the authors wrote that "while there are minimal physiological impacts on wearing a mask … there may be consequential psychological impacts of mask wearing on the basic psychological needs of competence, autonomy, and relatedness."
Such downsides may be especially acute for students who are English-language learners, or those who are deaf or hard of hearing.
"Masks interfere with lip-reading, which has a major impact on communication," Javid said.
The reality is that "there is minimal evidence" on how severe these sorts of impacts could be for most children. "This is the first time in most of our lifetimes we have faced the prospect of continued isolation and masking, so it is not surprising we have insufficient evidence to guide us," said Amy Price, a senior research scientist at Stanford University.
Still, there is evidence that children are adaptable. In a December 2020 study of children's ability to read the facial expressions of masked people, researchers at the University of Wisconsin-Madison found that "while there may be some challenges for children incurred by others wearing masks, in combination with other contextual cues, masks are unlikely to dramatically impair children's social interactions in their everyday lives."
And child-development experts caution against assuming that any deficits from masks will linger over the long term.
Most children "don't like wearing pants or shoes at first, but they adjust, like they do for all the other things we require of them," said A.E. Learmonth, a professor with the cognition, memory and development lab at William Paterson University. "In many ways, a mask is just another article of clothing. In the beginning it could be distracting and uncomfortable, but like shoes, they will get used to it."
Meanwhile, polling suggests that parents are open to masks in schools. A KFF survey taken in July and August found that 63% of parents wanted masks required in schools for people who are unvaccinated.
PolitiFact'sGabrielle Settles and Jason Asenso contributed to this article.
The options are slim for people who suffer rare life-altering injuries after a COVID shot — a problem whose significance has grown as states and the federal government ponder vaccination mandates.
This article was published on Wednesday, August 18, 2021 in Kaiser Health News.
Angela Marie Wulbrecht jumped at the first chance to get a COVID-19 vaccine, driving three hours from her Santa Rosa, California, home to a mass-vaccination site on Jan. 19. Twelve minutes after her Moderna shot, she stumbled into the paramedic tent with soaring blood pressure and a racing heartbeat. And so began a calvary of severe fatigue, brain fog, imbalance and other symptoms that are still with her eight months later.
Wulbrecht, 46, had been a nurse for 23 years before the shot. She was healthy, ate a vegan diet and was an accomplished salsa dancer. Since January she's had to leave her job and missed out on many activities with her husband and 12-year-old daughter, Gabriella. She has spent about $35,000 on out-of-pocket medical bills, despite having insurance.
"I wanted to get vaccinated as soon as I could to help fight the pandemic," said Wulbrecht, who still supports the vaccination campaign. Her husband got his shots despite her reaction, and Gabriella was scheduled to get her first dose Wednesday. "But it would help those who are hesitant if they took care of those of us who got injured."
The options are slim for people who suffer rare life-altering injuries after a COVID shot — a problem whose significance has grown as states and the federal government increasingly ponder vaccination mandates.
A federal program compensates people experiencing vaccine injuries, but not injuries from COVID vaccines — not yet, anyway.
Such injuries are rare, but "if you're going to take one for the team, the team has to have your back," said Katharine Van Tassel, a vaccine law expert at the Case Western Reserve University School of Law in Cleveland. "That's a moral imperative."
Since it began operations in 1988, the vaccine court has paid more than $4 billion to over 8,000 families who could provide a "preponderance of evidence" that vaccines against diseases like measles and pertussis hurt their kids. The court also covers vaccine injuries in pregnant women, and from the flu vaccine. But it does not cover aftereffects from COVID vaccines.
A smaller federal program, the Countermeasures Injury Compensation Program, addresses illnesses resulting from drugs or vaccines administered during a public health emergency, such as the COVID pandemic.
But that program requires evidence that's harder to pin down, does not pay attorney fees and rules by administrative fiat, while the vaccine court has judges. The countermeasures program has yet to pay a cent to anyone hurt by a COVID vaccine, and its largely invisible decisions are "an inscrutable enigma," said Brian Abramson, an expert on vaccine law.
David Bowman, a spokesperson for the Health and Human Services Department's Health Resources & Services Administration, said the countermeasures program had a total of seven staff members and contractors and was seeking to hire more. He declined to answer questions about how COVID vaccine claims could be handled in the future.
In June, a bipartisan group of lawmakers led by Reps. Lloyd Doggett (D-Texas) and Fred Upton (R-Mich.) introduced legislation to address problems with the original vaccine court, including a two-year backlog of cases. That bill would also increase the pain and suffering or death payments to people who can prove an injury, from $250,000 to $600,000.
A spokesperson for Doggett said he hopes the bill — not currently attached to a larger package moving through Congress — would eventually allow COVID vaccine-injured patients to get compensation through the vaccine court. But that's far from guaranteed.
In general, it is very difficult to prove a vaccine caused an injury that appears post-vaccination, since the ailments can be coincidental. But the rare vaccine injury can devastate a person's health and financial resources.
Wulbrecht, whose care has included five ambulance trips, each billed for $3,000, filed a claim in February with the Countermeasures Injury Compensation Program. She got a note acknowledging her claim but hasn't heard further from the program.
She's in a Facebook group created for people reporting grievous COVID vaccine-related neurological issues. It was launched by Dr. Danice Hertz, a retired gastroenterologist in Santa Monica, California, who has been diagnosed post-vaccination with mast cell activation syndrome, a rare condition in which part of the immune system goes haywire.
Hertz got her first Pfizer-BioNTech shot on Dec. 23, shortly after the Food and Drug Administration authorized the vaccine. Within 30 minutes she suffered terrible numbness and pain in her face and tongue and "felt vibrations going through my whole body," she said.
More than 90% of the 150 people in the Facebook group are women, Hertz said. She is careful to keep what she terms anti-vaccine "riffraff" off the list, but she said many of the injured people have been frustrated at being unable to get a diagnosis or find doctors who understand the nature of their injuries.
Talk of vaccine injuries is sometimes muted in public health circles because of reluctance to feed the anti-vaccine movement and its bogus claims of vaccine injury ranging from infertility to magnetism to microchips secretly implanted by Microsoft founder Bill Gates.
But rare reactions like the ones Hertz and Wulbrecht report are scattered through the vaccine literature and often attributed to a phenomenon called "molecular mimicry," in which the immune system responds to an element in the vaccine by attacking similar-looking human proteins. Guillain-Barré syndrome, or GBS, is caused by an immune attack on the nervous system in reaction to a vaccination — and to viral infections. It has been reported after influenza shots, and the single-dose Johnson & Johnson COVID vaccine.
Hertz and others have been in contact with Dr. Avindra Nath, chief of clinical medicine at the National Institute of Neurological Disorders and Stroke, whose specialty is the study of immune-modulated neurological illness. Nath told KHN he was studying some of the patients but hadn't confirmed their illnesses were caused by a COVID vaccine.
"We have to find these answers, but they aren't easy to come by," Nath said. "I know these reactions are rare, because there were 36,000 NIH employees vaccinated against COVID and, if it was common, I could study it here. But I don't have a single NIH employee" who experienced it.
Regardless of how common the reactions are, vaccine law specialists worry about the impact of a failure to help those hurt by shots administered before the products gain full FDA approval, which could come this fall.
Congress created the vaccine court to keep pharmaceutical companies from abandoning production of common childhood vaccines by protecting them from damaging lawsuits, while at the same time offering support for kids hurt by a vaccine.
The Countermeasures Injury Compensation Program, however, arose as part of the 2005 Public Readiness and Emergency Preparedness Act, and was pushed through to shield drug companies from lawsuits over products like the anthrax and smallpox vaccines, which had a relatively high rate of dangerous side effects. COVID vaccines shouldn't be in the same category, Van Tassel said.
The PREP Act is likely to set an almost insurmountable burden of proof for injury compensation, she said. Rewards depend on "compelling, reliable, valid medical and scientific evidence," which doesn't exist for COVID vaccines because they are so new.
But cause and effect appear clear to women like Brianne Dressen, a Saratoga Springs, Utah, preschool teacher who was bedridden for months with neurological symptoms that began after she got an AstraZeneca shot in a clinical trial last November.
"Vaccines are an important piece of the puzzle to get us through the pandemic," she told KHN. "But some people are going to draw the short straw with any drug or vaccine, and we need to take care of them.
When the Food and Drug Administration announced last week that a third dose of Moderna or Pfizer-BioNTech COVID-19 vaccine may boost the immunity of some people who are immunocompromised, officials repeated their stance that fully vaccinated, healthy people do not need another dose.
With this caveat: "The FDA is actively engaged in a science-based, rigorous process with our federal partners to consider whether an additional dose may be needed in the future," said acting FDA Commissioner Dr. Janet Woodcock.
But the Biden administration reportedly said this week that most Americans will need a booster. And a White House press conference slated for 11 a.m. Wednesday was expected to address boosters.
Meanwhile, doctors and researchers caution that the public needs to stick to the advice of the FDA and the Centers for Disease Control and Prevention.
Those federal agencies "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.
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 is expected to be free. According to Pfizer and the White House, the federal government purchased 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."
Kyle Austin, a traveling pharmacist, set up his mobile clinic in Virginia City on a recent Saturday, the latest stop on his circuit of Montana's vaccine deserts.
This article was published on Tuesday, August 17, 2021 in Kaiser Health News.
VIRGINIA CITY, Mont. — While many businesses in this southwestern Montana "ghost town" reel in tourists with its mining and Wild West vigilante past, one businessman arrived offering a modern product: COVID-19 vaccines.
Kyle Austin, a traveling pharmacist, set up his mobile clinic in Virginia City on a recent Saturday, the latest stop on his circuit of Montana's vaccine deserts.
"In any business, going to the people is better than waiting for the people to come to you," the 38-year-old pharmacist said.
While many businesses scaled back at the height of the pandemic, Austin saw COVID as an opportunity. He opened his own shop, Pharm406, in Billings — a nod to Montana's lone area code. Then when the COVID vaccine became available, and thousands of people across Montana were stuck on waitlists, he hit cities large and small in a school bus turned vaccine clinic, offering shots with no appointment needed.
"When they started talking about COVID coming out I was like, 'All right, we're gonna create a vaccine, there's gonna be a big demand for it, and Montana doesn't have a lot of access,'" he said. "I hate to say it, but I literally took advantage of COVID-19 to open up and push forward."
Now, with demand at a trickle and the nation grappling with how to finish distributing vaccines, collecting stragglers is part of Austin's business model as he rotates among towns. He sees it as a service to rural Montana that could also pay off for him.
In some parts of the state, Austin is the only person administering Pfizer-BioNTech vaccines, the sole shot approved for those ages 12 to 17. When the mobile clinic leaves, local leaders must figure out how to fill the gaps between his visits.
Dressed in blue scrubs, Austin talks like a businessman who knows rural Montana. He's from Havre, a Montana town about 35 miles south of the U.S.-Canada border, population roughly 9,000. For years, he traveled across the state as a relief pharmacist for drugstores. That work stalled when COVID arrived.
Austin then wanted to create a mobile pharmacy, but a brick-and-mortar base was required to obtain a state pharmacy license. So, in July 2020, he opened his own shop in Billings, Montana's largest city.
There he offered rapid COVID tests, which had been in short supply. He also expanded beyond what's found in typical drugstores: After trying cryotherapy once himself, he bought a machine to add to his pharmacy's list of services. When he noticed people could rent electric scooters in town, he began selling them. Then he used flu shots to conduct a test run of his vaccine tour last fall on the slogan "Get a brew, not the flu," partnering with breweries to give a free drink to anyone getting a shot. In April, he hit the road with COVID vaccines, leaving his team of seven employees to keep his Billings drugstore running.
His mobile clinics have been the easiest way to turn a profit. He doesn't have to rent space or staff an entire pharmacy for the trips. Health departments advertise the clinics for him, and locals provide space for him to park and patients to wait. When the weather is nice, he keeps costs low by camping along the way.
And COVID vaccines have had more demand and higher reimbursement rates than any other vaccine he could have used to propel his business. In most cases, Austin said, he can break even by giving as few as 20 doses a day. So far, the government has supplied the shots for free, and he estimated he gets paid roughly $30 on average to administer a dose between payments from insurance companies and federal reimbursements — as opposed to the $17 he said he saw last year for flu vaccines.
Some days he gives out 200 shots, other days five, but said that adds up. He said it's financially possible because he doesn't pay another pharmacist to do the work.
"If I paid someone to do it, I would probably be upside down," Austin said.
Austin's recent trip to Virginia City to offer a second round of doses came at the request of the town and local health department. This time he drove a Jeep, leaving his school bus behind, because he expected only about 15 customers.
But in a town of 120 year-round residents, in a county of fewer than 9,000, a few shots can make a difference. "Even an incremental increase in uptake could have a big effect on our statistics," said Emilie Sayler, county health director.
Virginia City is at the center of Madison County, where 43% of those eligible for the COVID shot are fully vaccinated — compared with 49% statewide and 59% nationally.
Teenagers remain the county's age group with the biggest vaccine shortfall.
Virginia City doesn't have a pharmacy. The county's vaccine providers are two hospitals that don't stock Pfizer doses. At the beginning of the rollout, Sayler said, the one-nurse health department couldn't handle both vaccines and contact tracing. And as demand dwindled, she worried they wouldn't be able to use up doses — especially Pfizer's. That brand comes in shipments so large that most rural towns can't or won't offer it.
Now the department is balancing educating people about vaccines without coming off as aggressive. It's a county where many locals call incentives — like a free beer or ice cream cone for a jab — a bribe.
Brothers Nicholas and Jacob Johnson, 17 and 16, showed up first to Austin's recent clinic, coming for their second shots. Their next option was going to Bozeman, at least a 100-mile round trip.
"And we would have needed to do it for two shots," Nicholas said, adding he has a summer job and is busy with football and lacrosse.
"I just wanted to get it over with," Jacob added. "I trust the science."
Some of the county's vaccination gap can be attributed to lack of time. Dr. Douglas Young, chair on the county's Board of Health and a veterinarian, came for his shot straight from tending to a sick mule. Young said he always planned to get vaccinated but held off in case it triggered a reaction that knocked him out of work for a few days during the busy spring.
"I didn't want to be down and out during calving season," Young said.
Virginia City Mayor Justin Gatewood, a 44-year-old farmer in a pink pearl-snap shirt and work-stained jeans, stood outside the Pharm406 tent and greeted locals by name and occasionally answered questions for tourists, such as where to find Wi-Fi.
The season of visitors is booming, Gatewood said. That's a relief for the town that survives on tourism. But that traffic is also a concern as the delta variant sparks new COVID surges nationwide.
"Now we're dealing with this pandemic of the unvaccinated," said Gatewood, before nodding toward the clinic. "This brings it back into the consciousness of folks, just makes them aware and, hopefully, maybe, minds are changing."
About a block from the COVID vaccine clinic, Adam Root, 41, said he hadn't known about the clinic but wouldn't have gone anyway. He hasn't liked the federal pressure to get vaccinated.
"I'm not vaccine-hesitant, it's just a hard 'no' for me," Root said. "I don't like being told what to do, for one thing, and, two, I believe health comes from how you take care of your body."
By the time Austin headed back to his campsite along the Madison River, he had vaccinated 20 people — adding five people who got first doses. He planned to return to give them their second shots and pick up any new takers.
He's already booked for much of the fall and expects to see an uptick as schools start.
In the meantime, Gatewood said, he can direct adults in Virginia City to the county's hospitals and families with teens to locations outside the county. Otherwise, he hopes he can get people to show up when Austin returns.
With nearly 60% of the eligible U.S. population fully vaccinated, most of the nation's blood supply is now coming from donors who have been inoculated.
This article was published on Tuesday, August 17, 2021 in Kaiser Health News.
The nation's roiling tensions over vaccination against COVID-19 have spilled into an unexpected arena: lifesaving blood transfusions.
With nearly 60% of the eligible U.S. population fully vaccinated, most of the nation's blood supply is now coming from donors who have been inoculated, experts said. That's led some patients who are skeptical of the shots to demand transfusions only from the unvaccinated, an option blood centers insist is neither medically sound nor operationally feasible.
"We are definitely aware of patients who have refused blood products from vaccinated donors," said Dr. Julie Katz Karp, who directs the blood bank and transfusion medicine program at Thomas Jefferson University Hospitals in Philadelphia.
Emily Osment, an American Red Cross spokesperson, said her organization has fielded questions from clients worried that vaccinated blood would be "tainted," capable of transmitting components from the COVID vaccines. Red Cross officials said they've had to reassure clients that a COVID vaccine, which is injected into muscle or the layer of skin below, doesn't circulate in the blood.
"While the antibodies that are produced by the stimulated immune system in response to vaccination are found throughout the bloodstream, the actual vaccine components are not," Jessa Merrill, the Red Cross director of biomedical communications, said in an email.
So far, such demands have been rare, industry officials said. Dr. Louis Katz, chief medical officer for ImpactLife, an Iowa-based blood center, said he's heard from "a small handful" of patients asking for blood from unvaccinated donors. And the resounding answer from centers and hospitals, he added, has been "no."
"I know of no one who has acceded to such a request, which would be an operational can of worms for a medically unjustifiable request," Katz wrote in an email.
In practical terms, blood centers have only limited access to donated blood that has not in some way been affected by COVID. Based on samples, Katz estimated that as much as 60% to 70% of the blood currently being donated is coming from vaccinated donors. Overall, more than 90% of current donors have either been infected with COVID or vaccinated against it, said Dr. Michael Busch, director of the Vitalant Research Institute, who is monitoring antibody levels in samples from the U.S. blood supply.
"Less than 10% of the blood we collect does not have antibodies," Busch noted.
In addition, outside of research studies, blood centers in the U.S. don't retain data noting whether donors have been infected with or vaccinated against COVID, and there's no federal requirement that collected blood products be identified in that manner.
"The Food and Drug Administration has determined there's no safety risk, so there's no reason to label the units," said Dr. Claudia Cohn, chief medical officer for AABB, a nonprofit focused on transfusion medicine and cellular therapies.
Indeed, the FDA does not recommend routine screening of blood donors for COVID. Respiratory viruses, in general, aren't known to spread by blood transfusion and, worldwide, there have been no reported cases of SARS-CoV-2, the virus that causes the disease, being transmitted via blood. One study identified the risk as "negligible."
All donors are supposed to be healthy when they give blood and answer basic questions about potential risks. Collected units of blood are tested for transmissible infectious diseases before they're distributed to hospitals.
But that hasn't quelled concerns for some people skeptical of COVID vaccines.
In Bedford, Texas, the father of a boy scheduled for surgery recently asked that his son get blood exclusively from unvaccinated donors, said Dr. Geeta Paranjape, medical director at Carter BloodCare. Separately, a young mother fretted about transfusions from vaccinated donors to her newborn.
Many patients expressing concerns have been influenced by rampant misinformation about vaccines and the blood supply, said Paranjape. "A lot of people think there's some kind of microchip or they're going to be cloned," she said.
Other patients have balked at getting blood from people previously infected with COVID, even though federal guidance greenlights donations two weeks after a positive test or the last symptom fades.
Last month, a woman facing a cesarean section for a high-risk pregnancy said she didn't want blood from a donor who had had COVID, recalled Cohn with AABB. "I said, 'Listen, the alternative is you don't get the blood and that's what will affect you,'" Cohn said.
Some industry experts were hesitant to discuss the vaccine-free blood requests, for fear it would fuel more such demands. But Cohn and others said correcting widely spread misinformation outweighed the risk.
Patients are free to refuse transfusions for any reason, industry officials said. But in dire situations — trauma, emergency surgery — saving lives often requires using the available blood. For patients with chronic conditions requiring transfusion, alternative treatments such as medication or certain equipment may not be as efficient or effective.
People who require transfusions also may donate their own blood in advance or request donations from designated friends and family members. But there's no evidence that the blood is safer when patients select donors than that provided by the volunteer blood system, according to the Red Cross.
Earlier in the pandemic, many blood donations were tested to see whether they contained antibodies to the COVID virus. The hope was that blood from previously infected people who had recovered from COVID could be used to treat those who were very sick with the disease. Tens of thousands of patients were treated with so-called convalescent plasma under a Mayo Clinic-led program and through authorization from the FDA.
But the much-hyped use of convalescent plasma largely fell flat after studies showed no clear-cut benefits for the broad swath of COVID patients. (Research continues into the potential benefits of treating narrowly targeted patient groups with high-potency plasma.) Most hospitals stopped testing blood and labeling units with high levels of antibodies this spring, said Busch. "It's really no longer a germane issue because we're not testing anymore," he said. "There's no way we can inform recipients."
Busch stressed that the studies also have shown no harm associated with infusing antibody-containing blood plasma into COVID patients.
Past health crises have raised similar concerns about sources of donor blood. In the mid-1980s, recipients scared by the AIDS epidemic didn't want blood donated from cities such as San Francisco with large gay populations, Busch recalled. Even now, some recipients demand not to receive blood from people of certain races or ethnicities.
Such requests, like those for vaccine-free blood, have no medical or scientific basis and are soundly refused, blood center officials said.
The most pressing issue for blood centers remains the ongoing shortage of willing donors. As of the second week of August, the national blood supply was down to two days' worth or less at a third of sites affiliated with America's Blood Centers. That can limit the blood available for trauma victims, surgery patients and others who rely on transfusions to survive.
"If for some reason we didn't want vaccinated people to donate blood, we'd be in a real problem, wouldn't we?" Karp said. "Please believe us when we tell you it's fine."
Elizabeth Groenweghe got a kidney transplant 14 years ago. She now takes several medications to prevent her body from rejecting her transplant organ. But these medications also weaken her immune system, putting her at higher risk of becoming seriously ill if she catches COVID-19.
When the pandemic began last year, Groenweghe, 29, worked from home for the first month and a half. But then in May 2020, as the chief epidemiologist for the public health department in Wyandotte County, Kansas, she returned to the office.
"Obviously, I was nervous about it because I'm so immunosuppressed," said Groenweghe.
She felt relatively safe because her co-workers wore masks and strictly followed infection control protocols. But now that vaccinations have become widely available, her workplace has stopped requiring or enforcing mask use. There is no vaccine mandate for her office, and she knows some co-workers are unvaccinated. She feels uncomfortable working around them.
"I am debating putting a sign on my door that says 'Please do not enter if you are unvaccinated,' because I am really concerned about getting COVID … and have even had a couple co-workers test positive recently," said Groenweghe.
"Knowing that I don't have any protection against COVID, I'm still wearing a mask and I'm trying to avoid in-person meetings," she added. "It has been frustrating because, at home, my bubble of protection is great; all of my family and friends are vaccinated. At work I don't have as much control."Bottom of Form
While the emergence of the delta variant in the U.S. has made many companies delay the return to in-person work or mandate vaccinations, in other offices, immunosuppressed people like Groenweghe are left to cobble together their own strategies to minimize their risks. The delta variant raises the stakes for many who were already concerned about catching COVID when they return. Those who have the option to keep working remotely have done so — but worry about what it means for their careers as their colleagues return to the workplace.
Research showing how well vaccines protect those with weakened immune systems is limited. In part that's because immunosuppressed people, who make up at least 3% of the U.S. population and include people with cancer, HIV and many chronic health conditions, were not included in the original clinical trials for the three COVID vaccines authorized for emergency use.
Scientists didn't include them because they needed to conduct the clinical trials quickly and were concerned that this group's immunosuppressive medicines and increased likelihood of developing infections in general would complicate interpreting the study results.
Research does show that those who are immunosuppressed are at higher risk of becoming severely ill from COVID, passing the virus to others in their household and getting infected even if vaccinated. A recent study reported that 44% of hospitalized "breakthrough" cases in the U.S. were in immunosuppressed people.
Concerns about her elevated COVID risk led Groenweghe to obtain a third dose of the Moderna vaccine on her own — and participate in a Johns Hopkins University research study that involved measuring transplant recipients' immune response to an extra vaccine dose. Hopkins recently told her she hadn't produced any antibodies.
But, while the third dose might not have helped Groenweghe, early research shows that a booster shot seems to strengthen the immune response for some with weakened immune systems. Israel began distributing additional doses to the immunosuppressed in July. Britain and France have said they plan to start distributing booster doses to high-risk groups in September. However, the World Health Organization recently called for a moratorium on booster shots until more vaccine could be distributed globally to countries with low vaccination rates.
Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, said in a July Senate hearing that immunosuppressed people "may actually need a boost as part of their initial regimen in the sense of getting them up to the point where they are protected."
And soon, third doses may indeed become part of the regimen. The Food and Drug Administration reportedly is closing in on amending the emergency use authorization requests for the Pfizer-BioNTech and Moderna vaccines to allow third doses of those shots to be given to those with weakened immune systems. The vaccine advisory committee of the Centers for Disease Control and Prevention was set to meet Friday and is expected to vote on whether to officially recommend that doctors can prescribe third doses to immunocompromised people. Still, federal officials said these third doses would be recommended only for a small number of immunocompromised people, and it's not yet clear who will be included.
Well in advance of this green light, patients were asking their doctors about additional shots.
Andrew Clifford is one such patient. (KHN is identifying him by his first and middle names because he fears retaliation from his workplace.) Andrew, a marketing manager from Missouri, is working from home indefinitely and worries about what he might be missing. The 40-year-old has multiple sclerosis and takes immunosuppressive medication.
"The fear of missing out is a tremendous anxiety," he said. Recently his entire team went back to the office for two weeks to meet with an outside agency. While Andrew was able to go in for two days, he could tell he had missed out on things on the days he stayed home.
"I missed out on the lunchtime convos. When I did show up in the Zoom meetings, I was playing a lot of catch-up," he said. "I was trying to figure out who I was actually talking to and what they did."
Some patients, such as transplant recipient Elyse Thomas, aren't waiting for new guidance from the U.S. government. (KHN is identifying her by her middle and last names because she is worried about pushback from her employer.) Instead, Elyse, a 30-year-old social worker for a high school district in the Bay Area of California, pursued third and fourth doses of a COVID vaccine on her own since her school district had staff members return in person in early August.
"Some of us transplant patients have had to take matters into our own hands," Thomas said. "We can't wait for the recommendation while we could be dying."
She asked for an accommodation to continue working remotely during the 2021-22 school year, as she did the year before, but was told all employees must return. Thomas was offered the option to take medical leave without pay if she didn't want to come into the office, but that would strain her finances. Her workplace does have a mask mandate, but she's not sure physical distancing will be enforced and she's even more anxious now that the delta variant is circulating.
"I don't feel safe and I don't understand why I have to be there in person," Thomas said. "I don't want to risk my transplant for a paycheck. I don't want to risk my life for a paycheck."
CAIRO, Ill. — Lee Wright was hard at work, constructing a nail salon near the city's abandoned hospital, when Jody Johnson stopped by to introduce himself on a recent afternoon.
Johnson, who works for the University of Illinois Extension program, chatted with Wright casually in the summertime heat. For Johnson, it was the first step to building trust in this city of fewer than 2,200 people as extension programs across the U.S — long valued in many rural communities for helping farmers and supporting 4-H clubs — expand their service to include educating the public about COVID-19 vaccines.
Wright, 68, was unvaccinated and planned to remain so, even though he'd followed other public health guidelines during the pandemic. When it came to getting the shots, he decided to leave his fate to his faith.
"Doctors are good. Don't get me wrong," Wright said. "But we got to have something that we can really depend on."
Johnson didn't talk to Wright about the vaccines that day. He just listened instead. "No one wants to feel ashamed or belittled because they're not doing something," Johnson said later.
Only 16% of residents here in Alexander County are fully vaccinated against COVID-19, the lowest rate in Illinois, according to the state health department. And case counts of coronavirus infections are rising. So the Cooperative Extension System, which is tied to a network of land-grant universities, plans to spend the next two years talking about vaccines in this community and elsewhere. It may take that long or more to persuade enough people to get vaccinated.
The extension system has a tradition of bringing research-based information to communities on a wide variety of topics, including water quality, food safety and disaster preparedness. With its roots sunk deep in rural America, where vaccines have been slow to catch on, the system is now using state and federal funding to pay for immunization education efforts tailored to specific communities.Bottom of Form
Already 4-H clubs have been making masks and face shields. In Illinois, the agency has a COVID resource guide for families, business owners and farmers. The office covering the southern portion of the state is now looking to hire someone in the community to help get out the word on why vaccinations matter. Johnson also wants to team up with local churches, civic groups and business owners to get the job done.
This time around, the extension service's strategy could also help in these rural communities and the urban areas it serves. But local leaders say there's no quick solution for improving vaccination rates in Cairo or across the country. Getting people vaccinated is a nuanced challenge in every community. In Cairo, a long history of racial tension dating to the Civil War still stings. Like many rural towns across the U.S., the community also feels underappreciated and misunderstood.
Vaccine apathy is common here, where infection rates remained low until recently.
"We haven't had great turnouts," said Tyrone Coleman, president and co-founder of the Alexander and Pulaski NAACP chapter, which has helped organize vaccine clinics in Cairo.
In June, he invited the health department to the city's Juneteenth celebration at St. Mary's Park. More than 300 people attended. But the event's pop-up clinic hosted by the state didn't have many seeking vaccinations during its six hours of operation.
"We only had two," Coleman said.
More than 15,000 people lived in Cairo in the early 20th century, helping it earn the nicknames "Little Chicago" and "the Gateway to the South." Old factories, antebellum homes, an ornate library and a vacant hospital remain as reminders of the city's majestic past. The city's library prominently displays the work of Samuel Clemens, the American writer best known as Mark Twain. After traveling through Cairo, Twain wrote about the city in his 1884 novel "The Adventures of Huckleberry Finn."
In the novel, Cairo represents freedom and the chance for a better life.
But the hospital shut down in 1987. The only grocery store in town closed years ago, public housing was torn down in recent years, and the only nursing home closed during the pandemic, forcing residents to find a new place to live without much notice. On top of all that, flooding has threatened to wipe the city out more than once.
Today, fewer than 2,200 people, the majority of them Black, live here. And locals say the population has continued to drop with all the closures. The city is often mislabeled by the press and travel guides as abandoned.
"Cairo is not a ghost town," said Ronnie Woods, a local pastor and retired schoolteacher. "It's not dead at all."
Tourists still stop by to see the confluence of the Mississippi and Ohio rivers. But they don't typically see the rocky riverbank where residents fish for their dinner. Beverly Davis, 60, heads there often with rod in hand and gives much of her catch away to other members of the community. The scenic waterfront, though, is carpeted with driftwood and dead fish that washed ashore.
"I guess it's meant to be like this," Davis said, standing on the riverbanks among the fish carcasses. "'Cause if not, it would be better."
But many residents continue to believe their city will return to its past glory. "The world hears that this is a negative part of the country, and it's not," Johnson said. "We've got too many good things and people here."
On this day, the only outdoor basketball court in the city, anchored by a single hoop, was busy in a rural community that was fighting to stay alive long before the pandemic hit. The men on the court didn't seem worried about catching COVID.
"I haven't had COVID, so I feel like I don't need to get vaccinated right now," said Jeffery DeWitt, 24. "I'll just take it as it goes."
Wright's son, Roman Wright, 36, said much the same thing while helping his dad build the nail salon across town. He works for the prison system, and one of its facilities nearby reported COVID cases. But he hadn't contracted the disease. Like his father, he said he didn't plan on getting the shots.
"I'm like my dad," Roman Wright said. "I was born and raised in church all my life. So I say we believe in God. I know my parents pray for me. We pray for each other and we just believe in God."
Woods, the pastor, has a different point of view. He keeps his vaccination card in a plastic sheath and carries it with him wherever he goes.
"I have strong faith," said Woods, 66. "And at my age, my risk factors, I just felt that God placed science there to help us."
But Woods said it's going to take work to persuade others in Cairo to get vaccinated, even if they know someone who died of COVID. A prominent doctor was among the dead in the community. "It's going to take more than explaining, it is going to take a cultural shift because people are just not trusting," he said.
That's one reason Johnson is searching for a local voice to lead the extension service's vaccine education program over the next year. As a 51-year-old white man who grew up in a predominantly white community 45 miles outside of Cairo, he recognizes that local residents would be more likely to share their thoughts with someone who lives here. Plus, he spends most of his time talking with community leaders and public officials. He is searching for someone who will spend time with locals who don't hold titles and positions.
"Everybody doesn't think like me," Johnson said. "So we need to take that into consideration."