Kaitlyn Romoser first caught covid-19 in March, likely on a trip to Denmark and Sweden, just as the scope of the pandemic was becoming clear. Romoser, who is 23 and a laboratory researcher in College Station, Texas, tested positive and had a few days of mild, coldlike symptoms.
In the weeks that followed, she bounced back to what felt like a full recovery. She even got another test, which was negative, in order to join a study as one of the earliest donors of convalescent blood plasma in a bid to help others.
Six months later, in September, Romoser got sick again, after a trip to Florida with her dad. This second bout was much worse. She lost her sense of taste and smell and suffered lingering headaches and fatigue. She tested positive for covid once more — along with her cat.
Romoser believes it was a clear case of reinfection, rather than some mysterious reemergence of the original infection gone dormant. Because the coronavirus, like other viruses, regularly mutates as it multiplies and spreads through a community, a new infection would bear a different genetic fingerprint. But because neither lab had saved her testing samples for genetic sequencing, there was no way to confirm her suspicion.
"It would be nice to have proof," said Romoser. "I've literally been straight up called a liar, because people don't want to believe that it's possible to be reinfected. Why would I lie about being sick?"
As millions of Americans struggle to recover from covid and millions more scramble for the protection offered by vaccines, U.S. health officials may be overlooking an unsettling subgroup of survivors: those who get infected more than once. Identifying how common reinfection is among people who contracted covid — as well as how quickly they become vulnerable and why — carries important implications for our understanding of immunity and the nation's efforts to devise an effective vaccination program.
Scientists have confirmed that reinfections after initial illness caused by the SARS-CoV-2 virus are possible, but so far have characterized them as rare. Fewer than 50 cases have been substantiated worldwide, according to a global reinfection tracker. Just five have been substantiated in the U.S., including two detected in California in late January.
That sounds like a rather insignificant number. But scientists' understanding of reinfection has been constrained by the limited number of U.S. labs that retain covid testing samples or perform genetic sequencing. A KHN review of surveillance efforts finds that many U.S. states aren't rigorously tracking or investigating suspected cases of reinfection.
KHN sent queries about reinfection surveillance to all 50 states and the District of Columbia. Of 24 responses, fewer than half provided details about suspected or confirmed reinfection cases. Where officials said they're actively monitoring for reinfection, they have found far more potential cases than previously anticipated.
In Washington state, for instance, health officials are investigating nearly 700 cases that meet the criteria for possible reinfection, with three dozen awaiting genetic sequencing and just one case confirmed.
In Colorado, officials estimate that possible reinfections make up just 0.1% of positive coronavirus cases. But with more than 396,000 cases reported, that means nearly 400 people may have been infected more than once.
In Minnesota, officials have investigated more than 150 cases of suspected reinfection, but they lack the genetic material to confirm a diagnosis, a spokesperson said.
In Nevada, where the first U.S. case of covid reinfection was identified last summer, Mark Pandori, director of the state public health lab, said there's no doubt cases are going undetected.
"I predict that we are missing cases of reinfection," he said. "They are very difficult to ascertain, so you need specialized teams to do that work, or a core lab."
Such cases are different from instances of so-called long-haul covid, in which the original infection triggers debilitating symptoms that linger for months and viral particles can continue to be detected. Reinfection occurs when a person is infected with covid, clears that strain and is infected again with a different strain, raising concerns about sustained immunity from the disease. Such reinfections occur regularly with four other coronaviruses that circulate among humans, causing common colds.
Centers for Disease Control and Prevention guidelines call for investigating for possible reinfection when someone tests positive for covid at least 90 days after an original infection (or at least 45 days for "highly suspicious" cases). Confirmation of reinfection requires genetic sequencing of paired samples from each episode to tell whether the genomes involved are different.
But the U.S. lacks the capacity for robust genetic sequencing, the process that identifies the fingerprint of a specific virus so it can be compared with other strains. Jeff Zients, head of the federal covid task force, noted late last month that the U.S. ranks 43rd in the world in genomic sequencing.
To date, only a fraction of positive coronavirus samples has been sequenced, though the Biden administration is working to rapidly expand the effort. On Feb. 1, CDC Director Dr. Rochelle Walensky told reporters that sequencing has "increased tenfold" in recent weeks, from 251 sequences the week of Jan. 10 to 2,238 the week of Jan. 24. The agency is working with private companies, states and academic labs to ramp up to 6,000 sequences per week by mid-February.
Washington's state epidemiologist for communicable diseases, Dr. Scott Lindquist, said officials have prioritized genetic sequencing at the state laboratory, with plans to begin genotyping 5% of all samples collected. That will allow officials to sort through those nearly 700 potential reinfections, Lindquist said. More important, the effort will also help signal the presence of significantly mutated forms of the coronavirus, known as variants, that could affect how easily the virus spreads and, perhaps, how sick covid makes people.
"Those two areas, reinfection and variants, may cross paths," he said. "We wanted to be in front of it, not behind it."
The specter of reinfections complicates one of the central questions of the covid threat: How long after natural infection or vaccination will people remain immune?
Early studies suggested immunity would be short-lived, only a few months, while more recent research finds that certain antibodies and memory cells may persist in covid-infected patients longer than eight months.
"We actually don't know" the marker that would signal immunity, said Dr. Jason Goldman, an infectious diseases expert at Swedish Medical Center in Seattle. "We don't have the test you could perform to say yes or no, you could be infected."
Goldman and colleagues confirmed a case of reinfection in a Seattle man last fall, and since then have identified six or seven probable cases. "This is a much more common scenario than is being recognized," he said.
The possibility of reinfection means that even patients who've had covid need to remain vigilant about curbing re-exposure, said Dr. Edgar Sanchez, an infectious diseases physician at Orlando Health in Florida.
"A lot of patients ask, 'How long do I have to worry about getting covid again?'" he said. "I literally tell them this: 'You are probably safe for a few weeks, maybe even up to a couple of months, but beyond that, it's really unclear.'"
The message is similar for the wider society, said Dr. Bill Messer, an expert in viral genetics at Oregon Health & Science University in Portland, who has been pondering the cultural psychology of the covid response. Evidence suggests there may not be a clear-cut return to normal.
"The idea that we will end this pandemic by beating this coronavirus, I don't think that's actually the way it's going to happen," he said. "I think that it's more likely that we're going to learn how to be comfortable living with this new virus circulating among us."
The rural death rate plateaued in January while the urban death rate continued to swell. Even so, the rural death rate in January was more than six times as high as in November.
This article was published on Friday, February 5, 2021 in Kaiser Health News.
In the past two months, covid-related infection and death rates have jumped exponentially in California’s least populated counties.
From March through November, the state’s 25 least populated counties collectively reported 235 covid-related deaths, a per-capita death rate about 60% lower than that of the rest of the state. (California has 58 counties.) From Dec. 1 through Jan. 29, those same rural counties reported 427 covid deaths. That is nearly twice as many deaths in 60 days as in the preceding 250.
These 25 rural counties encompass some of the state’s most dramatic and rugged terrain, spanning mountains, forests and vast grasslands in California’s far north and along its eastern border. About 1.2 million people live in those counties, in small towns and agricultural outposts largely buffered from the state’s big cities and suburbs by distance and topography.
In the months after covid first emerged in California in January 2020, its reach was deadly but comparatively contained. It initially surged across densely populated areas of Southern California and the San Francisco Bay Area, then seeped into major agricultural and industrial hubs in the Central Valley and rural Imperial County, which shares a border and close community ties with Mexico.
For months, residents of the state’s remotest counties were able to move about more freely — and with less fear — than their urban peers. The covid death rate in the state’s 25 least populated counties was 90% lower from March through June than the rate in the rest of the state.
That began to shift in summer and changed dramatically during a third covid surge that exploded in late fall. In December, the 25 least populous counties collectively reported about 24,600 new covid infections — a 141% increase from November. In December, the death rate in those 25 counties roughly matched the rate in the state’s urban centers.
The rural death rate plateaued in January while the urban death rate continued to swell. Even so, the rural death rate in January was more than six times as high as in November.
Epidemiologists point to several reasons for the shift. While these counties are remote, they are not walled off. Many rural residents regularly drive to urban areas for goods and services. They get tourists. Several of California’s rural counties are home to large state prisons, teeming facilities that have experienced some of the worst covid outbreaks in the nation. Those outbreaks infect not only inmates housed in close quarters, but also guards and other staffers who live and shop in the surrounding communities and carry the virus out with them.
Once covid arrived, it multiplied. Rural communities tend to have a few central places where many people congregate. Those places became breeding grounds for the virus.
“In very small towns, you’ve got Dollar General, the coffee store, Walmart, church,” said Alan Morgan, chief executive officer of the National Rural Health Association. “You get the entire community going into three or four chokepoints, you’re going to infect the whole town.”
While covid has stressed public health agencies across the state, the challenges are brutal in rural areas, which tend to operate on tight budgets, with minimal staffing. As covid cases multiplied, rural health directors struggled to expand their response.
Dr. Gary Pace is the public health officer in Lake County, a wine-growing region and recreational mecca in north-central California that’s home to about 63,000 residents. Pace recounted how, early in the pandemic, his department was able to conduct intensive contact tracing as cases emerged, keeping outbreaks contained.
“There was a farmworker outbreak in June or July, and we basically drove out to that vineyard and set up a testing site and tested 150 people that day,” he said. “Same thing happened with the tribal outbreak recently. So in these high-risk communities where the spread can get out of control really fast, we were able to sort of jump on it and really try to stay on top of it.”
The county reported an average of four infections a day from March through November. In December and January, the figure jumped to about 31 a day. Contract tracing became untenable. “That worked until it didn’t,” Pace said.
In some rural counties, the viral spread was exacerbated by politicization of basic public health safeguards like wearing masks and physical distancing. California’s rural counties tend to run politically conservative, and many residents and elected leaders were indignant about state covid mandates that closed businesses and strictly limited social gatherings.
“You have two segments of people,” said Valerie Lakey, executive director of community relations and business development at Mayers Memorial Hospital District in Shasta County. “You have the people that are definitely on board with doing all the things they’re supposed to be doing, and then you have the rest of the people that don’t want to be told what to do.”
Lakey’s hospital is in Fall River Mills, a short drive from the border with Lassen County, a mountainous tourist destination that’s home to 29,000 people — and where covid deaths jumped to 14 in December and January from only two in the previous nine months.
Mayers Memorial normally sees three or four patients each day in its acute care hospital. In mid-January, it was seeing about 14 a day, Lakey said. Her small staff has struggled to keep up.
Lakey noted that the hospital’s covid patients “have all been on the older side, like probably 70-plus,” underscoring another vulnerability for rural counties. Residents of California’s least populous counties tend to be older than the statewide average: about 20% are 65 or older, compared with 14% of residents statewide. Age has emerged as the No. 1 risk factor for covid-related hospitalization and death.
In rural enclaves, as in the rest of the state, the number of new covid cases reported each day has begun to subside, though case rates are still much higher than in November. The state’s expansive vaccine rollout offers further hope, but in the short term it serves as another stress on resources as health officials try to vaccinate thousands of people while continuing to manage the pandemic.
“Everybody’s been working seven days a week for the whole 10 months now,” said Lake County’s Pace, “and it’s starting to show.”
Phillip Reese is a data reporting specialist and an assistant professor of journalism at California State University-Sacramento.
Counting the dead is one of the first, somber steps in reckoning with an event of enormous tragic scope, be it war, a natural disaster or a pandemic.
This dark but necessary arithmetic has become all too routine during the covid-19 outbreak.
The total U.S death toll has now surpassed 450,000.
Each death is unique, a devastating loss that ripples through a family, a network, a community. But in the aggregate, the national death toll can feel abstract, and its repetition in the news can become numbing. Journalists, commentators and public officials are left searching for new ways to convey the deadliness of this pathogen, and the significance of its mounting fatality rate.
Many have turned to history, citing Pearl Harbor (2,403 killed) or the 9/11 attacks (at least 2,977 killed) as a way of providing perspective when the number of daily covid deaths in the U.S. reached those levels. (Currently, more than 3,000 Americans are dying from covid every day.)
Jan. 21, 2021, offered another opportunity for historical comparison: That was the day when the covid death toll in the U.S. reached — and then exceeded — the 405,399 Americans who died in World War II.
For many, attempting to compare the two death tolls — or even take note of their brief conjunction — is misguided or offensive. It is certainly a morally fraught exercise. The true emotional and social impact of either event can never be quantified, but many media outlets still mentioned it.
This raises the question: Are we as a society too quick to reach for these historical comparisons? Should a politically driven world war and a biologically driven pandemic, more than seven decades apart, be put side by side at all?
"This is comparing apples to oranges," wrote NPR listener Kris Petron in December in response to a story that made use of that comparison. "It is extremely disrespectful to our nation's veterans, who write a blank check with their lives, to defend our Constitution."
This type of response, over time, has convinced medical historian Dr. Howard Markel not to draw parallels between death tolls from war and a pandemic.
The notion that combat deaths carry a unique meaning or value is deeply rooted in human culture. Societies tend to valorize those who died for a cause on a battlefield.
But in this pandemic it's the frail elderly — many of them living in nursing homes and assisted living facilities — who have died in vast numbers.
"But, I don't think we have a right to weigh up lives and say which is more important," Snowden added.
Unlike covid-19, the global influenza pandemic of 1918-19 killed many people in their 20s and 30s — yet, as Snowden noted, there wasn't much collective mourning for those young adults, despite dying in the prime of life.
"People were so used to mortality because of the [first world] war that even the horrible tallies that were coming with the 'Spanish' influenza had lost their capacity to horrify the way that one might expect," he said.
When We Do Compare Death Tolls, What Exactly Are We Comparing?
The effort to compare the death toll of the pandemic with that of a war strikes historian Samuel Biagetti as an especially "modern" exercise.
"Through the vast majority of human history, people have understood warfare and disease to go hand in hand and to be inextricably linked," said Biagetti, who is the creator and host of the podcast "Historiansplaining."
The flu pandemic 100 years ago was fueled by the conditions of World War I and ultimately killed more people than the war, with an estimated 50 million flu deaths worldwide and upward of 700,000 flu deaths in the U.S.
Biagetti pointed out that World War II was the first conflict in American history in which combat killed more fighters than disease, a pattern that has continued since and reflects medical advances such as vaccines and antibiotics.
The carnage of war doesn't end just because peace is declared. The spillover effects of war continue long after formal hostilities end, and include disability and disfigurement, mental trauma, addiction, homelessness and suicide.
One example is the ongoing suicide crisis among U.S. veterans. From 2005 to 2017, 78,875 veterans died by suicide — more than the number of soldiers killed in Vietnam, 58,220.
For all these reasons, Biagetti said he worries about comparing the current pandemic to any war, even if just for the purpose of counting the dead: "You can't just try to sum up in a simple statistic how big is this disaster versus that disaster, as if they can even be summed up in a simple number at all."
And yet the language of warfare permeates so much of the national discourse about the pandemic.
Nurses work on the "front lines." Coronavirus is described as an invisible "enemy." The country is "battling" the virus. In his inaugural address, President Joe Biden said the pandemic has "taken as many lives in one year as America lost in all of World War II."
'War' Metaphor Is a Call to Action, a Recognition of Sacrifice
Some Americans whose relatives have died of covid embrace the rhetoric of war and believe comparing the pandemic to past wars is imperative.
"The scale of this is that of a war, it's just a different type of war and it's not one that we're necessarily taught in our history books," said Kristen Urquiza, who co-founded the advocacy group Marked By COVID after her father died from the disease over the summer.
Urquiza said the country struggled collectively to respond to the coronavirus because Americans have little understanding about what it takes to overcome a pandemic.
"In a way, it's sort of more dangerous [than war] because we are culturally unprepared for it."
There are also veterans who feel the war analogies are appropriate, and even helpful. Dr. Cleavon Gilman, an emergency physician in Yuma, Arizona, has treated covid patients from the early days of the outbreak and readily compares the pandemic to a war.
"It's very hard to communicate the severity of this pandemic if you're not in a hospital, where this war is being waged," said Gilman, who served as a Marine combat medic in Iraq in 2004.
World War II was the deadliest war in world history, but not in American history: That distinction belongs to the Civil War. The death toll has traditionally been estimated to be about 618,000, but new research indicates 750,000 may be more accurate.
But World War II looms large in America's cultural memory as a "good war," one that united the country against a clear-cut enemy, said Catherine Mas, a professor at Florida International University who studies the history of medicine, race and religion.
In retrospect, the American response to World War II stands in sharp contrast to the current political divisions over the coronavirus, and the fragmented and uneven national response.
Despite the differences, Mas said the comparisons can still be powerful tools as the country tries to reckon with a crisis that has taken place out of sight for many Americans. People are dying in hospitals without family members at the bedside, and only healthcare workers are there to bear witness.
"The reason we want to compare covid-19 deaths to something like World War II is not just because the numbers are there, but to acknowledge this is a significant rupture in society," she said.
"This mass death is going to create trauma: How are we going to deal with that? How have we dealt with that in the past? I think it's part of our human condition to try to search for some reference points."
This story was produced in partnership with NPR and KHN.
HELENA, Mont. — When the pandemic hit, health officials in Montana's Beaverhead County had barely begun to fill a hole left by the 2017 closure of the local public assistance office, mental health clinic, chemical dependency center and job placement office after the state's last budget shortfall.
Now, those health officials worry more cuts are coming, even as they brace for a spike in demand for substance abuse and mental health services. That would be no small challenge in a poor farming and ranching region where stigma often prevents people from admitting they need help, said Katherine Buckley-Patton, who chairs the county's Mental Health Local Advisory Council.
"I find it very challenging to find the words that will not make one of my hard-nosed cowboys turn around and walk away," Buckley-Patton said. "They're lonely, they're isolated, they're depressed, but they're not going to call a suicide hotline."
States across the U.S. are still stinging after businesses closed and millions of people lost jobs due to covid-related shutdowns and restrictions. Meanwhile, the pandemic has led to a dramatic increase in the number of people who say their mental health has suffered, rising from 1 in 3 people in March to more than half of people polled by KFF in July. (KHN is an editorially independent program of KFF.)
The full extent of the mental health crisis and the demand for behavioral health services may not be known until after the pandemic is over, mental health experts said. That could add costs that budget writers haven't anticipated.
"It usually takes a while before people feel comfortable seeking care from a specialty behavioral health organization," said Chuck Ingoglia, president and CEO of the nonprofit National Council for Behavioral Health in Washington, D.C. "We are not likely to see the results of that either in terms of people seeking care — or suicide rates going up — until we're on the other side of the pandemic."
Last year, states slashed agency budgets, froze pay, furloughed workers, borrowed money and tapped into rainy day funds to make ends meet. Health programs, often among the most expensive part of a state's budget, were targeted for cuts in several states even as health officials led efforts to stem the spread of the coronavirus.
This year, the outlook doesn't seem quite so bleak due in part to relief packages passed by Congress last spring and in December that buoyed state economies. Another major advantage was that income increased or held steady for people with well-paying jobs and investment income, which boosted states' tax revenues even as millions of lower-income workers were laid off.
"It has turned out to be not as bad as it might have been in terms of state budgets," said Mike Leachman, vice president for state fiscal policy for the nonpartisan Center on Budget and Policy Priorities.
But many states still face cash shortfalls that will be made worse if additional federal aid doesn't come, Leachman said. President Joe Biden has pledged to push through Congress a $1.9 billion relief package that includes aid to states, while congressional Republicans are proposing a package worth about a third of that amount. States are banking on federal help.
New York Gov. Andrew Cuomo, a Democrat, predicted his state would have to plug a $15 billion deficit with spending cuts and tax increases if a fresh round of aid doesn't materialize. Some states, such as New Jersey, borrowed to make their budgets whole, and they're going to have to start paying that money back. Tourism states such as Hawaii and energy-producing states such as Alaska, Wyoming continue to face grim economic outlooks with oil, gas and coal prices down and tourists cutting back on travel, Leachman said.
Even states with a relatively rosy economic outlook are being cautious. In Colorado, for example, Democratic Gov. Jared Polis proposed a budget that restores the cuts made last year to Medicaid and substance abuse programs. But health providers are doubtful the legislature will approve any significant spending increases in this economy.
"Everybody right now is just trying to protect and make sure we don't have additional cuts," said Doyle Forrestal, CEO of the Colorado Behavioral Healthcare Council.
That's also what Buckley-Patton wants for Montana's Beaverhead County, where most of the 9,400 residents live in poverty or earn low incomes.
She led the county's effort to recover from the loss in 2017 of a wide range of behavioral health services, along with offices to help poor people receive Medicaid health services, plus cash and food assistance.
Through persuasive grant writing and donations coaxed from elected officials, Buckley-Patton and her team secured office space, equipment and a part-time employee for a resource center that's open once a week in the county in the southwestern corner of the state, she said. They also convinced the state health department to send two people every other week on a 120-mile round trip from the Butte office to help county residents with their Medicaid and public assistance applications.
But now Buckley-Patton worries even those modest gains will be threatened in this year's budget. Montana is one of the few states with a budget on a two-year cycle, so this is the first time lawmakers have had to craft a spending plan since the pandemic began.
Revenue forecasts predict healthy tax collections over the next two years.
In January, at the start of the legislative session, the panel in charge of building the state health department's budget proposed starting with nearly $1 billion in cuts. The panel's chairperson, Republican Rep. Matt Regier, pledged to add back programs and services on their merits during the months-long budget process.
It's a strategy Buckley-Patton worries will lead to a net loss of funding for Beaverhead County, which covers more land than Connecticut.
"I have grave concerns about this legislative session," she said. "We're not digging out of the hole; we're only going deeper."
Republicans, who are in control of the Montana House, Senate and governor's office for the first time in 16 years, are considering reducing the income tax level for the state's top earners. Such a measure that could affect state revenue in an uncertain economy has some observers concerned, particularly when an increased need for health services is expected.
"Are legislators committed to building back up that budget in a way that works for communities and for health providers, or are we going to see tax cuts that reduce revenue that put us yet again in another really tight budget?" asked Heather O'Loughlin, co-director of the Montana Budget and Policy Center.
Mary Windecker, executive director of the Behavioral Health Alliance of Montana, said that health providers across the state are still clawing back from more than $100 million in budget cuts in 2017, and that she worries more cuts are on the horizon.
But one bright spot, she said, is a proposal by new Gov. Greg Gianforte, a Republican, to create a fund that would put $23 million a year toward community substance abuse prevention and treatment programs. It would be partially funded by tax revenue the state will receive from recreational marijuana, which voters approved in November, with sales to begin next year.
Windecker cautioned, though, that mental health and substance use are linked, and the governor and lawmakers should plan with that in mind.
"In the public's mind, there's drug addicts and there's the mentally ill," she said. "Quite often, the same people who have a substance use disorder are using it to treat a mental health issue that is underlying that substance use. So, you can never split the two out.
Even as the pace of vaccination against covid-19 has steadily accelerated — hitting an average of 1.3 million doses a day in the last days of January — the frustration felt by many of those unable to secure an appointment hasn't waned.
Why, they wonder, can't I get one if 100 million shots will soon be administered?
Of course, the answers aren't simple. Rules keep changing. Data about the number of vaccines delivered and administered — backed by computer systems that often can't efficiently exchange information with one another — lag. Sign-up systems are clunky and balkanized.
But here's the real bottom line: Demand far exceeds supply — at least for the moment.
Here are four things to know:
1. Many states don't know exactly where the doses are, and the feds don't either.
According to the Centers for Disease Control and Prevention, nearly 56 million doses of the Moderna and Pfizer-BioNTech vaccines were distributed and 33.9 million administered by the first week in February.
Still, questions swirl around the difference between administered and shipped doses. Some have likely reached people's arms, but the record-keeping and reporting from the various medical providers within states can be slow.
In California, where the rollout per capita has trailed other states' progress, frustration with tracking doses led officials to name one large health insurer — Blue Shield of California — to coordinate allocation, replacing a strategy that relied on multiple agencies, including health departments, health systems, hospitals and the Department of Corrections and Rehabilitation.
Health and policy experts, too, express confusion.
"It's very opaque to many of us," said Dr. Amesh Adalja, a senior scholar at the Johns Hopkins Center for Health Security, who is following the rollout closely. "The CDC tracker shows how many are distributed and how many are given. Everything else is ephemeral and hard to pin down."
For example, Biden administration officials have maintained that they hold a two- to three-day supply in reserve, but Adalja said it isn't clear how many doses that represents.
The administration announced plans to increase shipments to states for a few weeks in February from approximately 8.6 million a week to 10 million. But medical providers still may not know from week to week how much they will receive from the state.
"There's a lot of unpredictability," Adalja said. "You can't track the vaccine the way you track an Amazon package. I have a colleague who works with hospitals taking deliveries and they themselves are not understanding when they will get vaccine."
Despite the problems, the U.S. has vaccinated just over 8.2% of the population, putting it about sixth in the world, according to a tracker maintained by The New York Times. And, according to a Bloomberg report, more people in the U.S. had received at least one of the two-shot regimen by early February — 33.9 million — than the number of reported cases, 26.3 million, although that number is likely an undercount.
"The percentage of the population vaccinated in a relatively short period is pretty good," said Dr. Marcus Plescia, chief medical officer for the Association of State and Territorial Health Officials.
The main concern, he added, is the difference between shipped amounts and administered dose: "That's where there's some controversy."
He suspects much of the discrepancy involves delays in entering information into state vaccine data systems, "which are pretty challenged and haven't been invested in in decades."
2. Simple math signaled the first few phases would quickly exceed available doses.
After deliberating on the fastest way to roll out the vaccines — and trying to foster equity among groups — the Advisory Committee on Immunization Practices issued a report in late December recommending to the CDC guidelines on prioritizing people.
The first group, called "1a," should include front-line healthcare workers and residents and staff members in long-term care facilities, totaling an estimated 24 million people, the committee said. Those vaccinations began in December, when Pfizer and Moderna were set to deliver about 45 million doses, or enough of the two-dose regimen for 22.5 million people.
Next in line: those who deal with the public in essential jobs, such as first responders, grocery clerks and educators, as well as people age 75 and up.
That "1b" group, when added to the first, brought the total potential number of people eligible for vaccination to 73 million.
Those numbers exceeded the approximately 120 million doses that Pfizer and Moderna had contracted to deliver by the end of March, which was enough for 60 million people. So, even with reported vaccine hesitancy among some groups, it was clear at the start that supplies would be limited into the spring.
Of course, states did not have to follow the recommendations. And many did not.
Some states moved early to expand priority to people 65 and older. There are an estimated 53 million in that group, according to the advisory committee, although some may have overlapped with the first phase.
One of the first states to loosen eligibility was Florida, where Republican Gov. Ron DeSantis in late December said he would open up vaccines to anyone age 65 or older, and moved essential workers, such as grocery clerks, further down in the rollout. Long lines immediately formed, with seniors sometimes waiting overnight in front of healthcare facilities in hopes of getting a shot.
"Once you tell everyone over 65 they can get it, it's difficult to take that back," said Plescia. "But it got their hopes up and they think it's just a matter of perseverance. The fact is, there isn't enough vaccine to do it and won't be for at least several more weeks."
3. The problem grew in the waning days of the Trump administration.
Further complicating the situation, in January the outgoing Trump administration urged states to consider expanding eligibility to all people 65 and older.
"It's simply much easier to manage allocating vaccines and appointments to everyone 65 and over rather than narrower, more complex categories," Alex Azar, then-secretary of Health and Human Services, said Jan. 12 at an Operation Warp Speed news conference.
At the time, the administration had contracts in place to buy 400 million doses, following a Dec. 23 decision to buy an additional 200 million doses from Moderna and Pfizer. The contract called for delivery by the end of June or July.
Azar's comments played into an ongoing debate in public health circles between those who advocated strictly following the rollout guidelines to try to maintain equity while balancing limited supplies, and others who said it was important to vaccinate as many people as possible, as quickly as possible, even if that meant changing the guidelines.
Don't wait, Azar urged states, for everyone in group 1a to be vaccinated before moving on to the next group. And, he added, "we're now making the full reserve of doses we have available for order."
"Some states stayed the course as far as their original priority groups, but others instantly opened up to be consistent with federal guidelines," said Katie Greene, a visiting policy associate at the Duke-Margolis Center for Health Policy and co-author of a report to the National Governors Association that outlined the CDC's guidance on vaccine rollout. "In some ways, it has helped speed up vaccinations. In other respects, there's a fundamental limit to the number of vaccines available."
Going to over-65 eligibility "wasn't a mistake," if regions were delaying vaccinations while waiting for those in the first groups to overcome hesitancy about getting the shots, said Adalja. In some cases, "the initial groups were an obstacle for getting vaccines into arms."
Yet some experts said the move falsely hyped people's expectations of when they would get the vaccine.
Revising the priority groups potentially furthered inequity in distribution, benefiting those best able to work the internet, or their connections, or those who could drive long distances to mass vaccination centers. Many vulnerable people who are older, poorer, in worse health or in public-facing jobs with little time off now had to compete with a far larger group of eligible folks when trying to get in line.
"The politics have trumped science," said Scott Ratzan, a distinguished lecturer at the City University of New York graduate school of public health. "We started with Florida lowering to 65 as fast as it could, which had to do with the politics of who the voters are. Now Florida cannot match the demand for vaccines with either the supply or the need."
4. Help is on the way, but patience is required.
Although vaccine supply is limited now — and likely will be for weeks — good news is on the horizon.
Between them, another 200 million doses are expected to be fully delivered by July, under the December purchase by the Trump administration. Pfizer recently told investors it was on track to deliver its doses by the end of May, two months early, mainly because an additional dose of vaccine can be extracted from each vial with special syringes.
Finally, Biden administration officials said in late January they are close to a deal to purchase another 200 million doses from the two manufacturers, although a final agreement has not been announced. If it goes through, the U.S. will receive 600 million doses in all this year from the two manufacturers, enough for 300 million residents.
And there is likely another vaccine in the wings. Johnson & Johnson on Thursday asked the Food and Drug Administration for emergency use authorization for its vaccine and said it could provide 100 million doses to the U.S. by the end of June. That's enough of the one-shot product for 100 million people.
"We won't see the impact until spring and summer. Right now, the supply is where it is," said Adalja at Johns Hopkins. "These bigger amounts will get us over the hump of getting eligible populations vaccinated. It's clear to everyone that vaccination will continue through the summer."
Patience will be key, said Plescia at the state health officers association: "We've got to readjust people's expectations. The public is not going to get vaccinated for a while. Even for people over 65, it will be a little while."
Outdoor dining is resuming in California under state and local orders issued last week — but with covid cases, hospitalizations and deaths still far higher than they were when the bans took effect, restaurant owners and workers are wary of reopening their patios and parking lots.
Los Angeles County’s outdoor dining ban began Nov. 25, and a statewide ban, part of a broader stay-at-home order, took effect Dec. 5. No clear data from contact tracing could justify outdoor dining bans, public health officials acknowledged.
New cases in California are down nearly 65% from last year’s peak on Dec. 15, but still high enough to prompt confusion about why Gov. Gavin Newsom allowed outdoor dining and other activities to resume.
As has frequently been the case during the pandemic, messaging is mixed regarding the safe way to return to outdoor dining. When California Health and Human Services Secretary Mark Ghaly appeared in a video to explain the lifting of the ban, a slide alongside him said, “If you miss a friend, you can go out to eat outside at a restaurant together.”
Some scientists think the policy whiplash erodes trust in health messaging.
“The original decision to close was not data-driven, and therefore the decision to reopen wasn’t data-driven,” said Dr. Monica Gandhi, a professor of medicine and an infectious diseases doctor at the University of California-San Francisco. “It looks like you’re not cleanly following numbers and making recommendations appropriately, and that can really confuse people.”
Measuring the impact of outdoor dining on covid transmission is difficult because the activity changes with the seasons, and it coincides with other activities that move from indoors to outdoors in nicer weather, said Aaron Yelowitz, a professor of economics at the University of Kentucky, who co-authored a nationwide analysis that measured the effects of the earliest shutdown orders on covid transmission.
Covid transmission in L.A. decreased within two weeks of the outdoor dining ban, a data point suggesting that the stop played a role in curbing the spread of the coronavirus.
With conditions no better, or even worse, than they were in November, the new order “doesn’t make sense,” said Billy Silverman, owner of Salazar, a Mexican barbecue restaurant in Los Angeles.
The county department of health seemed to affirm Silverman’s observation on Friday, the first day L.A. restaurants could reopen for outdoor dining.
“Although some restrictions were just lifted, we’re still in a very dangerous period in terms of cases, hospitalizations and deaths,” said county health officer Dr. Muntu Davis. He noted on Friday that L.A. County had 7,112 new cases and 228 deaths, and that 5,855 people were hospitalized with the disease.
While much lower than in mid-January, the covid burden is far higher than it was on Nov. 22, the day the county announced the outdoor dining ban, when it reported a daily tally of 2,718 cases, nine deaths and 1,401 hospitalizations.
If the covid numbers don’t improve in coming weeks, Silverman said, he can’t justify reopening his 120-seat, mostly outdoor restaurant. Though completely closed for more than half a year and then operating at 50% capacity in the fall, the business has managed to stay afloat with the help of a federal Paycheck Protection Program loan.
Silverman tried to operate with only takeout and delivery when L.A. County instituted its outdoor dining ban, but he couldn’t break even on sales to cover the labor costs. Having laid off around 65 people in March, he furloughed his workers — a much smaller kitchen crew by then — a second time in early December.
“I’ve talked to a lot of staff members, and they don’t feel comfortable rushing back to a potentially hazardous situation,” Silverman said. “I’m not going to do that to them.”
Christian Albertson, co-owner of the Monk’s Kettle tavern in San Francisco, was also stunned by the reversal.
“I can’t wrap my head around it, especially when the vaccine is so close,” Albertson said. “It just feels crazy. It is absolutely insane that we’re opening right now.”
The slow, uneven vaccine distribution makes this a precarious moment, said Jennifer D. Roberts, an assistant professor at the University of Maryland school of public health. As the shots trickle out through the community, starting with the eldest and most vulnerable residents, younger service workers — many of whom live in multigenerational homes — could be put at risk if customers relax habits like mask-wearing and physical distancing, she said.
Still, Albertson plans to resume outdoor dining in mid-February, to coincide with California Craft Beer Week. He’s confident in the protocols his restaurant developed last year to keep staffers and customers safe in a 30-seat patio area. Revenue in 2020 was down 55% compared with 2019 at Monk’s Kettle; the business is being kept afloat with governmental loan programs.
“I’d much rather wait a month or more and then have everyone come back permanently,” he said. “Right now, it’s ‘Come back, and let’s see if we can get past the first couple of weeks before cases start going up again.’”
At the heart of the issue is the lack of data showing that outdoor restaurant dining has had a role in the spread of covid. The strongest research to date includes a Centers for Disease Control and Prevention study that found covid-positive people were more than twice as likely to report eating at a restaurant two weeks before getting sick. A Stanford-led study found that restaurants operating at full capacity spread four times as many additional covid cases as the next-worst venue, indoor gyms. Neither of these studies differentiated between indoor and outdoor seating.
In the final few months of 2020, cases were rising rapidly in Los Angeles and throughout the state, however, and officials targeted outdoor dining in the absence of anything else they could regulate. With the state’s spotty contact-tracing efforts insufficient to connect outdoor dining to disease transmission, officials gave different explanations for the ban.
L.A. County’s department of public health director, Barbara Ferrer, said it was needed because outdoor dining required customers to take off their masks, raising the risk of transmission. Ghaly, the state official, said the ban had a broader aim. Transitioning to takeout and delivery “really has to do with the goal of trying to keep people at home, [and is] not a comment on the relative safety of outdoor dining,” he said Dec. 8.
“That was the frustrating part for us — that it was like a hunch,” said Jot Condie, president and CEO of the California Restaurant Association, which represents about 22,000 restaurants in the state. “They had a hunch that this was probably not safe, and let’s just shut it down.”
Condie’s association won a lawsuit against the county to overturn the ban, but by then the state’s regional orders were in place. Since the orders restricted individuals from everything except work, essential errands and exercise, the group didn’t escalate its suit to the state level, as restaurants weren’t being singled out.
Restaurants, perhaps more than any other industry, have borne the brunt of back-and-forth pandemic restrictions. Up to 1 million Californian restaurant workers have been laid off or furloughed since the pandemic began, according to the California Restaurant Association, and 30% of the 396 restaurant owners the association surveyed said they were at risk of closing or downsizing.
The loss of so many restaurant positions has made the job market extremely competitive for laid-off workers, adding pressure to job searches.
Vincent Campillo, a 38-year-old bartender in Los Angeles, lost both his jobs at the beginning of the pandemic and has been living on unemployment benefits since. He began to pick up occasional fill-in shifts toward the end of 2020.
“It’s ridiculous that L.A. is opening right now,” Campillo said. “It blows my mind and I can’t understand it.”
Newsom’s announcement seemed to divide the city into haves and have-nots, he said. Customers are cheering a return to outdoor restaurant dining, but Campillo is filled with dread. While young and healthy, he joked that he didn’t know if he and covid would “get along,” and didn’t want to find out.
Yet Campillo said he would return to work if asked, to maintain the relationships and networks he needs to remain employed long term. He hopes to get a vaccine as soon as they are offered to food service workers.
“I don’t know why I should be put in that place just so that someone can have a glass of natural wine and a charcuterie plate,” Campillo said. “People who are desperately in need of an income have to be the ones to serve them and put themselves in harm’s way.”
At a time when officials in parts of the nation are facing backlash from business owners who have been hurt by covid restrictions, Mesa County's 5-star program encourages them to partner with the local health department to promote the directives.
This article was published on Thursday, February 4, 2021 in Kaiser Health News.
GRAND JUNCTION, Colo. — On a sunny Saturday this month, Ruth Hatfield was sitting with a friend’s dog on a sidewalk bench in downtown Grand Junction. Back home in Snowmass Village, 120 miles away through winding Rocky Mountain roadways, local officials had just shut down indoor restaurant dining as covid cases reached some of the highest levels in Colorado.
Here in Grand Junction, though, restaurants were open, and Hatfield had sought out those with the local health department’s “5-star certifications,” a designation meant to reassure people it is safe to patronize businesses during the pandemic. Those 5-star restaurants are part of an innovative program that allows businesses that agree to follow certain public health protocols to be open with less stringent rules than would ordinarily apply.
At a time when officials in parts of the nation are facing backlash from business owners who have been hurt by covid restrictions, Mesa County’s 5-star program encourages them to partner with the local health department to promote the directives.
Whether the approach boosts compliance with health directives remains to be seen. This largely rural county of 154,000 people on the Utah border is divided about covid protocols, with many still skeptical of wearing face coverings.
For example, Hatfield recalled a recent visit to a 5-star certified restaurant in Grand Junction where a party of four ignored a host’s request that they wear masks while waiting to be seated.
“I’m impressed with the 5-star program, but I’m not impressed with the level of mask-wearing here,” she said.
Mesa County public health director Jeff Kuhr and Diane Schwenke, president of the Grand Junction Area Chamber of Commerce, came up with the idea for the 5-star program in June.
“It is a way of encouraging [businesses] to do the right thing, that they could then use as a marketing tool,” Schwenke said.
Businesses interested in the program fill out a form and the health department sends them a list of program requirements, which include mask enforcement for employees and customers, regular cleaning schedules, hand-sanitizing stations and spacing of furniture, Kuhr said.
The program launched in July with about 100 businesses, including restaurants, gyms and bars, and has since grown to around 600.
“This whole event is about juggling viral suppression” while preventing economic devastation and the upheaval it brings to families and communities, said Jill Hunsaker Ryan, executive director of the state health department.
The 5-star program has helped keep restaurants open despite rising covid numbers, but state officials are still analyzing data to see if it helps reduce spread of the virus, Hunsaker Ryan added.
In practice, public health isn’t just about medicine. It’s about politics too, said Kirsten Bibbins-Domingo, professor and chair of the Department of Epidemiology and Biostatistics at the University of California-San Francisco. Though covid health directives have sometimes pitted business owners against public health officials, the 5-star program aims to unite the two.
“Ultimately, you have to deal with compliance not just with the hard hand of enforcement, but also with strategies that engage people in the goals of public health,” Bibbins-Domingo said.
Because participation in the program provides the opportunity to operate with looser restrictions on capacity and hours, businesses have incentive to comply, “even if they don’t think that the coronavirus exists — and we still have people here who believe that,” said Bill Hilty, medical director of the emergency department at St. Mary’s Hospital in Grand Junction.
“The program doesn’t impugn people who didn’t believe in covid or in masks,” Hilty said. “Their freedom was not infringed.”
Any business is eligible for the program, but it is especially appealing to gyms, restaurants and bars, which face restrictions on capacity and, in some cases, hours. For instance, Mesa County’s restaurant capacity limit under current covid rules is 25%, but eating establishments in the 5-star program are allowed to seat up to 50% capacity. Schwenke estimated that at least half the county’s restaurants have signed on.
The 5-star program has “absolutely saved us,” said Josh Niernberg, executive chef and owner of restaurants Bin 707 Foodbar, Taco Party and Bin Burger in Grand Junction.
Even so, he said, he has mixed feelings. The program allowed his businesses to remain open, but support in enforcing the rules has been minimal, he said.
Niernberg worries about the risk to his employees, who face “a daily struggle with anti-maskers” who visit his restaurants and demand to know why they’re being asked to wear a mask there, when other establishments not in the program don’t require them.
Even with the 5-star program, Bin 707 is operating at about a 20% loss each week, he said. Mesa County’s 5-star restaurants may be allowed 50% occupancy, but they’re also required to have 6 feet between tables. That spacing allows just 22% occupancy at Bin 707, Niernberg said.
In Mesa County, compliance is enforced by the honor system, reports from the public and occasional compliance checks by health department employees. About 10 establishments have been booted from the program for noncompliance.
Kuhr said his department does not release the names of businesses that have left the program.
On the face of it, loosening rules imposed to slow covid might seem like a bad idea, but if the 5-star program can produce better compliance with public health rules, it might be a good strategy for slowing the coronavirus, said Bibbins-Domingo of UCSF.
“I don’t want to dismiss the strategy, because buy-in is the holy grail in public health communication,” she said.
At the same time, when cases and community spread reach critical levels, as they did recently in Colorado and across the U.S., then at some point there’s a faulty logic to keeping businesses open, even with restricted hours, which may not do much to slow transmission. Density, on the other hand, “is very clearly related to transmission, so it’s the one thing I’d be very loath to ease up on,” Bibbins-Domingo said.
Whether the 5-star program would nudge businesses to accept public health directives or would simply be used as license to open was something considered as the program was coming together.
“We discussed this early on — who’s going to use this as a loophole and then not require masks,” Schwenke said. “We were worried about that initially, but the interesting thing is that this has seemed rare.”
President Joe Biden and a group of Republicans agreed this week on how much Congress should spend on vaccine distribution, covid-19 testing and other health investments that public health officials say are desperately needed to fight the pandemic.
But agreement on those popular programs, which make up only 9% of Biden's $1.9 trillion relief proposal, is not enough to dispense that money quickly.
It will likely have to wait as the president and lawmakers hash out a bigger deal to also address the pandemic's economic toll, or as Democrats pursue the lengthy process that would allow them to pass their relief plan without Republicans. The latter would require the support of nearly every Democrat in Congress.
The disagreements that nearly torpedoed December's relief package remain, underscoring how differently lawmakers view the pandemic and their responsibility to support the millions of Americans suffering from it. And Biden's wide-ranging, high-dollar proposal, which also includes provisions increasing child care tax credits and raising the minimum wage to $15 that Republicans said would be deal breakers, has ignited new tensions.
This week 10 Senate Republicans offered a $618 billion counterproposal, matching Biden's requests for $160 billion for vaccinations, testing, treatment and other measures to contain the coronavirus; $4 billion for mental health and substance use disorder services; and $12 billion for nutrition assistance. They also provided lower counteroffers on spending to reopen schools, sending direct payments to some lower-income consumers and enhancing unemployment benefits, and on a handful of other programs. Those are cuts that some progressive Democrats said they could not support.
Biden has called for both parties to work together to right the economy and stop the virus. But it is unclear whether either party is willing to compromise at a time when emotions are still raw over the insurrection at the Capitol and the looming impeachment trial. However this is resolved could potentially set the tone for his presidency.
While some have suggested a "shots and checks" strategy to initially just deliver aid in the form of vaccinations and stimulus checks, many Democrats worry that would leave other urgent problems unaddressed, like the enhanced jobless benefits for millions of Americans that expire next month.
After Biden met with the Senate Republican group earlier this week to discuss their proposal, White House press secretary Jen Psaki said Biden "will not settle for a package that fails to meet the moment."
That leaves lawmakers trading proposals and jumping through procedural hoops to pass a big package, while public health officials — from the government's top infectious disease expert, Dr. Anthony Fauci, to the state officials who testified before the House this week — pleading for critical funding that already has the approval of members of both parties.
"Getting vaccines out quickly has become more important than ever," Dr. Joneigh S. Khaldun, Michigan's chief medical executive, told lawmakers.
Here are a few of the key disagreements — among the many — that could hold up public health funding.
Stimulus Checks
The Senate Republicans' counterproposal suggested the strictest limits yet on which Americans would be eligible for the next round of relief checks, arguing Congress should not spend extra money to help higher-income Americans.
Individuals making up to $50,000 — or couples making up to $100,000 — would receive up to $1,000 per person under the Republican proposal.
Last year's relief packages also imposed income limits on recipients. The most inclusive proposal, passed last March, sent up to $1,200 to individuals making as much as $99,000 a year (or as much as $198,000 for couples).
Biden's proposal would send $1,400 per person. Democrats are discussing making those payments more targeted. They argue the checks could help support those who get infected and must stay home from work to recover and protect others.
Democrats are describing the $1,400 checks as rounding out the $600 checks many Americans recently received from the December relief package.
That legislation was delayed when former President Donald Trump and Democratic leaders pushed to more than triple the payments to $2,000 per person — a proposal that Minority Leader Mitch McConnell, then the majority leader, said could not pass the Senate.
Progressive Democrats have argued for monthly payments, a suggestion that party leaders have not embraced.
State and Local Funding
The Republican proposal did not include additional emergency funding for state and local governments, an exclusion some Democrats say makes the package a non-starter.
Both proposals would give states money specifically for reopening schools, distributing vaccines and more. But Biden also proposed $350 billion for states and localities that generally could be used at their discretion to cover budget shortfalls and unexpected expenses directly related to the pandemic.
"The financial burden being placed on states is tremendous," Dr. Courtney N. Phillips, secretary of Louisiana's Department of Health, told lawmakers Tuesday.
"The resources provided to states, communities and families will allow us to come out the other side of this pandemic successfully and not looking at a new financial problem facing our country," she said.
In the first, $2.2 trillion relief package last year, Congress established a $150 billion fund to help state, local and tribal governments coping with the pandemic. The money was distributed based on population, with broad guidelines: State and local governments generally may use the money for "necessary expenditures" that arose from the pandemic.
States have put those dollars toward a variety of needs, from hazard pay for health workers to improved internet access. Some, like Oregon, Mississippi and North Dakota, sent additional relief checks to residents. Others, like Colorado, helped renters and homeowners facing eviction or foreclosure.
States have until the end of this year to spend the money, at which point the federal government will reclaim any unspent funds.
Republicans have argued that states do not need more money, because some of the original funding remains unspent. In December, for instance, some sounded the alarm that Texas had about $2 billion left of its disbursement — even as state officials pleaded for more help for rural hospitals, renters and food banks.
Experts note the pandemic has not taken as heavy an economic toll on state and local governments as once feared. But a recent analysis from the Brookings Institution estimated state and local governments, which already have cut about 1.3 million jobs in less than a year, stand to lose roughly $350 billion over the next three years.
Jobless Benefits
In the month after Trump declared a national emergency, more than 22 million Americans filed for unemployment benefits. By December, 10.7 million people remained out of work.
Those who filed for unemployment assistance in the early months of the pandemic received an additional $600 a week, among other benefits expanded under the first relief package — until the end of July, when the extra cash expired. In December, Congress gave the jobless an extra $300 a week.
Republicans have proposed another short-term extension of the additional $300-per-week benefit, expiring at the end of June. Biden proposed raising it to $400 and extending the benefit through September.
The current benefits are set to expire March 14, the date Democrats are now calling the unemployment benefits "cliff" — and citing as the deadline for the next relief package.
Sen. Ron Wyden (D-Ore.), the incoming chairman of the Senate Finance Committee, called an extension of at least six months "essential."
"We can't keep jumping from cliff to cliff every few months," Wyden said in a statement. "Workers who have lost their jobs through no fault of their own shouldn't be constantly worrying that they are going to lose their income overnight."
With millions of older Americans eligible for covid-19 vaccines and limited supplies, many continue to describe a frantic and frustrating search to secure a shot, beset by uncertainty and difficulty.
The efforts to vaccinate people 65 and older have strained under the enormous demand that has overwhelmed cumbersome, inconsistent scheduling systems.
The struggle represents a shift from the first wave of vaccinations — healthcare workers in healthcare settings — which went comparatively smoothly. Now, in most places, elderly people are pitted against one another, competing on an unstable technological playing field for limited shots.
"You can't have the vaccine distribution be a race between elderly people typing and younger people typing," said Jeremy Novich, a clinical psychologist in New York City who has begun a group to help people navigate the technology to get appointments. "That's not a race. That's just cruel."
While the demand is an encouraging sign of public trust in the vaccines, the challenges facing seniors also speak to the country's fragmented approach, which has left many confused and enlisting family members to hunt down appointments.
"It's just maddening," said Bill Walsh, with AARP. "It should be a smooth pathway from signing up to getting the vaccine, and that's just not what we're seeing so far."
Glitchy websites, jammed phone lines and long lines outside clinics have become commonplace as states expand who's eligible — sometimes triggering a mad dash for shots that can sound more like trying to score a ticket for a music festival than obtaining a lifesaving vaccine.
After being inundated, some public health departments are trying to hire more staff members to handle their vaccination hotlines and specifically target seniors who may not be able to navigate a complicated online sign-up process.
"Just posting a website and urging people to go there is not a recipe for success," said Walsh.
'Terribly Competitive'
Like many other seniors, Colleen Brooks, 85, had trouble sorting through the myriad online resources about how to find the vaccine where she lives, on Vashon Island in the Puget Sound near Seattle.
"It was an overwhelming amount of information," she said. "I knew it was here someplace, but it wasn't easy to find out how to get it."
After making calls, Brooks eventually got a tip from a friend who had spotted the vaccines being unloaded at their town pharmacy. When she dropped by her health clinic to inquire about how to sign up, it happened they were giving out shots that same day.
"That was totally serendipitous for me, but I actually personally know several seniors who just kind of gave up," said Brooks.
Finding out how to get a vaccine appointment was more straightforward for Gerald Kahn, 76, who lives in Madison, Connecticut.
Kahn got an email notice from the state's vaccine registration system telling him to make an appointment, but he ran into problems at the very end of the sign-up process.
"As much as I would pound my finger on the face of my iPad, it didn't do me any good," he said.
So Kahn did what many have and called a younger family member, who was able to help him finish signing up.
"I think there are a lot of people my age, maybe the preponderance, who can only go so far into the internet, and then we're not only stymied but also frustrated," he said.
When Helen Francke, 92, logged on for a vaccine at the designated time, she discovered the spots available in Washington, D.C., filled up almost instantaneously.
"It was evident that I was much too slow," she said. "It's terribly competitive and clearly favors those with advanced computer skills."
The next week, Francke tried calling and going online — this time with the help of her neighbors — without success.
"If I had had to depend on the D.C. vaccination website and telephone, I'd still be anxious and unsuccessful," said Francke, who got a shot only after finding information on a neighborhood discussion group that directed her to a hospital.
In Arizona, Karen Davis, 80, ended up on a roundabout quest through state and hospital websites with no clear sense of how to actually book an appointment.
"I kept trying to do it and kind of banged my head against the wall too many times," she said.
Davis, a retired nurse, called her doctor and the pharmacy and then eventually turned to a younger relative, who managed to book a 5 a.m. appointment at a mass vaccination site.
"I'm sure they did not expect older people to be able to do this," she said.
Miguel Lerma, who lives in Phoenix, said his 69-year-old mother has been unsuccessful in finding a shot.
"She's not an English speaker and doesn't know technology well, and that's how everything is being done," said Lerma, 31.
Lerma said it's especially painful to watch his mother struggle to get the vaccine — because he lost his father to covid last year.
"She's mourning not only for my dad, but she's also suffering as an adult now because she depended on him for certain tasks," Lerma said. "He would've handled all this."
'Desperate' Seniors Look for Help
Philip Bretsky, a primary care doctor in Southern California, said his older patients would typically call him or visit a pharmacy for vaccines like the annual flu shot, rather than rely on novel online scheduling systems.
"That's not how 85-year-olds have interacted with the healthcare system, so it's a complete disconnect," he said. "These folks are basically just investing a lot of time and not getting anything out of it."
California's recent decision to change its vaccination plan and open it up to those over 65 only adds to the confusion.
Bretsky said his patients are being told to call their doctor for information, but he isn't even sure when his office, which is authorized to give the vaccines, will receive any.
"Patients in this age group want to know that they're at least being heard or somebody is thinking about the challenges they have," he said.
There are some local efforts to make that happen.
In the village of Los Lunas, New Mexico, public health workers held an in-person sign-up event for seniors who needed assistance or simply a device connected to the internet.
A Florida senior center recently held a vaccination registration event and a clinic specifically for people over 80 who might not have a computer.
Novich, the clinical psychologist in New York, teamed up with a few other people to create an informal help service for older adults. It began as a small endeavor, advertised through a few synagogues and his Facebook page. They've now helped more than 100 people get shots.
"We have a huge number of requests that are just piling up," said Novich.
"People are really desperate and they're also confused because nobody has actually explained to them when they are expected to get vaccinated. … It's a big mess."
The ongoing shortage of vaccines has led Novich to halt the service for now.
This story is part of a partnership that includes NPR and KHN.
April 30 will mark the end of the first 100 days of President Joe Biden's tenure. That's a benchmark presidents often set for making good on high-priority campaign promises.
In early December, Biden announced that one promise would be to get 100 million covid-19 vaccines into the arms of Americans in the first 100 days, averaging about 1 million daily doses. The U.S. reached that pace around Inauguration Day but will have to maintain it for the next three months for Biden to reach his goal.
If realized, how will everyday life change? We asked the experts.
Could 100 Million Doses Achieve Herd Immunity?
First, does 100 million doses translate to 100 million people being vaccinated by April 30?
The short answer: no.
Biden has emphasized that his goal doesn't mean 100 million people will be fully vaccinated, but rather that 100 million shots will be administered. After all, both the Moderna and Pfizer-BioNTech vaccines require two doses.
When we first reached out to Biden team members in early December to ask about this target number, they said they were aiming for 50 million people to receive both doses and become fully inoculated. Then, in early January, they said the president-elect instead favored releasing most of the vaccine supply as it's produced, rather than holding back doses for people's second shots, on the assumption that new vaccine being produced would cover those booster shots on schedule. The Trump administration, still in office, announced a similar plan. Even now, though, about two weeks into Biden's term, confusion continues to surround the implementation of that policy, which could influence the number of people who receive both vaccine doses within the first 100 days.
At a Jan. 26 press briefing, Biden said his goal of 100 million shots "means somewhere between 60 — maybe less, maybe more — million people" will receive at least one dose of vaccine.
Some critics have said the target number should be higher. A day earlier, Biden suggested he would like to eventually increase the rate of vaccinations to 1.5 million a day.
Whether it's 50 million or 60 million people who are fully inoculated by the end of April, that number is still well below the prevailing herd immunity threshold recommended by public health experts.
Remember, herd immunity is achieved when enough people in a population become resistant to a disease so that it has difficulty spreading. Epidemiologists estimate at least 70% of a population must be protected to reach herd immunity. Because it's unknown how long natural immunity lasts after being infected with the coronavirus, it's recommended that even those who have had covid be vaccinated to reach herd immunity. Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, has suggested the herd immunity benchmark could be higher, up to 90%, especially since it seems some new covid variants are more transmissible than the dominant U.S. strain.
For now, let's leave the herd immunity estimate at 70% and figure out how long it would take to reach that level.
Dr. Bruce Y. Lee, a professor of health policy and management at the City University of New York, walked KHN through the math. About 330 million people live in the U.S. Seventy percent of that figure equals about 231 million.
Currently, the U.S. has access only to the two-dose Moderna and Pfizer vaccines, meaning the nation would need 462 million doses to fully vaccinate enough people to reach that 70% mark.
At a rate of 1 million doses administered per day, it would take more than 460 days. "Which we would reach sometime in early 2022," said Lee.
An additional challenge: Of the estimated 330 million people in the U.S., about 70 million are children and not yet eligible to receive a vaccine, so the vast majority of adults would have to be vaccinated to achieve this level of herd immunity.
Others have sketched out how the timeline accelerates if vaccination numbers improve. For instance, KFF chief executive Drew Altman wrote in a column that if the U.S. increased vaccine administration to 1.9 million shots a day, 70% of the population could have vaccine coverage by Labor Day. If vaccinations were increased to 2.4 million a day, that threshold could be reached by July 4. (KHN is an editorially independent program of KFF.)
In addition, other vaccines are in the pipeline that require only one dose, such as the Johnson & Johnson vaccine, and could change these projections.
At the White House's second covid response team briefing on Jan. 29, Andy Slavitt, senior adviser to the team, said about 1.2 million vaccine doses per day had been administered in the past week. Vaccine trackers from Bloomberg News and The Washington Post also report about 1 million people in the U.S. receiving their first dose of vaccine every day in the past week. And the Biden administration expects this number to increase significantly in the coming weeks and months.
But roadblocks loom, including a short supply of vaccine.
Between the Trump and Biden administrations, the U.S. has agreed to purchase 600 million doses, in all, of the covid vaccines from Moderna and Pfizer. One-third, or 200 million, of that amount was supposed to be delivered by the end of March. The remaining doses aren't slated to arrive until late spring and summer.
"The brutal truth is it's going to take months before the majority of Americans are vaccinated," Biden acknowledged during his Jan. 26 news conference announcing the United States' latest vaccine acquisition.
The difficulty of reaching people who may have trouble accessing the vaccine, such as rural residents or communities of color, could also hamper vaccination efforts. And certain individuals are likely to be hesitant or refuse to get vaccinated.
When Will Life Return to Normal?
What if you become one of the lucky ones to get vaccinated during Biden's first 100 days of the vaccine rollout?
People will still not be able to return to their pre-pandemic activities, said public health experts. A sense of normalcy won't return until we approach 70% or more of Americans vaccinated.
"As hard as it is to hear, if you get your second dose of the vaccine before we have vaccinated the majority of the population, we all still need you to take the same protective measures you were taking before you were vaccinated," said Dr. Rachel Vreeman, director of the Arnhold Institute for Global Health at Mount Sinai's medical school in New York City.
That means, even if you're vaccinated, you should continue to wear a mask, practice physical distancing with those outside your household, stay home and regularly wash your hands. The same precautions are recommended for those who won't be inoculated by April 30.
Vreeman added that a week or two after you receive your second dose of the vaccine, you are less likely to get seriously ill from covid. But you could still get sick. And it's possible you could pass on the virus to others not yet vaccinated. Clinical trials for the covid vaccines didn't evaluate whether it stopped asymptomatic transmission, only if symptoms were reduced.
"Immediately at the end of April, for the average American, there won't be a dramatic change in what they're seeing in regards to social distancing and masking," said L.J Tan, chief strategy officer for the Immunization Action Coalition, a nonprofit that works with the Centers for Disease Control and Prevention to distribute vaccine information.
Jeffrey Shaman, an environmental health professor at Columbia University, said states should maintain covid restrictions, such as those related to face coverings, remote work and limited travel, during the vaccine distribution process. In a recent modeling study, Shaman and his colleagues found that if such restrictions were lifted this month, 29 million additional covid infections could emerge by summer. He recommends keeping them in place through July.
"The bottom line is, if we lift our restrictions and we go back to what it was like before the pandemic, the virus is going to take off again," said Shaman. "Then the race to get vaccines in arms will be complicated because more people will get sick."
Experts also said that with multiple covid variants circulating in the U.S., some of which appear to be highly transmissible, taking precautions seriously is critical — especially if vaccines aren't as protective against them. Plus, the fewer people who get sick, the less likely it is the virus can replicate, mutate again and create more variants.
As for when things will return to normal? That depends on the rate of vaccinations and how many Americans are willing to roll up their sleeves.
"I think we will be back to life in the fall, hopefully before Thanksgiving," said Tan.
Other experts we asked said it's possible there could be some semblance of a return to normalcy in the summer.
But, they all agreed, it certainly won't happen by April 30.