In many ways, the pandemic has never felt quite so paradoxical. In the United States, cases and hospitalizations are falling, and millions of people are as vaccinated as they can be. A rash of coastal-state mayors and governors is peeling back mask mandates—a stateside mirror of countries such as Denmark, Sweden, and Norway, where pandemic restrictions have all but disappeared. Things are definitively better than they were just a few weeks ago. And yet--and yet--they are nowhere near anything we’d ever call good. Immunization rates on the whole are still far too low. The next variant of concern is inevitably on its way. The health-care system is still stretched too thin, and the COVID-conscious cohort is thinning by the hour. The pandemic has always been a tricky behavioral landscape for individuals to navigate. But now? It’s like all of us are walking an isthmus between islands of dread, the mainland still very much out of sight. [Read: Calling Omicron ‘mild’ is wishful thinking]
The best move right now isn’t to dive into a maskless mosh pit. But it also isn’t to resign ourselves to staying home forever. As binary as our choices might sometimes seem, it is possible to shed some of the pandemic’s crumminess while helping it come to a less catastrophic end. To socialize and enjoy things on a personal level, without compromising public well-being. Finding these small graces “is necessary right now,” says Bertha Hidalgo, an epidemiologist at the University of Alabama at Birmingham. The pandemic is not over. But if we let it, this stretch may be defined less by what we can’t do, and more by what we safely, carefully, finally can. At the very least, our basic infection-prevention template has not really changed; at this point, many people can recite the rules in their sleep. Outdoors is better than indoors, smaller gatherings better than large; masks, ventilation, tests, vaccines, and distance can all buoy safety. Separating ourselves from others will cut down on spread—an intuitive-enough idea. But very few things check all of those boxes; certainly, a lot of the activities people have been craving—indoor dining, house parties, concerts, aerobics classes—do not. Which leaves us to make tough decisions at the individual level, choices that are subject to the same tortuous pandemic math we’ve been running through for many, many months. The problem is that the arithmetic here has never just been my benefit minus my cost; infectious diseases don’t respect the boundaries of any single body at once. When a virus is at play, it’s more my benefit minus my cost and everyone else’s, a calculation in which some variables will always be unknown. “Our brains are just not good at this,” Rupali Limaye, a public-health researcher at Johns Hopkins University, told me. Complicating this further is the fact that, for many people, individual risk has clearly, and thankfully, shrunk. Millions of Americans are now triply dosed with vaccines that can slash the odds of disease and death; a large fraction have an added bump of immunity from infection too. That’s making the net benefits of certain individual behaviors look all the more appealing, while collective risk remains abstract. Meanwhile, the cost of caution is only growing; many are weary of gaining marginal returns from the precautions that have swallowed their lives for 20-some months. “People don’t want to wait anymore,” Kenneth Carter, a psychologist and risk-behavior expert at Emory University, told me. Delayed gratification doesn’t work so well when the delay has no clear end in sight. “I get that,” Carter said. He, too, gladly acknowledges that he’s sick and tired of the pandemic. But he’s trying to channel his energy into finding small, sustainable joys with very low collective cost. He’s dined indoors, always in well-ventilated restaurants, and attended masked movie matinees. These decisions have factored in his own vaccination status (boosted) and the fact that he’s not in close contact with anyone vulnerable. Alison Buttenheim, a health-behavior researcher at the University of Pennsylvania, told me that she’s thinking similarly. She met a close colleague for an indoor latte and doughnut—one of the first times she’d been able to enjoy her friend’s company in two years. “The social and professional return justified it,” she said. The latte-doughnut date was also carefully timed and placed, at a café that checked vaccination status and kept tables spaced far apart, in a city where case rates have been dropping. This small act, given the circumstances, felt, for the first time in a long time, okay. [Read: Will Omicron leave most of us immune?] Bigger, bolder behavioral swings are possible too—though they make the calculus of individual benefit and collective risk that much more complicated. Daniel Goldberg, a public-health-policy researcher at the University of Colorado Anschutz Medical Campus, told me that after a 15-month hiatus, he restarted his training in Brazilian jiu-jitsu in June—and he has kept it up through the rise and fall of Delta and now in the age of Omicron. Prior to the pandemic, he’d discovered the sport to be “one of the most powerful mental-health and well-being tools in my life,” he said. But jiu-jitsu is a full-contact martial art, a mishmash of bodily tackles, sweat-slicked grapples, and extended on-the-ground pins; heavy breathing is a given and training in a mask is essentially impossible. “If you’re going to design an activity for the spread of a dangerous respiratory virus, you’d be hard-pressed to find a better example than jiu-jitsu,” he said. Goldberg knows that the risks to him—a relatively young, healthy, thrice-vaccinated person—are quite low. The same goes for his partner and their 14-year-old daughter, who both have also been triply dosed. But the perks of jiu-jitsu, Goldberg said, are primarily for him; the risks, meanwhile, might not be. If he were to contract the coronavirus, it could pass from him to someone unvaccinated, older, or immunocompromised; it could saddle even someone low-risk with long COVID. These are all unlikely events. But Goldberg, as a self-described population-health enthusiast, is conscious of a planet of people who do not get a say in his jiu-jitsu training schedule. So he spars in tight-knit groups, with partners who share his COVID conscientiousness. He tests himself at home frequently. And he’s avoiding indoor dining, large gatherings, and nearly all travel to keep his overall risk budget trim. “I do that one thing and nothing else,” he said. He also keeps close tabs on local case rates, viral surveillance in wastewater, and hospital capacity. When there’s a transmission uptick or if someone in his training group has an exposure, they’ll skip class, or even stop sparring for a week or two. I asked Goldberg what would persuade him to reenter total jiu-jitsu hibernation. He’s not sure; nothing, so far. He’s also still trying to figure out what would help him expand his behavioral boundaries. Jiu-jitsu aside, his family has been living very COVID-spartan since the spring of 2020. He often defaults to caution in his behavioral repertoire, because he doesn’t “have the answer on whether or not it’s ultimately okay.” Maybe things will change if case numbers keep ticking down; it’s tough to say, with everything still so up in the air. But he’s taking what he can get for now. “I’ve tried to sort of embrace the idea that things will have to be dialed up and dialed back,” he said. It’s worth acknowledging here that all of us can hear “Patience, grasshopper” only so many times before we decide to burn everything to the ground. This is a trash place to be, after spending such a long time in crisis. And as my colleague Derek Thompson has written, the “Stay vigilant” ask may feel especially unfair for the people who have been holding the line on caution for years, only to watch their neighbors and colleagues—some of the very people they’ve been trying to protect—snub or exploit that graciousness. COVID has not gone away, despite their best efforts, and maybe worse, the still-COVID-conscious are having to bear more of the burden, even as their ranks dwindle. Vigilance is that much tougher when you feel like you’re the only one on watch. [Read: Hospitals can’t accept this as ‘normal’] But that is many people’s reality, and not everyone has the wiggle room to act more freely. Hidalgo, of the University of Alabama at Birmingham, told me that living in a state where vaccination rates are low and enthusiasm for other infection-prevention measures is scarce has prompted her to draw sharper borders around her behavior. She feels confident saying that her family of four is living far more strictly than most in her community. Her two sons, ages 8 and 12, are the only kids on their respective basketball teams who play fully masked; even the crowds at their games have turned into a sea of uncovered faces. She, her husband, and the kids are all vaccinated. But they’re still avoiding restaurants, movie theaters, and large gatherings of any kind. They’ve traveled only twice in the past two years, and visit vulnerable relatives, including Hidalgo’s parents, only sparingly. Things might feel rosier if they lived in California or New York, but they don’t. “Our situation is completely different,” she said. Hidalgo knows that her risk tolerance is “on the low end,” but she prefers not to frame it that way—her decision calculus isn’t about what she wants, or about what will make her comfortable. “Have we eliminated a lot from our life? Yes,” she said. “But there is sufficient need to prevent infection.” Nearly every expert I spoke with for this story pointed out that the possibility of taking risks small and large still remains heavily predicated on circumstances—for example, having the means to find and purchase tests and high-quality masks, or to work from home—and the luck of being healthy and young or hosting a functional immune system. When making choices, Limaye, of Johns Hopkins, told me that it helps to remind herself of the potential good that small actions can do: for those who can, donning a mask, taking a test, skipping a gathering. “I don’t think it’s asking for a whole lot,” she said, when those costs are stacked against the protection that others might gain. For Emory’s Carter, that feeling is empowering on an individual level too. Masks, tests, ventilation, and vaccines are now helping him engage in activities that were out of the question during the pandemic’s early days. It’s easy to center conversations about risk around the negatives—how bad individual choices can compound into collective chaos. But tiny, wise decisions, as my colleague Ed Yong has written, can also add up to a whole lot of good. New variants and new surges, like natural disasters, will keep happening: Carter told me that his approach to the pandemic has morphed into a version of hurricane watch, in which the right tools can be rapidly deployed when danger threatens and shelved when it clears. If we truly are heading into a low-case-number lull, then it’s actually a time to prepare—to come to a mutual understanding about taking risks wisely, about selecting joys judiciously, about distributing protection as widely and equitably as we can. During a pandemic, there will always be loss: disease, death, avoidance, restriction. But that doesn’t have to erase the opportunity for gain, Goldberg told me, before the door for it slams shut. “This is our collective opportunity to take care of each other.” from https://ift.tt/MyDCQS6 Check out http://natthash.tumblr.com
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With cases decreasing, well more than 65 percent of the eligible population inoculated with effective vaccines, and new COVID therapeutics coming to market, the United States is in very different circumstances than it was in early 2020. Life is currently feeling a little more stable, the future a good deal more clear. But one thing about the pandemic has remained largely unchanged: Political and scientific leaders are still struggling to communicate recommendations to the American public. Are mask mandates warranted at work and school? First we were told no; then, yes; now the answer, for good reasons this time, is changing again. Are fourth mRNA shots necessary for the most vulnerable? First the CDC said no; then, to get one five months after the third dose; and now the waiting period has been reduced to three months. The Omicron surge that the country is now exiting may not be our last of this pandemic, and SARS-CoV-2 will surely not be the last virus to cause a pandemic. If we are to get through whatever lies ahead without more unnecessary mass death, we need to reflect on how pandemic communication has fallen short and how the country can get better at it. Over the past six months, I have planned and led a small faculty seminar at the Harvard T. H. Chan School of Public Health on the pandemic, the press, and public policy. I’ve gleaned four lessons about transmitting clear, practical information in changing circumstances. Our leaders would be wise to heed them. 1. The conventional wisdom about avoiding ambiguity and uncertainty is wrong.A former local public-health official told me last year that aides to the elected official for whom they worked had advised them that the key to pandemic communications was to “keep it simple; never say ‘on the other hand.’” This may (or may not) be good practice in an election campaign, but it has proved both common and exceedingly bad counsel in a pandemic, when officials frequently need to offer guidance from a position of uncertainty. In March 2020, for example, public-health officials needed to tell people whether they should avoid contact with suspect surfaces and whether they needed to wear masks outside clinical settings. In an excess of caution and based on experience with other pathogens, the CDC advised Americans to wipe things down. But when it came to masks, the agency seemed to abandon that precautionary approach. The situation was complicated: The best masks were in terribly short supply and urgently needed by the health-care system. Rather than receiving an explanation of the situation and advice to improvise cloth masks, the public was told to forgo masks altogether because they were unnecessary. [Read: How to talk about the coronavirus] Public-health officials’ failure to trust Americans with the truth was not sophisticated or even practical. When the advice was belatedly revised in a manner that revealed it had always been faulty, an erosion of trust began and has only accelerated over the ensuing two years. Moreover, this mistake has been repeated again and again in new contexts. Last summer, for instance, advice was given to take off your mask outside, only to be sort of retracted for fear that people would not wear them in crowds, or inside, especially as Delta struck. Throughout the past year, there has been far too much reluctance to offer varying advice to the vaccinated and unvaccinated, and to the very young and very old. Officials (and the press responsible for critiquing and distilling their advice) need to be more candid about uncertainty, more open about asking people to mitigate risks temporarily until our knowledge increases, more willing to vary guidance for different groups without worrying that this constitutes “mixed messaging.” In the short run, such an approach may be challenged as weakness, but in the long run it will be revealed as building credibility, trust, and thus strength. 2. In a pervasive crisis, science must adjust to politics.Over and over in the pandemic, public-health officials have been both surprised and disappointed to find out that concerns they consider “political” have trumped scientific knowledge. Not only their surprise but even a measure of their disappointment is worth reconsidering. This is not to say that public health should be held hostage to conspiracy theories or sheer mendacity, as was sometimes the case in the first year of the pandemic, when President Donald Trump was promoting quack cures and stubbornly resisting masking. But if “Follow the science” was once a watchword of public-health resistance, it later came to sometimes embody naivete. In a well-functioning system, science is not oppositional to politics, but neither does it supersede politics. Both are essential in a democratic society; they must coexist. [Jay Varma: Not every question has a scientific answer] When a public-health concern becomes a pervasive national crisis, under any leadership, it is inevitable—and actually proper—that what may be narrowly in the interest of optimal medical outcomes will be weighed against impacts on the economy, equity, educational imperatives, national security, and even national morale. In our democratic system, that weighing is left to our elected officials. Those officials have a duty to arm themselves with the best public-health advice, and public-health experts are obligated to make sure that both leaders and the public have access to that advice, whether the politicians wish to know it or not. In retrospect, the United States might have been wise to impose fewer restrictions on elementary and secondary schools over the past two academic years—not because school closures didn’t help stop the spread of the virus, but because the educational and economic losses from widespread remote schooling might have outweighed the gains in reduced cases. The question is clearly more than scientific. Top officeholders and scientists alike can do a better job of accommodating each other. On the one hand, political leaders would do well to remember that many of the most senior officials in relevant agencies, even those with appropriate professional training, have likely been selected (by them!) for political reasons, and may or may not be the most expert in a particular situation. It can be a grave error, particularly in a place like the White House, to make the leap from “We have our own doctors” to “We have the best doctors.” [Matthew Algeo: Presidential physicians don’t always tell the public the full story] On the other hand, scientists (and even amateur epidemiologists) would do well to formulate their advice to political executives with empathy for their perspective. This does not mean shading the truth or telling someone what you think they want to hear, but it does mean safeguarding a leader’s credibility and acknowledging the political or practical constraints they face. It also means understanding that, once decisions are made, as President John F. Kennedy reportedly observed, leaders must live with them while advisers can move on to other advice. President Joe Biden, for instance, has too often found himself personally announcing conclusions that were not yet certain and guidance that was likely to soon change. 3. Speak the same language the public does.Communication is difficult when people are not speaking the same language. In the pandemic, we have seen this play out in two major ways. First: Scientists use words they think their listeners understand, only to find out much later that they don’t. Some researchers concluded early on that SARS-CoV-2 was what they term “airborne.” When many people responded by limiting the big change in their behavior to standing six feet apart, the scientists were enormously frustrated. That’s because by “airborne,” they didn’t mean merely that the virus was borne through air, but that it was aerosolized, and thus highly contagious, especially indoors. They wanted the public to stop interacting closely, especially indoors and unmasked. Recognizing earlier that the scientific and colloquial understandings of airborne didn’t match in this context would have made a difference, at least in messaging and possibly in consequences. [Read: Nine pandemic words that almost no one gets right] Second: Only a distinct minority of the population has a firm grasp of statistics, but many scientists communicate as if everyone does. In addition to emphasizing the rarity of vaccine side effects or the significant protection offered by the shots, officials must give the public a lens through which to understand the exceptions some of them are sure to encounter in their daily lives. If a particular finding, for instance, applies to 99 percent of Americans, scientists and public officials need to acknowledge—clearly, candidly, right up front—that more than 3 million people will have a different experience from that norm. To duck this reality is to risk the sheer number of counterexamples seeming to “disprove” the valid conclusion. This is especially important in communicating to and through the press. 4. Never forget the heroes.The darkest early days of the pandemic were redeemed somewhat by the national rallying around health-care professionals, first responders, and other essential workers. That focus on the heroes among us underlined the fact that, in a pandemic, we are fundamentally in the fight together, and the virus is our common enemy. Leaders made a crucial communications mistake in not extending this lesson to the rollout of the vaccines, which were the result of both the genius and the hard and astoundingly fast work of another set of heroes. Greater celebration, beginning in late 2020, of these innovators, inventors, and even manufacturers could, I think, have made widespread division over the vaccines less likely and less pervasive. [From the January/February 2021 issue: How science beat the virus] It would, for instance, have helped if the editors of Time magazine had felt compelled to name the inventors of the mRNA vaccines as the 2021 “People of the Year,” rather than deeming them runners-up to Elon Musk. Glorifying pharmaceutical companies may be a stretch, but why not loudly praise the workers who churned out the “Warp Speed” vaccines as modern-day Rosie the Riveters? In the absence of these sorts of celebrations, the division over vaccines remains the greatest failure of the U.S. experience of the pandemic. More than a quarter of a million deaths were likely directly preventable by available vaccination. Undervaccination contributed to the horrible strength of the Delta and Omicron waves, lingering economic pain, and remote schooling, which might also have been avoided. Next time, the communication breakdown may or may not center on vaccines. But we’d all be much better off if we didn’t have a breakdown at all. from https://ift.tt/MBnao24 Check out http://natthash.tumblr.com Look, I think it’s fine that Joe Rogan said, with COVID-case rates coming down in April, he wouldn’t tell a healthy 21-year-old to get vaccinated. That’s a value judgment, not a lie. And we may as well ignore the fact that he treated himself with ivermectin in September, after he got sick himself. He was also taking monoclonal antibodies and steroids (and some studies did appear to show, at first, that ivermectin was effective). But a lot of bullshit spewed on The Joe Rogan Experience, his podcast, is gravely irresponsible; there’s just no arguing this point. He or his guests have said, for instance, that useful COVID treatments were suppressed by greedy hospital executives, that COVID deaths have been grossly overcounted, that masking simply cannot work to stop disease transmission, that public-health messaging has hypnotized the masses, that recovering from COVID confers permanent immunity, that mRNA vaccines represent “a major threat to reproductive health,” and many other things that aren’t true. The spread of these ideas wastes our time, at the very least. I suspect that it makes us dumber, too, by sucking any serious critiques of vaccine policy into a vapid swirl of blabbing and debunking. But does it change behavior? I mean to say: Is all of this nonsense not just dumb but deadly? “People are dying because of COVID misinformation that Spotify packages as glib podcast fodder,” a Washington Post column said over the weekend. This all started when a group of health-care workers and scientists accused Spotify, the sole distributor of Rogan’s podcast, of creating “mass-misinformation events” with “extraordinarily dangerous ramifications” for millions of listeners. Soon others joined the chorus claiming that Rogan’s show provides a platform for anti-vaxxers and is costing human lives. (The scandal has since expanded to Rogan’s history of using racial slurs and other past affronts.) Vaccine refusal, in its broadest sense, has taken a catastrophic toll in the United States, on the order of hundreds of thousands of preventable deaths. But the claim that pandemic falsehoods aired on Rogan’s show are substantially responsible ignores the sticky facts of our predicament. Surveys now suggest that roughly one in six American adults says they won’t get vaccinated for COVID-19. That’s roughly what the surveys showed over the summer; it’s also roughly what the surveys showed in the summer of 2020, when the pandemic was still young. One in six adults, some 45 million Americans in all, is seemingly immune to any change of context or information. One in six adults—a solid tumor on our public health that doesn’t grow or shrink. The vaccine skeptics have retained their numbers in spite of endless efforts at persuasion--sprints to vaccinate, months of action, reams of scary data. So, too, have the people in the vaccine-accepting crowd: The Americans who said they would consider getting shots have been holding firm, in spite of all the lies over the past two years. Indeed, there’s little evidence that any super-peddler of doubt—not even Alex Berenson, Tucker Carlson, or Joseph Mercola—has changed the numbers much at all. “Mass-misinformation events,” Lollapaloozas of lies about vaccines, have come and gone and come again. We know that, on some level, these messages are surely doing harm. Yet the U.S. is still mired in the same proportion of refusal as it was in 2020. One in six adults. Could things really be this stuck? If Rogan makes any difference for vaccines, it’s at the margins. In the spring, the political scientists Dominik Stecula and Matt Motta tried to quantify this nudge. For a set of surveys taken from April 2020 to February 2021, they asked U.S. adults about both their vaccine intentions and their media-consumption habits. After controlling for people’s age, political beliefs, and other factors, they found that regular Rogan listeners had grown 18 percentage points more hesitant to get the shots by the end of the study period. These results were never published in an academic journal, and the data were merely correlational, but they were still “consistent with the idea that Rogan listeners may be heeding his and his guests’ nonexpert medical advice,” the researchers argued in The Washington Post last year. Stecula and Motta have also tried to gauge the anti-vaxxer power of Fox News. In a paper posted in September that hasn’t yet been peer-reviewed, and drawing from the same set of surveys as above, they compared Republican adults who watched Fox News every day with those who never watched it. They found no difference between these groups—a “null effect” for Fox—on whether they intended to go in for a vaccine. But that was noteworthy in itself, the authors argued, because, for Republicans, daily exposure to other news outlets—CNN or network news, for example—was associated with greater vaccine acceptance. This is subtle work, finding whispers in the noise. If listening to Rogan’s podcast or watching Fox News every day is having some effect on individuals, we certainly can’t make out that effect on a macro scale. Since the fall, polls from Gallup, Harris, the Kaiser Family Foundation, and others have consistently pegged the proportion of adults who have already gotten at least one shot, or plan to do so, at 75 to 80 percent. The CDC tells us that 74.4 percent of U.S. adults are fully vaccinated. (It also says that nearly 90 percent of adults have received at least one dose, but that number appears to be substantially inflated, in part because of miscounted booster shots.) “What we’re seeing in our data, and I’m sure this is probably true for all data, is that the numbers are pretty frozen,” says David Lazer, a lead investigator for the COVID States Project, which has tracked pandemic attitudes and behaviors since early 2020. The proportion of adults who have gotten one or more shots “looks really static over the last few waves, across all demographics.” These rates haven’t simply flatlined—they’ve landed pretty much where polls predicted from the start. In summer 2020, surveys of people’s attitudes toward COVID vaccination found that roughly 16 or 17 percent were never-evers, while the rest fell in a split between immunize-me-now and immunize-me-maybe-later. Since then, we’ve seen the latter group—the maybes—slowly change their mind to yes. (They now represent just 5 to 10 percent of the adult population.) But the never-evers, whose numbers briefly spiked in the fall of 2020, soon snapped back to their baseline, where they’ve remained as never as they ever were. Lazer told me that he’s not at all surprised we’ve come to this plateau. “It was inevitable that there would be some set of people who weren’t going to wake up one morning and say, ‘Huh, why did I think vaccines would kill me?’” [Read: America is now in the hands of the vaccine-hesitant] Individual choices can still matter, of course, even in the context of a COVID-vaccine equilibrium. According to the CDC, a couple hundred thousand Americans are getting their first vaccine shot every day. That number includes children and, again, probably some mislabeled booster shots, but in any case it has important implications. All of those doses may not amount to much on a population level—200,000 recipients represent just 0.05 percent of the U.S.—but still they give protection to a huge amount of people. “A percentage-point movement here or there,” Matt Motta told me, means that “millions of Americans are choosing to vaccinate.” Rogan and others could be driving tiny movements that correspond to large effects in absolute terms, but the details there are muddy. In the meantime, our bigger picture remains both clear and unchanging. Mass misinformation events have not produced a mass hypnosis of young, impressionable Americans, as Neil Young implied they have last month. Rather, we’ve seen a steady and continued rise in vaccinations among adults, as the nation inches ever closer to a vaccine-acceptance ceiling that was present all along, and will remain a major cause of death in the months to come. Misinformation matters: It distracts, depresses, and divides us. But that’s not the same as saying that it’s the thing killing us in droves. Think of it like this: We have two kinds of animals living in the U.S. One group includes all of those who tend to do as they’re told, even when they’re feeling skittish. Let’s call them … sheep. A sheep might be a little scared of the vaccines, or distrustful of the government, but still it follows others in the flock. (Almost all Democrats are sheep, and so are most Republicans.) The other group includes the willful, fearful animals who will never agree to the vaccines, and who may end up as the sacrificial victims of a self-destructive ideology. Let’s call them goats. (Maybe one in 20 Democrats is a goat, compared with one in four Republicans.) Sheep and goats sustain themselves on separate diets: Sheep seek out official information and advice; they nibble in the open pastures and sip from the mainstream. Goats prefer to linger in the shade, digging out the woody underbrush of alternative news. Yet even a major change to the ecosystem—imposing a vaccine mandate, for example, fencing in the goats—doesn’t seem to affect the size of either group. Why? [Read: Vaccination in America might have only one tragic path forward] Matt Motta has one theory: Perhaps the environmental shifts are more or less in balance. Efforts to promote vaccines are really working, he suggests; mandates and incentives and public-service announcements are changing people’s minds, keeping goats in check, and helping sheep thrive. But the anti-vaccine activists’ campaigns are working too—their spread through podcasts and social media has fortified the goats, and maybe stopped some sheep from getting vaccinated sooner. In the end, the two population pressures cancel out, and the outcome looks the same: One in six Americans is a goat. The appearance of stability, Motta says, masks a more complicated story. But this would have to be a pretty grand coincidence, where the net effect of all our pro-vaccination policies and coverage just happens to match up, one for one, with the net effect of every bit of anti-vaxxer propaganda. Another theory holds that the effects aren’t really matched, but rather that the media ecosystem is so expansive and so lush that no animal ever has a problem finding food it likes. Spotify can “silence” Rogan; Twitter can deplatform Robert W. Malone. But the goats will keep on ambling from one patch of ground to another, never going hungry, never losing their resolve. When they can’t find anti-vaccine rhetoric on Fox, they’ll go to Facebook. When they’re getting starved by Spotify, they’ll go to Substack. Or here’s one more theory: Maybe our mistake is treating sheep and goats as if they’re eating different things. What if the very same roughage that sustains the sheep also helps the goats? Vaccine mandates surely lead to higher vaccination rates, but they also rally vaccine opponents on the right. Likewise, protests against Spotify, and their widespread coverage in the media, may end up bringing more attention to the host they mean to target. “We need to think about all the people who Joe Rogan has not reached yet,” Motta told me. “He is getting a ton of attention right now, and it would not be surprising to me if some people were like, Oh, I should check out what this show is all about.” If that’s the case, then stability in vaccination rates might be less a product of two equal and opposing population pressures than an indication that the population pressures are effectively the same. These theories aren’t mutually exclusive. However they might be summed together, they might allow for shows like Rogan’s to exert some effect on certain people’s attitudes, while having no perceivable effect on the course of vaccination in America. “I tend to think that, had Rogan’s platform not existed, overall rates would have been higher, even if only fractionally,” Motta said. But his platform is more a symptom than a cause—the latest efflorescence from a root system of distrust that has been in place for many years. “The idea that Rogan and Fox News are making the problem worse? Sure, I’m amenable to that,” Motta said. “But vaccines have been politically contentious well before the COVID-19 pandemic.” In other words: This whole ecology is tainted, and cleaning it up will take a very long time. from https://ift.tt/JBExqSk Check out http://natthash.tumblr.com There was the home health attendant who sucked her thumb before touching household items. And the one who brought her unvaccinated 4-year-old into the apartment where Mary and her immunocompromised husband live, near Pittsburgh, Pennsylvania. And the one who came by after her day shift at a nursing home. Many of the aides who circulated through Mary’s household were vaccine-hesitant or outright anti-vax; many wore their mask improperly while in the apartment, she told me. A few came in with sneezes, sniffles, and coughs that—as Mary and her husband learned only after asking—were symptoms of an active COVID-19 infection. The couple worked with 34 home-care attendants in 2021—24 of them since last July. On the worst days, Mary told me, no one showed up. (The Atlantic agreed to identify her by only her first name, because she and her husband fear that finding assistance will become even harder if they speak publicly about their experience.) Her husband, who has spinal muscular atrophy and uses a wheelchair, turns lights on and off with voice commands and can answer the phone and control the television with a smart device. But he relies on attendants for assistance with eating, toothbrushing, showering, cleaning, and other household tasks. At night, getting out of his wheelchair and comfortably into bed can take 45 minutes. It’s arduous work, and “I’m in trouble if we can’t get someone,” said Mary, whose osteoporosis means that she can’t do physically demanding caregiving without assistance of her own. When aides show up but misuse masks or have eschewed a vaccine, that necessary care becomes a threat. Managing a “parade” of home health attendants during the pandemic, Mary said, has been “absolutely, totally nerve-racking.” Any relationship between home-care workers and their clients modulates on a frequency of unavoidable intimacy. “That might be the only person they see that day,” says Nicole Jorwic, the chief of advocacy and campaigns for Caring Across Generations, an organization aimed at reforming home and community-based care and supporting those who receive care, their families, and caregivers. Some 2 million to 4.6 million direct-care workers support millions more older adults and people with disabilities or chronic conditions in the shelter of their home. “This is life-giving work,” Jorwic told me. Because of the physical proximity demanded by this labor, it also unavoidably poses a risk to those receiving it. Balancing the need for care and the stress of dependence on people who might infect you with COVID-19 is just one more way the pandemic is concentrating risk among the most vulnerable, and even more so the longer it goes on. “As a society, we’re craving a return to quote-unquote ‘normalcy,’” Jorwic said. “That return to normal is a return to not recognizing the value of the lives of people with disabilities and the elderly.” In one important way, the risk of home health care continues to be unnecessarily high: Direct-care workers tend to be unsure about the COVID-19 vaccines. When they first became available, some struggled to gain access. By the spring of 2021, just one-quarter of direct-care workers had been vaccinated, compared with about two-thirds of hospital workers and half of nursing-home workers, according to a poll conducted by the nonprofit Kaiser Family Foundation and The Washington Post. By August, uptake within different caregiver companies and subspecialties ranged from 40 to 90 percent, the National Association for Home Care & Hospice estimated. At least two industry groups—the NAHC and the Home Care Association of America—have publicly voiced support for the COVID vaccines. At the same time, surveys have documented low confidence in the vaccines among direct-care workers. “We need to be honest and recognize our shortfall in vaccinations as an industry,” the NAHC’s president and CEO said over the summer. Direct-care workers are not fully convinced that the vaccines are safe or effective; many worry that the vaccines have not been adequately tested in people of color. About 61 percent of direct-care workers are people of color, and in this way these slower rates of uptake reflect broader trends in the United States. How many direct-care workers are currently vaccinated is unclear. Vaccination rates are especially unknowable among the sizable number of direct-care workers in the unregulated, private-hire “gray market,” which is very difficult to measure. Today, an NAHC spokesperson told me, the range might be closer to 50 to 98 percent, depending on the company and whether workers are subject to a mandate. By comparison, by the end of 2021, at least 77 percent of hospital workers were fully vaccinated, and by now almost 85 percent of nursing-home workers are. Many disability-rights activists told me that they are keenly invested in the many labor issues facing direct-care workers. Long before COVID, these workers were undercompensated and overworked. Almost half live in or near poverty, bringing in a median hourly wage of $13.56. More than a quarter are immigrants. One out of six lacks any health insurance. Two years before the pandemic, the field’s turnover rate peaked at 82 percent; turnover slowed in 2020. At the same time, for the elderly and people with disabilities—communities that are vulnerable to COVID and deeply dependent on this precarious and neglected workforce—vaccine hesitancy adds yet another variable to the complicated equation for safely receiving care at home. Navigating the tension between risk and care can create “a palpable feeling of dread,” says Judy Mark, the president of the California group Disability Voices United whose 25-year-old son has autism and relies on home aides. Too often, this dilemma boils down to a lose-lose choice between inviting an unvaccinated aide into the household or facing a reality without help. Many in this position have made outsize sacrifices to minimize COVID risks. Jennifer Restle, who is blind and has a chronic illness, spent the first three months of the pandemic entirely alone in her house. “Not one person crossed my threshold,” she told me. From day one, she was on the same page about minimizing exposure to the coronavirus with the direct-care worker she’s employed since 2006. The aide, herself a cancer survivor with a suppressed immune system, monitored Instacart orders for Restle, dropped off goods on her porch, sorted her mail, and placed Post-it Notes on the signature line of checks for her. The two painstakingly reviewed grocery lists over the phone. Even now that both are vaccinated, the aide still wears a mask in Restle’s house. “I am extremely lucky,” Restle told me. “We’re more, like, in this together.” Others, such as Tim Jin, can’t receive the assistance they need from six feet away. Jin, who has cerebral palsy, uses a wheelchair and communicates by typing on an iPad with his toes. His health aides assist him with cooking, eating, toothbrushing, using the bathroom, and going to the gym and doctor appointments. For the first six months of the pandemic, Jin saw no one in person other than those caregivers. He used to employ his aides through an agency that sent a mix of people across three to four daily shifts. Even after he asked for vaccinated attendants, he told me, the agency still sent him unvaccinated staff. “At each shift, they were risking my life,” Jin said. “It was like picking a random number on a roulette wheel and hopefully I wouldn’t get exposed.” Jin now hires and manages his own staff—all of whom have been vaccinated, and half of whom are boosted. For many direct-care clients and their families, private employment may be the best way to assure that caregivers are vaccinated—even if it costs more in time and resources. Syra Madad, an infectious-disease epidemiologist at Harvard’s Belfer Center for Science and International Affairs, and her husband employ a half-dozen home health aides to take care of high-risk, elderly family members. To retain those direct-care workers during the pandemic, Madad told me, they offered hazard pay and provided personal protective equipment. “We knew if they left, we wouldn’t have anybody to help us,” she said. Not only was Madad able to keep her staff; she was also able to help them get vaccinated. Outside of such private, unregulated arrangements, the requirements that direct-care aides be vaccinated aren’t totally clear. November’s federal vaccine mandate through the Centers for Medicare and Medicaid Services—which was upheld by the Supreme Court last month--clearly covers Medicare-certified home health agencies, but not necessarily Medicaid providers of home-based services (whose availability and funding vary greatly from state to state). And because 90 percent of direct-care workers are employed by small agencies, federal rules requiring vaccination or regular testing at companies with 100 or more employees—which the Supreme Court sent back to the lower courts on the same day—will also not broadly apply to the industry. For Mary in Pennsylvania, those gaps parallel her chronic stress about getting through each day. She wonders every morning not only whether the aide scheduled to help her and her husband will show up—but whether that person will be willing to take precautions to protect the couple in their own home. “Sometimes I just cry thinking about it,” Mary said. “There are times where we look at each other and say, ‘Is this really all there is?’” Almost everyone I spoke with for this story told me that the pandemic’s earliest months offered a bittersweet hope that COVID might open more people’s eyes to the challenges people living with disabilities face, through firsthand experience. Shelter-in-place orders created a situation in which disability was simulated at large, Kathleen Bogart, an associate psychology professor at Oregon State University and the director of the school’s Disability and Social Interaction Lab, told me. Millions discovered what it meant to spend the majority of their time at home, require flexible work options, contract outside help with daily tasks, and receive virtual health care. “I shared, along with many other people with disability, the hope that this time may increase awareness,” Scott Landes, a Syracuse University associate sociology professor, told me. “It seemed like for a while we were in this together.” That moment has passed. Since 2020, Landes and his colleagues have studied how the risks, sacrifices, and tolls of the pandemic have been concentrated among some of the groups most likely to need in-home help. Early on, for example, many people with disabilities or rare disorders were cut off from regular care—monthly infusions, physical therapy for pain management, visits to the podiatrist to avoid overgrown toenails and other painful conditions. In periods of rationing COVID tests and PPE, home-care settings were often overlooked in favor of hospitals and nursing homes. In one study of almost 65 million patients, people with intellectual disabilities were more likely to die from COVID than people with congestive heart failure, kidney disease, or lung disease. Another study of nearly half a million people with positive COVID cases found that those with intellectual disabilities or developmental disorders were, respectively, 2.75 and three times as likely as others in their age group to die following their diagnosis. (Additional evidence shows that this disparity is even more pronounced in residential group homes.) About three out of four total COVID deaths in the U.S.—more than 650,000—have been people 65 and older. “It has underscored the fact that the system is broken,” Landes said. All the while, those populations have been largely hidden. Some of the most vulnerable among us have remained in lockdown, sheltering in place and out of sight. “Our value is not seen, so our experience is not considered important,” Restle said. “We were everybody’s afterthought because we could be left in our houses.” Bogart has been documenting the mental-health toll of that intense and prolonged social isolation. After surveying 441 U.S. adults with disabilities last winter, Bogart and her colleagues found that 61 percent of respondents met the criteria for a probable diagnosis of major depression. Fully half met the criteria for generalized anxiety disorder. People with disabilities or rare disorders also have had little way of knowing what danger their conditions might add to the baseline risks of COVID. Bogart, for example, has Moebius syndrome, a congenital facial weakness or paralysis condition that can prevent some from closing their eyes or mouth, leaving those mucus membranes exposed. “No one knew whether we were more susceptible to catching COVID-19,” Bogart said. Even two years in, “these groups are still left in the dark. In this omission is an implicit We don’t care about those people,” she said. The National Council on Disability echoed that sentiment in an October report, saying that for people with disabilities, “COVID-19 was not only a healthcare crisis but an extended test of the nation’s recognition of their human and civil rights.” Even if the risk of COVID disappeared tomorrow, the pandemic would have left home-care clients in a more vulnerable position—and added to their numbers. In 2019, 41 states had waiting lists for home and community-based health services—a nationwide total of about 820,000 people enduring an average wait of 39 months. “That was before the pandemic,” Caring Across Generations’ Jorwic said. “That number has certainly gone up.” Given what we know about long COVID, Bogart said, the pandemic could represent “a mass disabling event.” Already, at least 26 percent of U.S. adults have a disability, and she and others say we are neglecting their needs by neglecting the home-care industry. “I am very worried, looking forward. What does this mean for all of us down the line?” Madad, the epidemiologist, said. “There’s going to be a huge demand for it, and we’re not doing enough.” from https://ift.tt/KNhSZxw Check out http://natthash.tumblr.com When researchers consider the classic five categories of taste—sweet, salty, sour, bitter, and umami—there’s little disagreement over which of them is the least understood. Creatures crave sweet for sugar and calories. A yen for umami, or savoriness, keeps many animals nourished with protein. Salt’s essential for bodies to stay in fluid balance, and for nerve cells to signal. And a sensitivity to bitterness can come in handy with the whole not-poisoning-yourself thing. But sour? Sour’s a bizarro cue, a signal reliable neither for toxicity nor for nutrition. Really, it’s just a rough proxy for low pH, the presence of acid—the citric in lemons, the acetic in vinegar, and the like. “We don’t need sour to live,” Ann-Marie Torregrossa, a taste researcher at the University at Buffalo, told me. “It’s a weird sense to need.” It has been so scientifically neglected that Rob Dunn, an ecologist at North Carolina State University, considers it something of a “missing taste,” the gustatory litter’s forgotten runt. No one really knows for sure, Dunn told me, “what it’s all about.” And yet we taste sour, strongly, and are not alone in doing so. When Dunn and his colleagues recently set out to investigate the sensation’s evolutionary roots, he told me, they couldn’t find a single backboned species that had definitively lost the ability to identify acidic foods, be they birds or mammals or amphibians or reptiles or fish. Admittedly, that may be a function of how few animals scientists have surveyed—just several dozen—but already, that makes sour a standout. Cats, otters, hyenas, and other carnivores have lost the ability to suss out sugar; giant pandas are immune to umami; dolphins, which swallow their prey whole, don’t seem to be able to savor sweetness or savoriness, and have booted bitter sensitivity too. But sour sensing appears to have staying power that its cousins do not—which means that it must be doing something important, perhaps something ancient. What that something is remains a mystery, and it’s probably actually somethings, depending on the species. Part of the story, Dunn said, may begin with fish—the most ancient vertebrate group that’s had its sour-sensing superpowers assessed and confirmed. Fish have taste buds in their mouths, like we do, but also freckled all over their bodies (which you could think of as enormous scaled tongues). Some of these receptors can sense acid, which may have helped the animals navigate in and out of waters rich or poor in carbon dioxide, and kept their bodies’ fluids in chemical balance. [Read: Why does sweetness taste so good?] When the ancestors of today’s terrestrial creatures began their slow crawl ashore, sour sensing somehow stuck—and quickly splintered along species lines. Nowadays acidic foods are neither universally beloved among land animals nor universally reviled. Many apes, including us, seem to dig the taste, as do rats and pigs—at least up to a certain concentration, called a “bliss point,” past which the taste gets gross. “Just don’t give a tomato to a sheep,” Dunn warned me. “And certainly don’t give a lemon to a sheep.” (Dunn hasn’t tried to, but he and his colleagues did find a 1970 study that suggests that sheep think acidic stuff tastes baaaaad.) It’s not totally clear why some species find sour so odious, but scientists have guesses. Maybe animals that have been documented as disliking the taste--horses, vampire bats, rabbits, and axolotls, to name a few—take it as a hint that their food is still unripe, or has gone rancid and is therefore unsafe. At an extreme, acid itself can gnaw away at tissues or erode tooth enamel; it can screw with a body’s chemistry or discombobulate the sometimes-fragile microbes that inhabit the gut. “A lot of the explanations are aimed at the negative,” Hannah Frank, a crop and soil-sciences researcher at North Carolina State who’s been working with Dunn to untangle sour’s evolutionary past, told me. But they also “haven’t been well substantiated,” she said. Proving the why of evolution is always something of a scientific nightmare. And it’s not like history is peppered with case studies of “sad sheep that died because they ate too many lemons,” Dunn told me. Unlike sheep, though, we humans are, as a species, absolute sour stans. So are several species of apes and monkeys in our evolutionary vicinity—chimps, orangutans, gorillas, macaques, gibbons. Clearly, acid’s doing something right. For years, researchers have been floating a compelling reason: Sour can be a good indication that a food is rich in vitamin C, a nutrient that our ancestors lost the ability to manufacture about 60 to 70 million years back. A fresh appetite for sour might have helped spare us the ravages of scurvy. Even in the simplest version of this tale, though, the relationship with acidity is messy. Sour fruit, though sometimes an excellent snack, can also be too raw. Here, a partnership with sweetness might be key, says Katie Amato, a biological anthropologist at Northwestern University who’s been collaborating with Dunn. Very tart, very sugary foods could even signal a bonus benefit: that a bonanza of beneficial microbes have colonized our cuisine and started to break its carbohydrates down. This process, called fermentation, adds the taste of tang; it can also keep dangerous microbes out, and pulverize gnarly plant fibers that our own bodies struggle to digest on their own. And humans (some of us, anyway) really, really dig it—think kimchi, kombucha, sauerkraut, or yogurt. If sour’s a marker for fermentation’s marvelous musk, then “it would be selecting for the right kind of overripe fruit,” Amato told me. If those notions pan out, they open up far more questions than we have answers to. Paule Joseph, a nurse practitioner and taste and smell researcher at the National Institutes of Health, told me that scientists still don’t have a good explanation for variation for sour preference within species. Some of it might be inborn biology, drawn from genetics or age. (Some research has hinted that little kids might be more jazzed about sour foods than adults.) But Joseph says it’s also essential to consider how the foods in our environment shape our predilections. Even sort of “bad” tastes such as bitter and sour can become positive—black coffee, for example, has notes of both. [Read: The story of songbirds is a story of sugar] And the trends that pushed primates toward sourness won’t necessarily dictate tart tastes in other species. Pigs apparently think sour’s splendid, even though they can synthesize vitamin C just fine; Dunn ventures that their acid appetites might just be part and parcel of their propensity to “eat almost anything.” Then there are guinea pigs, which present the converse conundrum: They, like us, have lost their vitamin C–producing chops. And yet, a 1978 study showed that two guinea-pig species “rejected” citric acid in a taste test. Taste-preference studies in nonhuman species, to be fair, aren’t very easy to do. A typical experiment involves offering an animal a choice between plain water and flavored water—infused with something sweet, salty, bitter, umami, sour—and seeing which liquid most captivates the creature. An avoidance of somewhat-acidic water might not say all that much; maybe it’s missing that crucial, sugary X factor. Or maybe acidic water just seems too unnatural. And though some animal species produce many of the same reactions we make when we encounter something grody-tasting—wincing, nose wrinkling, mouth gaping, even a bit of dramatic limb flailing—the further scientists get from studying humans, the tougher it is to suss out enjoyment, or lack thereof. Hiro Matsunami, a chemosensory biologist at Duke University, pointed me to yet another complicating factor: Sour sensing’s apparent ubiquity among vertebrates may not necessarily be about taste. The same chemical receptors we use to zero in on acid in our mouths seem to perform other functions in the body that might be super essential. That evolutionary pressure alone could have made sour taste stick around too. Since embarking on their science-of-sour shenanigans, both Frank and Dunn have been conducting some very informal investigations to expand sour’s evolutionary tree. Dunn’s been throwing lemons to crows; Frank has been feeding pickles and citrus to her dog, Maple June. Neither species seems that pleased with the offering, though Maple June still, with an agonized look on her face, wolfs raw lemons down. “She just pains her way through” as many other dogs do, Frank told me. Maybe she’s attracted to sour’s beguiling acerbicness—the appeal of a food that somehow bites back. Then again, Maple June’s a canine, and perhaps the story is simple, Frank said: “She’ll eat anything.” from https://ift.tt/nrwBMUc Check out http://natthash.tumblr.com After months and months of being told to wait, then wait, then wait some more, parents eager to vaccinate their littlest kids against COVID-19 have been gifted some good and very confusing news. Yesterday, after weeks of weird and cryptic waffling, Pfizer kick-started the process of requesting an emergency use authorization from the FDA for their infant-and-toddler COVID-19 vaccine; if the agency’s advisory-panel meeting, scheduled for the 15th, goes smoothly, the under-5 shots could be available as a two-dose series shortly thereafter, pending a CDC recommendation. The most optimistic timeline for the arrival of an under-5 vaccine has suddenly shrunk to just a few more weeks. This pivot is, at first glance, bizarre. Six weeks ago, right before Christmas, Pfizer announced that late-stage trials of two mini shots had produced somewhat lackluster antibody results in 2-to-4-year-olds, and a third dose could be necessary to clinch protection. Nothing about the vaccine itself has changed since then; no new data (actually, no data at all) have been publicized. Pfizer still says that a third dose will probably be necessary, and may report results on the effects of that dose around early spring. And yet, the stance on the shots for this group of kids has shifted substantially. Somehow, we’ve gone in an instant from two doses aren’t enough to actually, they kind of are. And both statements, somehow, are meant to be true at once. Presumably, Pfizer and the FDA (which asked Pfizer to make its bid) have hit upon the fastest way for the company to jet at least some vaccine into little arms. But “it’s an odd message: We think you’re going to need a third dose, but take two now,” Chandy John, a pediatric infectious-disease physician and malaria researcher at Indiana University, told me. [Read: Why a three-dose vaccine for young kids might actually work out] Pfizer did not answer my questions about its new strategy when I reached out, only pointing me to a Tuesday press release announcing that it has sent its first round of data to the FDA. (But not, sadly, to the rest of us.) The company does seem to have collected and analyzed more data on how well the initial duo of shots is working since its last official update, a development reported by The Washington Post on Monday. And those data could well explain how two shots might have once appeared to fall short but now look pretty decent—decent enough, perhaps, to earn the FDA’s emergency okay. The key here is understanding the metrics by which the shots’ success will be judged. Back in December, Pfizer was sussing out its shots’ success on a micro, immunological scale: how much of an immune response the vaccines tickled out. Now the company has added another lens that operates on the macro, clinical level: how well the shots lowered the risk of some sort of disease-related outcome. Knowing that, Pfizer’s pivot does make some chronological sense. The company’s pediatric-vaccine trials were originally designed to focus on that first micro scale. Researchers had hoped that a pair of three-microgram doses of the company’s vaccine, administered three weeks apart, would prompt an antibody response comparable to that seen in older teens and young adults, who received two 30-microgram shots. This tactic, of trying to match outcomes between groups, is called “immunobridging.” The researchers did see a preview of that exact result in a small, early-stage trial, which included 32 children under the age of 5. (A 10-microgram dose also coaxed out a nice antibody response in this same age group, but saddled more toddlers with severe fevers as a side effect. Pfizer decided to nix that option.) But that tiny study was only meant to find the ideal dose so Pfizer could move forward with a larger trial, with a few thousand kids enrolled. And for some yet-to-be-determined reasons, the protective pattern didn’t play out in the larger group. In late-stage trials, kids under 2 churned out plenty of antibodies in response to two three-microgram doses; the 2-to-4-year olds, however, fell some undisclosed percentage short of the target, prompting Pfizer to reassess. (Scientists call this “not meeting non-inferiority.”) The company put forth a public Plan B—a third dose, given at least two months after the second, which would hopefully yank antibody levels up past the threshold. [Read: Why are we microdosing vaccines for kids?] Compared with full-on efficacy trials, which must wait for participants to get sick, immunobridging is fast and relatively easy. But the strategy also has to rely on some assumptions, Sallie Permar, a pediatrician, immunologist, and vaccine expert at Weill Cornell Medical Center, told me. It works best when researchers have already vetted a vaccine in a specific population (for instance, healthy adults) and pinpointed a certain, measurable immune response, called a correlate of protection, above which most folks in that group can be considered well shielded from disease. That number can then serve as a gold standard for other as-yet-unvaccinated populations (for instance, not-healthy adults). Alas: We still have not confirmed that perfect, magic correlate of protection against COVID-19. For many months now, data have been pointing to antibody levels as a great candidate, especially if we’re thinking about less severe infections. But there’s still a lot of uncertainty, and antibodies are not the entire defensive picture. (Hello, T cells. Hello, B cells.) Correlates of protection are dependent on what we’re trying to protect against (infection, severe disease, something else), and in whom. These key protective levels can also toggle up or down if a new variant appears, or even, sometimes, if we move from one age group to another. Infant and toddler immune systems are not identical to adults’. So maybe antibodies weren’t the best place to be looking. Or maybe the problem was just that teens and young adults, whose immune systems are still quite feisty, presented a “higher-than-necessary bar” for such an urgently needed vaccine, says Roby Bhattacharyya, an infectious-disease physician at Massachusetts General Hospital. “If antibody levels are not non-inferior to 16-to-25-year-olds, well, that’s a very different bar than not helpful.” (That said, the 16-to-25-year-old group has been the benchmark for Pfizer’s other pediatric trials as well.) Still, the antibody data were some of the best that the trial runners had to go on, at first. Now Omicron appears to have rejiggered the game board. Enough infections may have swept through the trial’s participants, according to the Post, that the company suddenly had data describing vaccine efficacy against bona fide COVID outcomes. Maybe Pfizer found that fewer kids among those who received the actual vaccine in the trial were getting infected or sickened by the virus, even after just their first two shots. [Read: Our relationship with COVID vaccines is just getting started] Without seeing the actual data, it’s hard to judge Pfizer’s new dosing plan, experts told me. But the company has already said that its infant-and-toddler vaccine appears to have a good safety profile. That, coupled with adequate preliminary efficacy, might be reason enough to grant the EUA for two doses, then wait for the third-dose data and hope they further buoy the shots’ success. (Third doses, in general, are also expected to help broaden immune responses against variants.) Permar thinks an efficacy of 50 percent against COVID might be a sensible bar for the first two shots, although “the closer you get to 80, 90 percent, the better,” she told me. John, of Indiana University, told me he thinks “most of us would accept it if it’s safe, which they’ve already said it is, and effective against severe disease … something like 70 percent effective against hospitalizations, or more,” he said. “Then it’s worth giving,” even if the antibody data aren’t a knockout. Shifting the goalposts to severe disease, experts told me, may end up being prudent here. All of our vaccines are an imperfect match for the highly mutated Omicron; while safeguards against hospitalization and death have held quite strong, antibodies have struggled to block less serious infections. Still, it’s reasonable to assume that the total number of COVID cases—especially serious ones—in the trial was not that high, making it tough to confidently compare vaccinated and unvaccinated cohorts. That alone could artificially inflate or deflate vaccine efficacy. Ibukun Kalu, a pediatric-infectious-disease physician at Duke University, also points out that vaccines should be expected to perform more poorly against infection during a surge caused by an antibody-dodging variant; the first efficacy numbers we record now might not be reflective of how our shots will fare in the future, against another variant or when case numbers dwindle. That punts some of the descriptive burden back to antibodies, which can, ideally, paint “a more complete picture about how and why vaccines work in the youngest groups,” Kalu told me. All of this adds up to some tough decisions for the FDA’s advisory panel. If Pfizer’s vaccine-performance data were unilaterally marvelous, we would have heard by now, but they’re also unlikely to be unilaterally abysmal. Data that sit between those two extremes do not make for a slam dunk. And compared with most other age groups, very young kids remain at relatively low risk of having a severe case of COVID-19, making a super-thorough risk-benefit analysis for infant-and-toddler vaccination especially important. To complicate things further, experts advising the FDA will also have to navigate the odd antibody split between the under-2s, who did mount a sufficient antibody response, and the over-2s, who, by Pfizer’s initial standards, did not. “I did wonder if the older kids could hold the younger ones back,” Permar said. Without the data from Pfizer’s third shot, authorizing two for now could amount to a high-stakes bet that a pair of initial doses will confer enough protection to make an early push worth it, and that the third will arrive in time to buttress those defenses. [Read: Calling Omicron ‘mild’ is wishful thinking] Say two doses do fine for kids—they’re safe, but don’t provide gobs of protection against less serious COVID. Say the FDA greenlights the vaccine, banking on the idea that the pair of shots will still tee up kids to be properly shielded by that third injection. And say that doesn’t pay off—say we don’t see a giant antibody uptick, or a hefty efficacy rise, after shot No. 3. Say the third dose’s effects are very, very temporary. What then? The third dose will almost certainly improve upon the initial response; thrice-vaccinated kids will still be better protected than they were before. But in the eyes of regulators, any additional vaccination still needs to look “worth it.” Parents did not wait this long for a meh vaccine. And prematurely granting an EUA to a vaccine that’s safe but not terribly effective could very well “backfire,” Tina Tan, a pediatrician at Lurie Children’s Hospital of Chicago, told me. Vaccine uptake has already been patchy among American children; as the age brackets tick down, experts are predicting that the inertia will only grow. Pfizer’s gamble isn’t just about immunology. It’s also about communication—that this new plan can keep parents on board without losing their trust. A snafu now could make it tough to vaccinate kids in the future, against COVID or anything else. At the same time, although COVID does pose a relatively low risk to little kids on “a population basis,” John told me, that risk is not zero. Children can catch and spread the virus; they can develop long COVID. And “we don’t want any kids to go to the hospital or die,” John said. In the past two years, more than 11.4 million coronavirus infections have been reported in children; close to a fifth of them have been logged in the past two weeks alone. Omicron’s surge has sent pediatric hospitalization numbers soaring to new heights. The under-5s are the last group of Americans to remain ineligible for vaccination. And the new variant, which seems to favor the upper respiratory tract, appears to cause treatable but serious crouplike symptoms that are very tough for the littlest kids to take, Kalu told me. Their airways are tiny; “they have fewer resources to deal with it than older kids or adults,” she said. Bhattacharyya, of Massachusetts General Hospital, told me the data will still be guiding his thinking, as both a researcher and a parent—his son is 3. But “I think the only thing that would give me pause at this stage is a new safety signal, or a complete absence of antibody response,” he said. After so many months of having no options to safely give his child immunity, he’s ready for a change. from https://ift.tt/DxC2iNutG Check out http://natthash.tumblr.com At the height of the recent Omicron surge, Advocate Trinity Hospital, in Chicago, was inundated with patients who spent more than 40 hours in the waiting room, holding tight for a bed in the emergency room, which was itself heaving with people who were waiting for a spot in the intensive-care unit, which was also full. Someone admitted at night might have seen two sunrises before they saw a bed. The hospital received more COVID-19 patients than at any previous point during the pandemic. These patients waited, as did people with other conditions. “We had patients waiting with bacterial infections, surgical problems, you name it … people who were sick to a degree that we’d never keep them waiting in normal conditions,” Michael Anderson, the emergency department’s medical director, told me. That the hospital could be so besieged two years into the pandemic “is something I never thought in my wildest dreams would occur,” Matt Fox, a respiratory therapist, told me. To see as many patients as quickly as possible, the hospital’s exhausted staff brought intensive care into the emergency room, using portable oxygen tanks sourced from a local company. They brought emergency services into the waiting room, installing catheters and ordering medical tests for people who couldn’t yet be given a bed. They resuscitated a patient who had had a heart attack while still in an ambulance, because there wasn’t anywhere for them to be off-loaded. But between staff shortages that had been getting steadily worse throughout the pandemic and the sheer deluge of sick people, the team simply couldn’t see everyone quickly enough. During one recent shift when just four nurses were on duty, three of whom had been hired from an agency and were on their first day, a COVID patient went into cardiac arrest in the waiting room, where they had been sitting for 10 hours. “They were talking and in a split second they weren’t,” Berenice Zavala, an emergency-department nurse, told me. Someone checked: no pulse. One nurse leaped to start CPR, while her colleagues tried to put personal protective equipment on her. Somehow, they found a room, which at one point filled with almost every available health-care worker on the floor. The team spent 45 minutes trying to revive the patient. They could not. “It really affected us all. People blamed themselves,” Zavala said. “I’ve never worked under these conditions.” Advocate Trinity is one of the few remaining health-care institutions that serves the predominantly Black communities of Chicago’s South Side—an area where several hospitals have either closed in recent decades or are now on the verge of doing so. A third of its patients are uninsured or on Medicaid. When the coronavirus arrived, Black Chicagoans were more likely to die from it than white ones; even before the pandemic, they already had shorter lives, poorer health, and fewer health-care services. Hospitals throughout the United States have struggled through the Omicron wave, but Advocate Trinity is America’s health-care system in microcosm. Its shrinking pool of workers is shouldering, at immense personal cost, several generations of inequality and neglect, and two years of a poorly controlled pandemic. “We’re asking heroic things of people to pave over the problems that the health-care system faces,” Anderson said. Many of Advocate Trinity’s workers have already left, while Anderson and others who are still there are committed to staying for the sake of their community. “If they don’t come to us, where else are they going to go?” Michele Roe, a nurse, told me. Many stressors from the early pandemic have abated. Having been vaccinated, Advocate Trinity’s staff members are less fearful about their own health or about fatally infecting their loved ones. With two years of experience under their belt, they better know how to treat COVID patients. They can save many people who might have died in early 2020. But like many institutions, the hospital was already short of nurses before the pandemic. Last year, that shortage grew steadily worse. Worn down by the relentless surges, many employees retired or took positions that don’t involve acute care. Others were lured away by travel-nursing contracts, which allow them to work more flexibly and for several times more pay. “We do provide incentives to keep nurses here, but they pale in comparison to the prices being offered” by travel agencies, Roe said. The exodus got so bad that on Halloween morning, a single nurse showed up to cover the emergency department’s 21 beds. The team scrambled, successfully, to pull more people in, “but that was when reality hit,” Anderson said. Ideally, no ER nurse would take on more than four patients. Of late, some have had six in their care. The staffing problems aren’t about just missing bodies, but also missing experience. As the oldest nurses resigned, their deep well of knowledge left too. Newly graduated nurses take twice as long to be onboarded as before the pandemic, Gwendolyn Oglesby-Odom, the chief nursing officer, told me, because the pandemic disrupted their training and left them with less clinical experience. Zavala said that travel nurses, too, used to be more seasoned and could be slotted into hospital routines after a short orientation, but agencies are now less stringent. Their workers need more hand-holding from experienced nurses who know that they’re earning significantly less. These factors all force physicians and veteran nurses to be extra vigilant about matters that they used to entrust to colleagues, adding to their already considerable strain. Meanwhile, the patients haven’t stopped coming. Although Omicron is less severe than Delta, it is still potent enough and transmissible enough to fill Advocate Trinity with people struggling for breath, more than 90 percent of whom are either unvaccinated or partially vaccinated. COVID also exacerbated a slew of existing health problems: Before the pandemic, 80 percent of Advocate Trinity’s patients had diabetes, and many had asthma and chronic respiratory diseases. “Our patients are pretty sick coming in the door, because they haven’t been able to afford care and they haven’t seen a physician in years,” Zavala said. COVID constrained sick people’s choices even further. Some people worried about contracting the disease in a hospital and spent months sitting on worsening chronic health problems. Others faced six-month wait times for a primary-care appointment and got sicker because they couldn’t get their medications. Opioid overdoses have surged, Anderson said, driven in part by the grief of losing loved ones and the pandemic’s other traumas. “We’ve been full since August, and there’s just a lot of people coming in for everything,” he said. “It’s not just that hospitals are busy on and off with COVID. We’re dealing with multiple crises at once, many of which are fueled by COVID.” In response, the hospital delayed some nonemergency procedures, petitioned the state and the federal government for resources, and closed down one of two critical-care units to ensure that its staff could adequately care for the other’s patients. “We flipped every lever that we could,” Rashard Johnson, the president of Advocate Trinity, told me. But with the virus running amok, the hospital was powerless in one crucial respect: It couldn’t slow the influx of patients. Normally, the hospital could get some slack by transferring people to other facilities or asking for ambulances to be temporarily diverted. But with every hospital full, transfers were impossible, and ambulance diversions were restricted by the state. The waiting room swelled with on-edge, fed-up patients who took their anger out on the nurses. Some simply couldn’t believe that all the beds could be occupied for so long, and accused nurses of lying to them. “Every patient we encounter, I feel like we’re always one step behind in terms of having to regain their trust,” Zavala said. The moral distress of being unable to sufficiently care for their patients is among the worst hardships that health-care workers have been forced to endure. “To feel like you aren’t able to give your patients the best, because the situation is poor, takes a deep toll,” Anderson said. “I’ve encouraged our physicians not to accept this as normal, but for their own well-being they also have to accept that some of these things, they can’t change.” The surge appears to be subsiding at Advocate Trinity. Since its peak, in the week after Christmas, the number of COVID patients has halved, as has the number of patients being held in the emergency department. Wait times are still long, running to 11 hours two Sundays ago, but they are now merely excruciating instead of unmanageable. “We see the light at the end of the tunnel,” Oglesby-Odom told me. But then what? With COVID set to be a permanent fixture in our lives, more surges and variants are possible. The hospital will have to deal with people whose care was postponed amid the surge and those with long-term problems because of their run-ins with COVID. Meanwhile, the staffing shortages that long preceded Omicron’s arrival will remain. A small community hospital will struggle to attract staff in a way that a larger, better-funded institution won’t. Nursing- and medical-school applications are up, but training the next generation will take several years. “We have to be able to navigate a path forward with less,” Oglesby-Odom said. “We’re never going to be able to go back to the way we were, because there’s not that same workforce.” For the first time in two decades, Advocate Trinity has started hiring licensed practical nurses, who have less education than registered nurses and mostly work in nursing homes and long-term-care facilities. It is assigning groups of patients to teams of nurses, resurrecting a model developed during nursing shortages after World War II. It may have to make hard decisions about which services to stop or deprioritize. Johnson said that his focus is on protecting his staff’s mental health, by allowing people to take time off to recuperate, offering resources for therapy and spiritual care, and creating quiet spaces where people can exhale. The hospital is also offering retention bonuses to encourage its staff to stay. Many of Advocate Trinity’s employees are staying. More than a third live in the area that the hospital serves. Nurses and doctors have treated one another’s family members. Oglesby-Odom was born near the hospital, went to high school a mile away, and visited as a patient long before arriving as a nurse. She has seen the area become a desert for both health and health care. The number of grocery stores has fallen. Other hospitals disappeared or scaled back their operations to the point where Advocate Trinity is the sole port of call for some necessary services, including obstetrics. So much rides on the hospital finding a way to survive the pandemic and the subsequent spell of scarcity. Its failures would ripple out far beyond its walls. But so would its successes. Over the summer, Advocate Trinity launched a mobile vaccination service that has since vaccinated almost 3,200 people in their homes and more than 350 at local churches. On a recent Sunday, the team vaccinated 44 people, including 10 in a single home, ages 5 to 90. Rosie Bernard, who leads the service, told me that the people she meets are not the belligerent, hard-line anti-vaxxers of stereotypes. They’re folks who had concerns about safety but came around after seeing that their vaccinated loved ones were still healthy; or who changed their mind once mandates came into force; or who were afraid about getting COVID by going to a vaccination site but were thrilled when the vaccines came to them; or who distrusted a medical establishment that has historically mistreated Black people but were persuaded when someone from their own community reassured them. “It’s a combination of trust and time,” Bernard said. “We’re getting more and more people to take that first dose.” The mobile unit reflects Advocate Trinity’s plan “to go outside the four walls of the hospital and wrap our arms around the community,” Oglesby-Odom said. Together with 12 other health-care providers, the hospital is also leading an ambitious project to infuse Chicago’s South Side with a new wave of primary-care physicians and community health workers who can help residents deal with medical needs and chronic problems before they get bad enough to warrant an emergency-room visit. The project will also partner with social-service organizations to help residents address issues such as food and housing insecurity. Such work normally falls within the purview of public health rather than medicine. A century ago, before the rise of modern hospitals, these disciplines were less disparate than they are now, and Advocate Trinity’s plans hint at a return to that era. After all, the pandemic has shown that if America simply waits for the victims of unchecked health problems to knock on its hospitals’ doors, those hospitals will be readily overwhelmed. The country needs to prevent more people from getting sick in the first place and address the social inequalities that make entire communities vulnerable to a new virus. So while Advocate Trinity works to deal with the aftermath of the past pandemic surges, it is also pursuing a longer-term solution to the hospital crisis: Keep as many people out of the hospital as possible. from https://ift.tt/NFyCW675H Check out http://natthash.tumblr.com Two years into the pandemic, and two months into Omicron’s globe-crushing surge, our COVID-19 vaccines are finally on the cusp of a federally sanctioned update. To counter the new variant’s uncanny knack for slipping past antibodies roused by our first-generation shots, Moderna and Pfizer have both kick-started clinical trials to see how Omicron-specific vaccines fare in people. Results are expected within the next few months, and if all goes well, syringes around the world could be locked and loaded with Omicron’s wonky-looking spike protein by the summer. Omicron-izing our COVID vaccines is a good, if unfortunately timed, move, experts told me. But the same strangeness that makes an Omicron-specific vaccine wise is also a warning against trashing our original-recipe shots too soon. We don’t know what the next major variant will look like. It could be an offshoot of Omicron, something that strongly mirrors the ancestral SARS-CoV-2, or something that resembles neither variant at all. Our vaccine regimens going forward should include Omicron “for sure,” Rafi Ahmed, an immunologist at Emory University, told me. But they should also “include one of the earlier strains,” and even leave room for a future variant, as the SARS-CoV-2 family tree continues to branch, he said. For the billions of people around the world who are still unvaccinated, including tens of millions of children under 5 in the United States—more of whom are being born every day—going all in on Omicron could backfire. The original shots, outdated as they are, likely still have a role to play. [Read: The coronavirus will surprise us again] The shots we’re currently using give us a limited set of options for building immunity. Although vaccine makers have cooked up Beta- and Delta-specific versions of their COVID vaccines along with Omicron-specific ones, the only formulas with an FDA green light are the ones that use a spike from a coronavirus version that hasn’t been spotted in many, many months. That wasn’t so bad when the most common variants were Alpha, Delta, or even the slightly immune-evasive Beta and Gamma, because they weren’t such big departures from their parent; our original-recipe vaccines still worked. Think of SARS-CoV-2 variants like breeds of house cats. Our coronavirus classic (RIP) was an American shorthair; Alpha was a British shorthair; Beta, a Siamese; Gamma, a Manx; Delta, a Maine coon. All furry, all whiskered, all a pretty good match for the generic feline template that the original-recipe vaccine lays down. Omicron, meanwhile, is a sphynx: decidedly still a cat, but wrinkly, whiskerless, and bald as a baby’s bottom. It looks like nothing the human immune system has been asked to deal with before. When antibodies trained on standard-issue shorthairs see the new variant’s spike, they’re thrown for a loop. The OG shorthair spike isn’t a total tutorial flop. It can still teach feline features to T cells, which are fairly variant-proof; that’s part of why multiply vaccinated people remain so well protected against severe cases of COVID. Antibodies, which are more easily flummoxed by mutations, benefit as well, because even a sphynx-like variant retains many core cat characteristics: retractable claws, pointy ears, glowy eyes with slit-shaped pupils. And each time our immune cells glimpse these features, they up the quantity and quality of antibodies available for attack, Rishi Goel, an immunologist at the University of Pennsylvania, told me. Though two doses of a classic-spike mRNA vaccine are shaky against Omicron, a three-dose course still works fairly well at keeping the new variant at bay. It’s not unlike how kids learn from pets or picture books: The more cats they see, the more primed they are to recognize the next one that saunters by. When a sphynx shows up in the body, not all vaccine-trained antibodies will recognize it as a bona fide foe. But the ones that do—those that home in on the catlike features it’s kept—will latch on confidently. That trend probably has a limit, Melanie Ott, a virologist at UC San Francisco’s Gladstone Institute, told me. “I don’t know if it’s wise to go four, five, six, seven times with the same spike,” she said. Eventually we’ll hit the point of diminishing returns; the body may even become too fixated on only the most common cat traits, and start to ignore what falls outside the norm. (Omicron? That’s just some giant, naked rodent.) That’s probably reason enough to avoid boosting in perpetuity with the original recipe. For the next round of COVID shots, whenever they might be necessary, we may be better off using something else—an “insurance policy,” as Goel put it, to help the body broaden its coronavirus scope. Omicron would seem to be the obvious choice; ideally “we should be vaccinating with what’s circulating,” Katie Gostic, an infectious-disease modeler at the University of Chicago, told me. “That has the best chance of protecting you today.” That sort of thinking is what seems to be driving Moderna’s and Pfizer’s new trials. Both companies are revaccinating twice- and thrice-immunized people with Omicron’s spike, a strategy that should bolster the defenses already laid down by prior vaccines, experts told me, while coaxing out new, Omicron-specific protections to complement them. But the products won’t be available to the public for at least another couple of months, by which time Omicron may be mostly blipping off the map, or being overtaken by another variant that renders a sphynx-specific shot less useful. Some experts have even argued that there will be no point to boosting with Omicron’s spike when that shot’s ready; it’ll be too late. That vaccine’s utility, then, hinges on what the next big move in SARS-CoV-2’s evolution might be. [Read: Will Omicron leave most of us immune?] No one’s willing to put down a confident prediction on that front, but experts have tentative guesses. Taia Wang, an immunologist at Stanford, thinks that the next variant to take over will be an Omicron descendent. (That’s generally how flu viruses work: Successful strains beget more successful strains in an almost linear, stepwise fashion.) It’s a numbers game, Wang told me, given how comprehensively Omicron is sweeping the world. Wang said she’d even favor the notion of dispensing with OG-spike vaccines entirely, and using only the Omicron recipe from now on for boosters and primary shots, should Pfizer and Moderna push it through. Of the two companies, only Pfizer’s testing this tactic directly: Some 200 people in its Omicron-vaccine trial are receiving their first three COVID shots as Omicron, Omicron, Omicron. Alex Sigal, a virologist at the Africa Health Research Institute, in South Africa, told me that he’s less confident such a plan will pay off. In his mind, the next major variant will probably reap its biggest advantages from snubbing a resemblance to Omicron; that would position it to escape whatever sphynx-ish immunity the variant’s currently coaxing out. That means leaning too hard into an Omicron-specific defense now could be dicey. Sigal and his colleagues have found that Omicron infections in unvaccinated people don’t goad the immune system into churning out antibodies that recognize other variants very well. Ott’s team has shown similar patterns in mice. Researchers are still working out the nitty-gritty of what’s behind this Omicron bias, but experts told me that they suspect the new variant’s weirdness can cut both ways: Original-recipe-trained immune fighters struggle to recognize Omicron; Omicron-trained defenders aren’t great at homing in on variants that look like OG. When Omicron lopes into an airway that’s never seen a coronavirus spike before (either through infection or vaccination), antibody-producing immune cells seem to lock on to features that are sphynx-like—its nudity; its webbed paws; its gaunt, stern, Clint Eastwood–esque face—but that are not necessarily all that helpful for ID’ing the average cat breed. “It’s just too specialized,” Sigal said. The new variant is too much of an aberration, compared with its cousins, to go all in on with our vaccination regimes; in a landscape of diversity, he said, betting on averages, rather than extremes, is safer. No one can yet say whether the myopia that unfolds after an Omicron infection will translate over to Omicron-based shots, but if it does, unimmunized bodies pumped up only with Omicron vaccines might get hitched to the wrong wagon. “If it were me going to the vaccination station, I wouldn’t want just three doses of Omicron,” Sigal said. That calculus might slightly shift for unvaccinated people who have had a brush with a non-Omicron flavor of the virus. For them, getting a couple of Omicron shots might still diversify their coronavirus-defense portfolio, though that’s yet to be confirmed. But few people know what version of the virus hit them, so keeping multiple spikes in rotation in our vaccine roster is a hedge. It might also be a good way to stay one step ahead of the virus, especially if we need to revaccinate people somewhat regularly—perhaps every year, as we do for the flu. Totally uninfected, totally unvaccinated people are also entering the population every day, as infants; when they need vaccines, a big menu of spikes might be what serves them best. [Read: Our relationship with COVID vaccines is just getting started] The point, Goel said, isn’t to stubbornly latch onto the OG spike and never let go. We may ditch that iteration eventually, especially as we get a better handle on how SARS-CoV-2 will likely evolve. The point is that a diverse spike regimen will usually be a better bet than a single-spike one, whether those spikes are from the classic SARS-CoV-2, Omicron, or another variant past, present, or future. “It’s no secret that broad immunity is elicited with a broad strategy,” Ott said. Vaccine makers might even be wise to toss Beta- or Delta-spike vaccines into the mix, she added, just to see what sorts of immunological oomph they offer. Several companies, including Moderna, are also testing shots that combine at least two spike flavors in one dose, which could make the logistics of multi-variant regimens easier. As research into SARS-CoV-2’s evolution continues, scientists may even glean enough intel to start to predict which variants might usurp the global throne next—and recommend that strain for use in, say, an annual shot. A massive worldwide surveillance program already makes this possible for the flu; equivalent programs for COVID are still in their infancy, but they are growing. Tactics like these could pave the path to universal vaccines—single shots that could teach the body to recognize a whole panoply of variants and that wouldn’t have to be updated every time the coronavirus undergoes a costume change, Padmini Pillai, an immunologist at MIT, told me. “Relying on new boosters every time we have a new variant of concern is not a viable strategy,” she said. For now, though, we can achieve at least some of the same effects by mixing and matching the tools we have. The original SARS-CoV-2 may be effectively dead. But with its ghost living on in our vaccines, what it has to offer us is not. from https://ift.tt/8xjwg2aTy Check out http://natthash.tumblr.com By now, we’ve all heard some version of how this ends. The same story has certainly been told often enough: We missed our chance to wipe the new coronavirus out, and now we’re stuck with it. Our vaccines are stellar at protecting against serious disease and death, but not comprehensive or durable enough to quash the virus for good. What lies yonder, then, is endemicity—a post-pandemic future in which, some say, our relationship with the virus becomes simple, trifling, and routine, each infection no more concerning than a flu or common cold. Endemicity, so the narrative goes, is how normal life resumes. (Some pundits and politicians would argue that we are, actually, already at endemicity—or, at the very least, we should be acting as if we are.) It is how a devastating pandemic virus ends up docile. Endemicity promises exactly none of this. Really, the term to which we’ve pinned our post-pandemic hopes has so many definitions that it means almost nothing at all. What lies ahead is, still, a big uncertain mess, which the word endemic does far more to obscure than to clarify. “This distinction between pandemic and endemic has been put forward as the checkered flag,” a clear line where restrictions disappear overnight, COVID-related anxieties are put to rest, and we are “done” with this crisis, Yonatan Grad, an infectious-disease expert at Harvard, told us. That’s not the case. And there are zero guarantees on how or when we’ll reach endemicity, or whether we’ll reach it at all. [Read: We’re not at endemicity yet] Even if we could be certain that endemicity was on the horizon, that assuredness doesn’t guarantee the nature of our post-pandemic experience of COVID. There are countless ways for a disease to go endemic. Endemicity says nothing about the total number of infected people in a population at a given time. It says nothing about how bad those infections might get—how much death or disability a microbe might cause. Endemic diseases can be innocuous or severe; endemic diseases can be common or vanishingly rare. Endemicity neither ensures a permanent détente nor promises a return “to 2019,” Abraar Karan, an infectious-disease physician and global-health expert at Stanford, told us. Its only true dictate—and even this one’s shaky, depending on whom you ask—is a modicum of predictability in the average number of people who catch and pass on a pathogen over a set period of time. Endemicity, then, just identifies a pathogen that’s fixed itself in our population so stubbornly that we cease to be seriously perturbed by it. We tolerate it. Even catastrophically prevalent and deadly diseases can be endemic, as long as the crisis they cause feels constant and acceptable to whoever’s thinking to ask. In a rosy scenario, reasonably high levels of population immunity could bring the virus to heel, and keep it there; its toll would be roughly on par with the flu’s. As coronavirus cases drop from their Omicron highs in the United States and other countries, there’s at least some reason to hope things are bending in that direction. But at its worst, endemicity could lock us into a state of disease transmission that is perhaps as high as some stretches of the pandemic have been—and stays that way. If endemicity contains a world of possibilities, not all of them good or even better, then it makes a poor goal, and an impractical conceptual framework for any action aimed at managing COVID in the months, years, and decades ahead. Simply declaring endemicity gets us nowhere. It doesn’t answer the real questions about what we want our relationship with this virus to be. And it doesn’t erase the difficult decisions we’ll need to make if we plan to shape that future, rather than risk letting the virus make our choices for us. It is an unfortunate coincidence that the word endemic begins with end. The arrival of endemicity is actually the beginning—of a long and complicated relationship between a pathogen and its host population. En demos. In the people. Exactly what kind of long and complicated relationship endemicity denotes, though, is impossible to say, even for experts. “It’s a very nonspecific notion,” Karan said. “There’s really no definition of endemic,” Emily Martin, an epidemiologist at the University of Michigan, told us. And the word is so “muddy and misused” that it’s “really hard to pin down why someone is using it wrong,” Ellie Murray, an epidemiologist at Boston University, told us. We spoke with more than a dozen experts for this article, and nearly every one of them explained endemicity differently. For some, endemicity entails a disease with stability, constancy. For others, it means one that concentrates in a specific geography. Some think a degree of predictability is a prerequisite; some do not. Others still adhere to a more technical definition: Endemicity refers to a state in which over, say, a year, each person who catches an infection will on average transmit it to one other person, so that the overall case burden neither rises nor falls. Much of the population has at least some immune protection, and the spread of the disease is limited by the rate at which vulnerable people are introduced (or reintroduced) into the population, by birth or waning immunity. Think of a bathtub with water flowing in and draining out at the same rate. But some experts think that notion’s too strict: Any amount of sustained spread, however turbulent, can qualify as endemicity. [Read: The worst of the Omicron wave could still be coming] What experts do agree on is that endemicity is not monolithic. The water in that tub might be hot or cold; the level it plateaus at can be very high or very low. The world’s pathogens run the gamut. Viruses such as herpes simplex 1, which causes cold sores and, less commonly, genital herpes, are considered endemic throughout the world. In the United States, HSV-1 affects, by some estimates, at least half of Americans, though most of the infections are asymptomatic or not terribly severe, especially among adults. Malaria, meanwhile, sickens more than 200 million people a year, and kills at least 400,000, most of them under the age of 5. That, too, is endemicity. Then there are flu viruses—so often held up as the paragon of endemicity, but actually a better example of just how absurdly confusing endemicity can get. In most places, flu viruses are seasonal, surging in the fall and winter, then subsiding in the warmer months. (They circulate year-round in parts of the tropics.) But they can also erupt into pandemics, as they did in 1918, 1968, and 2009, then tick back down. Flu is one of many examples that show why endemic can’t be thought of as the inverse of pandemic; the two terms are not opposite ends of a spectrum. Endemic doesn’t mean the virus is “suddenly not going to hurt us,” Murray said. Flu viruses actually present such a bizarre case of boom and bust that many researchers don’t consider them to be endemic at all. The experts we spoke with were pretty much evenly split among saying Flu is endemic, Flu is not endemic, and some version of Who knows? or It depends. This set of viruses, the not-endemic camp argues, are just too erratic to warrant the label, even when flu doesn’t reach pandemic proportions. The seasonality seems reliable, but that may not be enough to count as stable. The magnitude and severity of these annual-ish cycles can vary widely; some strains will play nicer with humans than others. One year, a flu virus will kill about 10,000 Americans. Another year, it will kill six times that. The question of the flu’s endemish nature takes on an almost existential cast: What does it mean to expect something? Others in the not-endemic camp contend that, in addition to being too unpredictable, the flu is also too global. An endemic pathogen, they say, must be restricted to a population in a specific geographical region, rather than “just everywhere,” Seema Lakdawala, a flu virologist at the University of Pittsburgh, told us. (The CDC agrees.) The Emory University virologist Anice Lowen, meanwhile, isn’t so bothered by the flu’s ubiquity. “I would call it endemic to humans,” she said. Martin, of the University of Michigan, doesn’t put herself in either camp. “Things get wiggly,” she said, “when you’ve got something like the flu.” Pretty much all we can say for sure about the flu is that—as Malia Jones, a population-health expert at the University of Wisconsin at Madison, told us—it is “a huge pain in the butt, but also not a global pandemic, most of the time. Unfortunately, there is not a single word for that.” Endemic or not, flu might still represent our best benchmark for what post-pandemic COVID will look like. Yes, okay, it remains true: COVID is not the flu, especially not while the pandemic’s still raging, so many people around the world lack solid immunity to the new coronavirus, and variants burst out at blistering speeds. In the past two years, COVID has already killed more people than any flu pandemic we have on record. But the comparison becomes less fraught when we project a lot further—a lot further—into the future. Flu, fundamentally, is another respiratory virus that’s enmeshed itself quite messily into our population. Which makes it, “with caveats, an excellent model” for what might happen next, Martin told us. Such familiarity might feel comforting, because flu has come to seem pretty normal to us—most people can visualize, maybe even shrug off, its threat. We name a season in honor of the flu; we design drugs and vaccines to battle it. In most of the world, we expect flu infections to intensify in the winter, then trail off again. We expect the viruses to batter older and immunocompromised people at higher rates. We expect our flu shots to slash the risk of hospitalization but allow for less severe infections, which are especially apt to spread among school-age kids. We know flu viruses can shape-shift enough while brewing in human or animal hosts to bamboozle even experienced immune systems, and that several of those strains and subtypes can trouble us with some regularity. We live with multiple post-pandemic flus, among them a muted descendant of the virus that caused the deadly 1918 pandemic. We can’t know what COVID’s future is, but flu offers concreteness where everything else feels like mush. Then again, SARS-CoV-2 is nothing if not a maverick, and it may warp the already disorganized template that flu viruses offer. Like flu shots, COVID shots seem to provide pretty stalwart protection against severe disease, and are arguably much more adept at this job; immunized people infected with the virus are swifter at subduing and purging it than the uninoculated. But the immunity we raise against low-level infections of both flavors has proved to be far more fickle, and needs to be somewhat frequently topped off. Both types of viruses are also pretty ace at splintering themselves into new and sometimes unrecognizable forms. These complementary trends—forgetful bodies, fast-changing viruses—push us to dose against the flu every fall. We could very well need yearly shots for this coronavirus too. Or not. We could still hit the point where a fourth or fifth dose of an mRNA shot, or the introduction of a next-generation COVID vaccine, will lock our anti-infection defenses on high. (But don’t count on it: That threshold of protection is very difficult for our bodies to maintain.) Vaccination frequency will also depend on whether we’re satisfied with preventing severe disease and death or aim to stamp out as many infections as possible—a higher bar than we’ve set, so far, in our anti-flu efforts. [Read: Will Omicron leave most of us immune?] How fast and how drastically the coronavirus rejiggers its genome also matters. Flu viruses and coronaviruses are different enough that they can’t be expected to engineer their evolution in an identical way. SARS-CoV-2 has already lobbed several very successful variants at us: first Alpha, then Delta, and now Omicron. The next globe-trotting variant could be a descendant of any of these, or none of them; it could be more virulent, or less. Like Omicron, it will probably be able to sidestep several of our immune defenses, and just how much slipperiness this virus is capable of is “the big open question,” Katia Koelle, an evolutionary virologist at Emory, told us. Maybe the virus is already starting to exhaust its flexibility. Or perhaps the pace at which the coronavirus alters itself will eventually slow as it runs out of super-hospitable hosts, as our colleague Sarah Zhang has reported. And SARS-CoV-2 could still break the bounds of seasonality, and become a near-year-round threat in some parts of the world, or all of it, which would complicate how and when we vaccinate. “I feel convinced that we’re going to have a winter season of it every year,” Martin told us. “But what’s going to happen outside of winter is the big question—are we going to have summer surges?” All of these factors—human immunity, virus mutability, and how and when host and pathogen interact—will shape our experience of COVID as a disease. We still don’t know what future COVID will be like. During the pandemic, SARS-CoV-2 has packed a far bigger wallop than the garden-variety flu, prompting more hospitalizations, as well as a bevy of chronic disease. This gap in severity might lessen as population immunity to the coronavirus continues to build through reinfections and revaccinations, but maybe not. SARS-CoV-2 also seems to spread faster than flu viruses, so far. If that pattern holds, that trait, combined with a decent bit of immune-slipperiness, could mean more COVID than flu overall—both on population and individual scales. The transition between pandemic and post-pandemic also can’t be expected to happen in an instant. We may not know what future COVID looks like until we get there. Given everything we still don’t understand, “like the flu” could actually be an underestimate of the twists and turns ahead. Even if COVID somehow perfectly pantomimes the flu, that should not come as a relief. “What we’re basically saying is we’re accepting another disease that kills 20,000 to 60,000 people a year,” Grad, of Harvard, said. That’s on top of the many, many other microbes that may pile into our airways during the chilly winter months—respiratory syncytial virus, rhinovirus, other coronaviruses, and a glut of different bacteria, just to name a few. The health-care system already struggles to shoulder this load during the winter, Bill Hanage, an epidemiologist at Harvard, told us. Increasing it “would not be a trivial outcome.” Yet we’re not at the mercy of the coronavirus’s whims. The post-pandemic period is an armistice between pathogen and host, and that means both parties get to dictate its terms. “You can have endemicity and have a lot of infections, or you can have endemicity and have very few infections,” Karan, of Stanford, told us. “What we do is what determines the difference between those two things.” That, in turn, reflects “how much we care” about a given disease, Brandon Ogbunu, an infectious-disease modeler at Yale, told us. [Read: America is not ready for Omicron] Endemic diseases, then, are the shades of suffering we’ve accepted as inevitable, no longer worth haggling down. The term is a resignation to the burden we’re left with. It can reflect unspoken values about whom that disease is affecting, and where, and the value we place on certain people’s well-being. Diseases such as malaria, HIV, and tuberculosis, which concentrate in less wealthy parts of the world, carry pandemic-caliber disease and death rates. And yet, they are commonly called endemic. COVID could follow suit. Already, rich, Western countries have enjoyed plentiful access to vaccines and treatments. They’ll inevitably find themselves best equipped to declare the crisis over first. But that risks concentrating COVID in the parts of the world least able to fend it off. Claiming endemicity can be a way of shifting disease to the vulnerable, and declaring these inequities tolerable. The enormous range contained by the endemic umbrella also showcases how human intervention can affect a disease’s impact. We can usher in endemicity (or something like it) by hastening a pandemic’s end. We can reduce endemicity’s boil to a simmer, or entirely ice it out. The level at which a disease first lands doesn’t have to be where it stays. We managed to eradicate smallpox, a once-endemic disease. Polio is in retreat as well, though the COVID pandemic has set many efforts back. Measles, formerly endemic to the United States, now causes only very infrequent outbreaks among Americans, though it is still found in many places abroad. Even malaria, though still a long way off from eradication, has become more manageable than it was before, thanks to dedicated prevention and management campaigns that have equipped at-risk populations with better access to vaccines, treatments, and mosquito control. The World Health Organization has declared its aim to slash malaria cases by at least 90 percent by 2030. [Read: The coronavirus will surprise us again] Our window to permanently purge SARS-CoV-2 from the planet has already slammed shut; it’s too widespread, and too many animal species can catch it, and our vaccines are imperfect shields against it. We probably won’t ever eradicate endem-esque influenza either, for very similar reasons, Lakdawala, of the University of Pittsburgh, said. But between what we’re dealing with now and total extinction, there’s a lot of room to “reduce flu’s burden considerably,” she told us. For a while, we inadvertently did: The viruses that cause it all but vanished during our first full pandemic winter, thanks to the masks, school closures, and physical distancing so many people took on to curb the coronavirus’s spread. Preserving just a few of the least disruptive infection-control strategies post-pandemic, even partially, could greatly reduce the flu’s annual toll. COVID’s march toward maybe-endemicity is an opportunity to “reflect on how many different diseases are out there that are preventable,” Grad said. Using the term endemic imposes a false sense of certainty on a fundamentally uncertain situation. “Everybody wants it to be simplified, but there is so much that we don’t understand yet,” Lakdawala told us. “We’re trying to cram it all into one word, and one word doesn’t cut it.” When we fail to consider the many possibilities that lie ahead—when we treat endemicity as unitary—the term becomes fatalistic. To say that the pandemic will give way to endemicity is to suggest a single end point; saying that SARS-CoV-2 will become endemic suggests that what comes next is up to the pathogen alone. But the post-pandemic phase will be shaped by the choices and actions we make. If our future with it is a truce we strike with the virus, it’s one that we can renegotiate, over and over again. from https://ift.tt/IHdSyaMF8 Check out http://natthash.tumblr.com |
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