The FDA and CDC have cleared the way for Americans older than 50 to get a second booster shot—but they don’t quite suggest that everyone in that age group should do so. Like masking and many other pandemic-control measures, a fourth dose (or third, for the J&Jers in the back) is now a matter of personal judgment, even as another wave of COVID cases seems poised to break. That leaves millions of Americans and their doctors to perform their own risk-benefit analysis. Or perhaps it’s just a risk analysis. The upsides of a fourth shot are indeed uncertain: The best we can say right now is that its protective effects are probably modest and temporary (with greater benefits for older people). But a modest, temporary boost is still better than nothing—so why not go ahead and get one, just in case? What, if any, risks would that actually entail? The potential downsides of an extra boost have so far been described in rather vague, confusing terms. A New York Times article published Tuesday, “Should You Get Another Booster?,” warned that repeated boosting “offers diminishing results.” (Again: Sounds better than nothing!) The article also said that getting too many original-vaccine doses could make your body less responsive to an improved formula, and that it might be worse for your longer-term immunity than waiting. Céline Gounder, a former member of President Joe Biden’s COVID transition team, pointed out on Twitter yesterday that repeated boosting could pose certain “psychological risks,” including “vaccine fatigue and skepticism”—but these are more relevant to public-health officials than individual Americans seeking shots. For those seeking clarity, here’s what we know for sure. A second round of boosters will come with two cons: They’ll cause side effects such as fever and body aches, probably at about the same level as side effects from a first booster, and they’ll be expensive for uninsured Americans, thanks to the government’s rejecting billions in COVID spending this month. Beyond that, the risks are only theoretical. “There’s no good data in humans yet for SARS-CoV-2 that boosting too frequently is going to cause damage to the system,” John Wherry, an immunologist at the University of Pennsylvania, told me. A couple of potential drawbacks can be ruled out right away. According to one idea, too many boosters could lead to something called “immune exhaustion,” in which a person’s relevant T cells, after trying to fight off an intruder for years on end, begin to wear down. They “become literally exhausted; they are no longer functional,” Akiko Iwasaki, an immunologist at Yale, told me. This can affect people with chronic infections such as HIV, or even tumors. But vaccines involve limited, not chronic, exposure to the coronavirus’s spike protein, and there’s no evidence that boosters spaced four months apart would exhaust anyone’s immune system, Iwasaki said—although “if you’re giving it every week, that’s a different story.” Another virtually moot risk is one floated in the Times: that repeated exposure to a vaccine designed around the original SARS-CoV-2 virus could train a person’s immune system (through a process called imprinting) so narrowly that it won’t recognize new variants. Such an effect is theoretically possible, but not supported by evidence and not worth worrying about at this point, Marion Pepper, an immunologist at the University of Washington, told me. Getting an unnecessary shot could, in theory, put you at an immunological disadvantage in another way, by interfering with your immune response to a previous COVID shot or infection. One recent study, set to be published in Cell in April, found that people who received three shots saw their antibody levels rise by a factor of up to 100. But among people who had also gotten COVID—that is, those for whom the booster represented a fourth exposure, rather than a third—the increase was much smaller. That’s an example of the “diminishing returns” problem, which wouldn’t really matter if you cared only about your antibody levels. (A lot plus a little is still more than a lot.) But Wherry, who led the Cell study, told me that the smaller increase might have knock-on effects in other parts of the immune system, and end up limiting the B cells that will react to the virus the next time you encounter it. Here’s how that works: When you get a booster shot or become sick with COVID after being vaccinated, some of your B cells will enter a structure in the lymphoid tissue called a germinal center, a sort of training camp that produces other, more diverse B cells that can respond to all sorts of invaders. If you leave those training camps alone for long enough, they’ll also produce long-lived plasma cells, which hang out in your bone marrow and manufacture antibodies all the time. But an extra booster shot could interrupt that process, Pepper told me, leaving you without the full, long-term benefit of those plasma cells. All of this means that the longer you wait between shots, the more durable the protection you get. In animals, Wherry said, the benefits of waiting start to plateau after about six months, but in humans, the optimal delay isn’t known. Pepper doesn’t think this drawback would come into play for those who got their third shot at least four months ago, as the CDC recommends. “I don’t think getting a booster is going to disrupt anything,” she said. She also recommended that people wait at least four months after their most recent infection for the same reason. But if you get two boosters within, say, a month, Pepper suspects that you’d end up with less protection in the long run than if you’d gotten only one. Wherry is more inclined to see a possible trade-off, albeit a small and uncertain one. Even if it’s been at least four months since your last booster or infection, choosing whether to get a shot could mean balancing some short-term protection against infection (largely conferred by antibodies) with some long-term protection against severe disease and death (the domain of B and T cells), he told me. Wherry said that older people should give more weight to the former, because as we age, our B- and T-cell responses tend to slow down. Still, everyone should make that decision with their doctor, taking their own health into account. “A 67-year-old marathon runner with no comorbidities, no health issues, is going to be a very different scenario than a 72-year-old lymphoma patient on immune-modifying drugs.” What about the risk of getting a booster now, and therefore missing out on the full effects of some new and better COVID vaccine in the next four months? For now, this doesn’t seem like a significant concern. New vaccines that have been tailored to the altered spike proteins of the Omicron variant so far don’t appear to work any better than the original formulas. And any new vaccine based on something other than the spike protein won’t be affected by an encounter with our existing shots, Wherry said. Yale’s Iwasaki, who works on mucosal vaccines, said that many designs might even be made stronger by a recent vaccination or infection. If we do get a truly unfamiliar variant and need a truly new vaccine to combat it, producing and distributing one would probably take more than four months anyway. from https://ift.tt/cH6alC9 Check out http://natthash.tumblr.com
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Last Friday, Lakshmi Ganapathi’s son turned 5, and finally became eligible for his first Pfizer COVID shot. Ganapathi’s family had been anticipating that moment for more than a year, yet as of late, she can’t help but feel the slightest bit deflated. At first, the COVID vaccines’ trickle down the age brackets felt worth the wait because the shots were doing such a stellar job at blocking symptoms. The clinical trials kept delivering knockout results: 94 percent efficacy, 95 percent efficacy, 100 percent efficacy, 91 percent efficacy—a near-perfect performance in every tested group from adults to elementary-school-age kids. Then Omicron swept in, slipping around the vaccines’ shields. Researchers studying Pfizer’s vaccine, the only shot available for American kids, began to report drops in protection, especially in children under 12, who receive a lower dose and haven’t yet been told to boost. Moderna, which reportedly plans to seek FDA clearance for its own kid-size shot in mid-April, has turned up lackluster stats too: In clinical trials, the vaccine blocked symptomatic illness just 40 percent of the time, thanks again in part to Omicron’s antibody-dodging ways. After all the anticipation, Ganapathi, a pediatric-infectious-disease specialist at Boston Children’s Hospital, still wants what any parent does—the best option possible for their child—which is why her son got his first dose this morning. But that hope suddenly feels a little hard to square with such anticlimactic data. “If he’s going to face COVID,” she told me, “I want to set him up to be as prepared as he can be.” [Read: America is about to test how long ‘normal’ can hold] An infant-and-toddler COVID vaccine, perhaps even two, could debut by summer’s start, if the FDA and the CDC give their official nods. But those long-awaited shots may not be met with much fanfare. “If this were January, I’d be like, Oh my god, get me whatever,” says Stephanie Langel, an immunologist at Duke University, whose son will turn 2 in July. Now that cases have come down, and Omicron has all but guaranteed that our original-recipe shots won’t deliver the same perks they once did, the decisions are tougher for everyone involved. The other COVID vaccines in our roster easily cleared the thresholds that had been set for success. In this last inoculation stretch, the tiniest doses on the table will push parents and federal regulators to grapple, in ways they haven’t before, with what makes a COVID vaccine good enough. The path to regulatory clearance for kids’ COVID vaccines has, by necessity, looked different from the one for adults. When our shots were untested, it made sense to inject huge numbers of adults and wait to see who fell ill. But throughout the pandemic, kids haven’t gotten sick as seriously or frequently as adults. Chasing efficacy data for them would have required “a very long, very large study,” says Ofer Levy, the director of the precision-vaccines program at Boston Children’s Hospital, who also sits on a committee that advises the FDA on COVID vaccines. Instead, the FDA let vaccine makers opt for a common alternative called immunobridging, in which researchers identify a group of people in whom vaccines are working very well (say, healthy adults), figure out what immune responses (such as antibody levels) are typical to them, then try to coax the same results out of another population (kids). [Read: What actually changed for little kids’ vaccines?] The process is trickier than it might at first sound. The first and foremost consideration for any kids’ immunization has to be safety, experts told me. The more vaccine in each shot, the more side effects it might cause. So companies tend to go after “the smallest dose possible that will still be as effective as possible,” Buddy Creech, a pediatric-infectious-disease specialist at Vanderbilt University Medical Center, where he’s running one of Moderna’s pediatric vaccine trials, told me in January. After tinkering with different amounts of mRNA in early-stage trials, Pfizer sliced its doses in rough thirds, offering 30 micrograms to individuals 12 and older, 10 micrograms to 5-to-11-year-olds, and three micrograms to kids under 5. Moderna, meanwhile, cut in halves, giving 100 micrograms to everyone 12 and up, 50 micrograms to 6-to-11-year-olds, and 25 micrograms to children under 6. Each company then ran much larger trials, to see if the antibody data—the information they’d need to present to the FDA—would hold, and to keep monitoring for bad side effects. At this juncture, both companies say they’re meeting safety criteria. Based on the information the firms have made public, “the rates of significant fevers are about on par with other vaccines” we give to kids, which is encouraging, Creech told me. (In Pfizer’s trial, researchers marked fevers as “severe” when they crested above 102 degrees Fahrenheit; in the Moderna trial, a few kids had fevers above 104 degrees.) But in the antibody realm, two doses of Pfizer’s three-microgram dose, which is still in trials, fell short in the 2-to-4-year-old group, prompting the company to add a third shot for all kids younger than 5. Moderna’s two 25-microgram doses for the under-6 crowd, however, did eke out enough antibodies to go toe-to-toe with adults. If antibodies were the end-all-be-all, Moderna’s infant-and-toddler vaccine might, in theory, be a total shoo-in. But alas, they are not. When efficacy numbers are available, they tend to trump all else—and during Moderna’s trials, enough infections, many of them caused by Omicron, swept through the kids enrolled in the study that the company suddenly had sufficient data to calculate the vaccine’s bigger-picture performance. And there, some might argue, is where the shot started to fall short. Back in June 2020, when COVID vaccines were still early in the pipeline, the FDA put its foot down: Successful COVID-19 shots, the agency said at the time, would need to “prevent disease or decrease its severity in at least 50 percent of people who are vaccinated.” The results in adult populations blew straight past that benchmark; now the data from kids seems like they may barely be grasping at it. (The FDA did not respond to my questions about whether that 50 percent efficacy standard applied to kids, who were meant to get by with immunobridging. A spokesperson said only that “we remain committed to conducting a timely and thorough evaluation of the available data and information on the use of COVID-19 vaccines in the youngest children.”) The numbers for infants and toddlers haven’t been … the best. “No one would argue that 40 percent protection is great,” Chandy John, a pediatrician at Indiana University, told me. Here, it’s tempting to blame the dose: Maybe just a little more mRNA would have nudged Moderna’s numbers right over the edge. Similar concerns have been raised about Pfizer’s vaccine, which in a recent study didn’t protect 5-to-11-year-old kids from infection or disease for as long as expected, even though the 10-microgram dose they received had met its immunobridging benchmark in clinical trials. (Another study released shortly after, however, found more encouraging results.) Perhaps immunobridging actually led each company to slightly undershoot their dose size. [Read: Why are we microdosing vaccines for kids?] At this point, such questions are fair game. Immunobridging can be a bigger gamble when researchers haven’t yet identified a specific antibody level above which people can generally be considered well shielded from disease. If such a threshold exists for SARS-CoV-2, it may not translate perfectly among age groups, Levy points out. Perhaps kids actually need more antibodies than adults do to hit the same efficacy benchmarks. Immunobridging was the most practical option for getting vaccines to kids swiftly, Levy said. But “it may not tell the whole story.” That said, Levy and the other experts I spoke with tend to more strongly implicate another culprit: the virus itself. Realistically, with kids’ trials running two doses of original-recipe vaccine during the Omicron era, the shots were probably never going to generate the knockout numbers that the adult shots did. There are now too many viral mutations in the picture; Moderna’s ballpark efficacy of 40 percent is “kind of what we would expect,” especially when transmission rates were as high as they were this past winter, Langel told me. It’s better, even, than the effectiveness of flu shots in years with vaccine-strain mismatches. In a press briefing last week, Anthony Fauci shared similar sentiments. Moderna’s new stats are “quite comparable,” he said, to what scientists have been seeing in other populations as of late. In adults, two mRNA doses just haven’t been as potent as three. All things considered, Fauci said, “the data looks pretty good.” It’s very possible that, were we to rerun studies in adults now, against Omicron, two full-size doses would struggle to get to 50 percent efficacy too. [Read: We’re zeroing in on the ‘holy grail’ of COVID-19 immunity] Forty-ish percent efficacy against symptomatic illness may be about as good as we can get with two doses of mRNA vaccines without sacrificing safety. Maybe a bigger dose for kids would budge the numbers up, but “we have to consider the downside in terms of adverse events,” says Kathryn Edwards, a pediatrician and vaccine expert at Vanderbilt University. (Edwards is a former adviser to the FDA on vaccines, and sits on a safety-monitoring board for Pfizer’s shot.) Fevers in the littlest kids are an especially big concern because they can cause (self-resolving) seizures, so, even if rare, they could pose a major hurdle to clearing a new shot for use. Myocarditis, too, could be a problem: Moderna’s vaccine, which includes more mRNA in each injection, appears to have produced slightly higher rates of the rare heart-inflammation issue than Pfizer’s in young men. (No cases of myocarditis were picked up in Moderna’s under-6 trials.) “I don’t know that we need higher doses,” Creech told me. Rather, he and others think success will come down to the number of doses and their pacing. Vaccine makers could add a third or fourth injection or space the shots further apart, or both. They could even include an extra immune-system-tickling ingredient to rev the body’s defenses further. Some experts said they were already thinking about 40-ish percent as a sort of interim efficacy; third shots for kids now feel more or less inevitable. Ahead of its request for emergency use authorization for its under-6-shot, Moderna is already considering asking the FDA to okay a pediatric booster somewhere down the line, Kate Cronin, the company’s chief brand officer, told me in an email. At this point, Pfizer’s under-5 vaccine will almost certainly be a three-doser, at least to start, and the company is “evaluating a third dose” in 5-to-11-year-olds as a booster, says Jerica Pitts, a company spokesperson. Just a few weeks ago, Sallie Permar, a vaccine expert, an immunologist, and the pediatrician in chief at New York–Presbyterian Hospital and Weill Cornell Medicine, told me that she hoped a COVID vaccine for kids would hit that 50 percent efficacy mark before getting the FDA’s emergency authorization. Still, if Moderna’s 40 percent efficacy estimate, which is still tentative, holds, “I’m comfortable with that,” she said. Maybe if kids were still dealing with the original version of the coronavirus, efficacy numbers would match what previous trials had produced. But OG SARS-CoV-2 is long gone. Vaccination is a series of judgment calls by institutions and individuals alike: authorizing a new shot, recommending a booster, deciding to sign up for any dose at all. Data can help inform these decisions, but these choices ultimately depend, in part, on the goal they’re meant to further, which might be shielding against severe disease alone—or blocking as many infections as possible. Policies in the U.S. still aren’t clear about what the ultimate aim of COVID vaccination is. And for kids, fewer of whom end up hospitalized with the virus, the possible gains of vaccination are that much murkier. Such a small number of little kids in the clinical trials ended up seriously sick, in fact, that neither Moderna nor Pifzer has yet produced reliable efficacy numbers against severe disease. But children do fall seriously ill with COVID-19. Since the pandemic’s start, the virus has killed more than a thousand kids; thousands more have developed a serious inflammatory condition called MIS-C. The Omicron wave hospitalized the youngest Americans—the least vaccinated Americans—at rates higher than in any other surge. Any chance to avoid those outcomes is a welcome one. Which is where vaccines should shine. In all other age groups, COVID vaccines have been best at guarding people from the most serious forms of disease, and “there’s no reason that wouldn’t hold true” in the youngest among us as well, says Ibukun Kalu, a pediatric-infectious-disease specialist at Duke. Here, again, experts have to lean on comparisons between adults and kids. But the stubbornness of our shots’ strongholds against severe disease should transcend even the hiccups of cross-age immunobridging, even the wiliness of Omicron; that’s fundamental to how the immune system should work. Even in a downer of a scenario, in which efficacy against serious outcomes came out to exactly 40 percent as well, that “would spare a lot of kids being hospitalized,” John, of Indiana University, told me. If the fundamental question facing the FDA is what performance floor it will accept for kids’ COVID vaccines, Permar and other pediatricians think that threshold must ensure that the shots at least stave off the most serious forms of disease. Moderna seems to be banking on this a bit. The antibody levels the company observed in late-stage trials “should provide protection against important and serious disease,” Cronin told me. [Read: Why a three-dose vaccine for young kids might actually work out] Creech also points to a benefit of vaccines that efficacy numbers alone don’t capture. The umbrella of “symptomatic illness” can cover a light bout of the sniffles, a critical case of COVID-19 that’s bad enough to land someone in the ICU or even kill them, and anything in between. But when post-vaccination infections occur, they’re less serious on average, effectively shifting people toward the gentler end of that spectrum of severity. As a parent, Creech told me, he still considers it a huge deal to make a kid’s course of illness less lengthy and cumbersome, even if the shots can’t block symptomatic disease entirely. (Vaccines may also help curb long COVID, which affects children of all ages.) Every year, experts recommend flu shots even though those vaccines, too, tend to top out at about 60 percent effectiveness against illness. These arguments won’t necessarily sway the FDA, especially if case rates stay low. The United States has eased pandemic precautions almost entirely; the FDA’s coming deliberations could reflect that attitude, and mire pediatric shots in dillydallying muck. Vaccines that are “good enough” to greenlight when the virus is running roughshod over the country may not pass muster during a quieter period, when the costs of not vaccinating shrink. And without actual efficacy numbers against severe disease, that bit of the risk-benefit equation will be very tough to weigh. Moderna, if it comes before the FDA and CDC first, may even end up getting a conditional okay—recommended only for high-risk kids, for example. At an extreme, if the FDA is dissatisfied with Moderna’s final stats, the agency could ask the company to add a third dose before it gets the official green light. The FDA’s and CDC’s finish lines won’t be the last for the shots to cross, either. For the youngest among us, the final arbiters of which shots are and are not worth their salt are America’s parents—who so far have been rather reluctant to queue their kids up for injections. As the COVID vaccines have shuffled down the age brackets, uptake has declined; with so many people now eager to put the pandemic behind them, these smallest shots may be our least welcome yet. In many ways, the fate of the next crop of pediatric shots may, more than anything else, mirror Americans’ current sense of the crisis. For now, the future feels foggy—which is exactly why Ganapathi, of Boston Children’s Hospital, was so eager to clinch protection for her 5-year-old son. (Her younger son will turn 2 in July, and will hopefully soon follow his brother into an inoculation line.) The next surge, she told me, is a matter of “when, not if.” She briefly considered holding off on giving her son Pfizer, so they could wait for Moderna’s higher-dose, longer-interval under-6 shot to come through. But of the two brands, only Pfizer was available now. “Do I want a more efficacious vaccine for symptomatic disease? The answer is yes,” she told me. “But we can only deal with what we have on hand, and make the best of it.” from https://ift.tt/RGIx0ZS Check out http://natthash.tumblr.com There is no good time for a war, but there are certainly bad ones. Even as Russia’s full-scale invasion of Ukraine enters its second month and the civilian death toll nears 1,000, the pandemic churns on. In Europe and parts of Asia, cases have shot up in recent weeks. A new and seemingly more transmissible variant has emerged, as we always knew it eventually would. The World Health Organization has expressed worry that the war could not only supercharge transmission within the region but worsen the pandemic worldwide. With its 35 percent vaccination rate, Ukraine was especially vulnerable even before the invasion forced 10 million people from their homes. That much of the population must now cram together in packed train cars and basement bomb shelters will not help matters. For many in Ukraine, though, such concerns are not top of mind. “Their priority is just to flee and survive,” Paul Spiegel, the director of the Center for Humanitarian Health at Johns Hopkins University, told me. In his research, Spiegel has found a strong connection between conflicts and epidemics. But assessing the interplay between disease and violence in Ukraine is difficult right now: After the invasion, reporting on case counts slowed to a trickle. To get a better sense of how the pandemic is affecting the war and vice versa, I spoke with Spiegel, who is currently in Poland as part of a WHO team helping to receive the flow of refugees. Our conversation has been edited for length and clarity. Jacob Stern: How does the situation look on the ground? Paul Spiegel: I’m currently with the WHO on a surge team based in Poland. We’re establishing a refugee health hub. Then there’s a whole other group working on Ukraine. And I want to distinguish that, because what we’re seeing right now in Ukraine is the destruction of cities and supply chains, and so it would not be surprising for an epidemic of some sort to occur there. On top of that, this is happening in the middle of a pandemic. Having people live underground for days at a time in bunkers, having people so close together, likely less concerned about some of the masking and social distancing, given that their priority is just to flee and survive—it would not be surprising if something like COVID were exacerbated. The other thing that I think is really important in any situation is history. What is the childhood immunization rate for measles, polio, diphtheria in Ukraine compared to the surrounding countries? We have to think about COVID, and that’s very concerning. We have to think about some of the vaccine-preventable diseases, and then we have to think about water- and sanitation-borne diseases, particularly diarrhea, given the destruction of what’s happening in Ukraine. Stern: You distinguished right at the beginning there between what’s going on in Ukraine and what’s going on with the refugees. How are these dynamics playing out among the refugees? Spiegel: So far, at least from what we’re seeing, we’re not yet aware of an increase in epidemics with the refugee movement. It’s often characterized--really stigmatized and stereotyped—as “refugees spread diseases.” And it’s not the refugees. It depends on what the prevalence may have been where they’re coming from. But if there is spread, it’s because of the conditions and the vulnerabilities and risk factors that they’re exposed to. I’ve rarely in my life seen such an outpouring of generosity among the surrounding countries. You have millions of people moving in an extremely short period of time, but in Europe right now, there are no camps. There are reception centers, but people are accepting them from all over Europe, and so they’re not going to be put into this position of very high-density camplike settings that we’ve seen in other situations, which are problematic for epidemics because of the proximity. So I’m hopeful at least that given the current situation, the chances for outbreaks is reduced. Stern: That’s an interesting connection you’re making between the tolerance and welcomingness of these countries and how that, aside from being the right thing to do, can actually benefit public health. Spiegel: Right now I’m in Kraków, and there are at least a couple hundred thousand refugees in Kraków, but you can’t really see that. Amazingly, even in my hotel there are Ukrainian refugees. It’s extraordinary to see. They are dispersed and they are being welcomed into a hospitable and sanitized environment. Stern: Either in Ukraine or among the refugees, what are some of the greatest health challenges your team is facing right now? Spiegel: In Ukraine itself, with the actual bombing and the conflict itself, we’re seeing a lot of trauma cases, and the WHO and other organizations have been sending in emergency medical teams to help. With the refugees, for the most part we’re not seeing many conflict-related wounds from people thus far, at least with people crossing over. What we are seeing is a challenge to continuity-of-care of diseases, particularly serious diseases and/or diseases that can spread, such as HIV and TB. We need to make sure that those people who were receiving treatment are going to continue to be able to receive treatment. The WHO and many other groups have been working in Ukraine to refer patients, and so there’s been over 350, maybe 400, pediatric cancer patients that have been referred from Ukraine to Poland and elsewhere. This is extraordinary to see, and the resources here are so much more than we’re used to in other places. However, what we’ve seen in other countries is that over time, there may be concerns, because even in a country that’s used to a certain amount of treating dialysis or cancer patients, or neonatal intensive-care units, when suddenly you have a million more people, it still may be a strain or a choke point. Stern: One kind of influx of cases that you didn’t mention there is COVID cases. Is that because that hasn’t been the primary issue, or is that also something that these health systems are dealing with right now? Spiegel: The health systems at the moment are not yet overwhelmed. When the invasion occurred, Ukraine and the rest of the surrounding countries actually had had their Omicron peak and cases were falling, but certainly there will be a number of people that are going to be hospitalized, there’s no question. But at this point, from what I’ve been hearing, there’s not an overwhelming of the hospitals. Unfortunately, it’s a stay-tuned moment. Stern: As we see cases start to tick up across Europe, given the lack of testing data coming out of Ukraine right now, what metrics or trends will you be looking at to gauge how and to what extent this conflict is affecting pandemic dynamics? Spiegel: It’s going to be hard because of what’s happening in terms of access and danger. But one of the key areas, when you have either poor data or you have a new variant, is going to be looking more at the hospitalizations and the ICU beds. Right now we’re seeing a surge in some parts of Europe, and therefore we might see an increase in certain countries where the Ukrainians are now, and there’s no evidence whatsoever that that’s occurring because of the Ukrainian refugees. Stern: Stepping back for a minute, the big question that I think people are asking here is really: How bad is this? And that question is really two different questions. The first is: How bad is the pandemic for the situation in Ukraine? The second is: How bad is the situation in Ukraine for the global state of the pandemic? Spiegel: Certainly it would not be unreasonable to think that transmission would increase when people are fleeing and they’re in bunkers, they’re in trains, they’re not necessarily using PPE and masks. So it wouldn’t be surprising, but again, it depends where we are in the epidemic, how many people have actually been infected, the vaccination rate, and where this new subvariant of Omicron is. I would not think that this crisis will change the trajectory of the pandemic given the levels of the previous Omicron surge, but it is always difficult to predict. I am more concerned about China/Hong Kong due to their previous strategy of containment, the large number of people who could get infected, and the possibility of another variant. The answer is: It’s hard to tell what happens next, but there’s probably no positive side you could see. from https://ift.tt/uPmOjd3 Check out http://natthash.tumblr.com At this very moment, the United States, as a whole, remains in its legit pandemic lull. Coronavirus case counts and hospitalizations are lower than they’ve been since last summer. There’s now a nice, chonky gap between us and January’s Omicron peak. And yet. Outbreaks have erupted across Asia. Massive swaths of Europe, including the United Kingdom—America’s best pandemic bellwether for much of 2021—are firmly in the grip of a more transmissible Omicron subvariant called BA.2 that’s been simmering stateside for months. Already, scattered spots throughout the U.S. look a shade foreboding. Several states’ wastewater-surveillance sites are witnessing a rise in viral particles, which, in previous waves, has preceded increases in documented infections by several days. Many states’ case rates have now hit a plateau, and a handful are even beginning a slow march back up. The other COVID shoe seems poised to drop in the U.S. at some point, perhaps quite soon. When it does, it won’t be pretty. “With policies, with supply, with vaccination rates, we are not prepared,” says Julia Raifman, a COVID-policy expert at Boston University. After two years of chaos, Americans do have some factors working in our favor. COVID vaccines, when delivered in multiple doses, work well against all known Omicron subvariants. The recent Omicron infections that shredded the U.S., and the smidges of immunity they left behind, might slow BA.2’s roll as well. The weather is warming, pushing more people outside. Perhaps spring will indeed bring a surge. But most of the experts I’ve spoken with think that the U.S. is unlikely to see a BA.2 peak that mirrors the magnitude of Omicron-classic’s (BA.1’s) record-breaking winter crush. [Read: Another COVID wave is looming] Then again, better than Omicron’s January zenith isn’t a high bar to clear. Even in a best-ish-case scenario, in which the country’s average curve remains somewhat subdued, Sam Scarpino, the managing director of pathogen surveillance at the Rockefeller Foundation, told me, we’re likely due for a patchwork on more granular scales, with a mix of plateaus, ups, and downs at the state and county level. If that variability sounds like a relief, it shouldn’t: COVID can be a local crisis without being a national one, and can batter the vulnerable all the same. However it manifests, the next American surge will be a stress test of the nation’s new COVID strategy, a plan that focuses on mitigating severe disease and death, and almost nothing else. Places that follow the CDC’s lead will let infections climb, and climb, and climb, until they’ve seeded a rash of hospitalizations, with more to follow. Only then will our new guidelines say that’s enough. The Biden administration’s sights have clearly been set on minimizing disruptions to American life. The cost? By the time the government says that it’s time to act, any wave we experience will be well under way. Whatever happens next, we’re living the reality the CDC’s guidance bargained for. The country’s new COVID rules have asked us to sit tight, wait, and watch. We may soon see the country’s true tolerance for disease and death on full display. When the next glut of infections might make landfall in the U.S., and how big it might balloon, still isn’t clear. Danger brewing abroad doesn’t guarantee an American encore, as my colleague Rachel Gutman reported last week. BA.2 has been here since at least December, and though it’s now starting to overtake BA.1, especially in the northeastern United States, it hasn’t yet gained the momentum that’s been carrying it through Europe. Maybe that’s a sign that we are a bit buffered—and this afternoon, at a press briefing, CDC Director Rochelle Walensky emphasized that the administration was watching for signs of hospital stress. But plenty of warning signs are already flashing. This subvariant is fleet-footed, even more so than BA.1; it will spill into the gaps its predecessor left. Our COVID defenses are also flimsier than they’ve been in a long time. U.S. vaccination rates are still way too low, especially among the elderly, and kids under 5 remain ineligible for any shots at all. (Moderna is now making a bid for emergency use authorization for its under-6 shot, and Pfizer is expected to follow soon with data from its expanded under-5 trial, using a triple-dose series.) Much of America has freshly eschewed masking and flocked back into indoor public venues, at the same time that federal pandemic funds necessary for vaccines, treatments, and tests have dried up. On the CDC’s risk map, the state of New York, for instance, where cases have been gently moseying upward for about a week, remains awash in a uniform shade of green—denoting “low” COVID-19 community levels. Counties would need to clear 200 new cases per 100,000 people over a seven-day period to warrant a flip to the yellow tones of “medium.” At that point, the CDC would suggest that people who rub elbows with folks at high risk for severe disease might want to consider self-testing or masking indoors. There are hidden-but-tangible taxes to that approach. Take the CDC’s current stance on masks: Only when counties hit “high” COVID-19 community levels—when hospitals are starting to fill up with severe cases—does the CDC say that masks should go back on for everyone. “That’s a lot like waiting until the outer bands of the hurricane are hitting the city before you trigger an evacuation order,” Scarpino said. And even then, not everyone will listen to the agency's suggestions. [Read: The Biden administration killed America’s collective pandemic approach] Dillydallying inevitably racks up the kinds of costs we can’t recoup. Two health-policy researchers, Joshua Salomon of Stanford and Alyssa Bilinski of Brown, recently ran an analysis of the CDC’s new guidance and found that waiting for the CDC’s “high” level to turn on additional protections could lock the country into at least 1,000 Americans dying each day from COVID. “We’ve embarked on this experiment to see how far we can push two extremes: how low we can push our level of response, and how high we can push our tolerance for avoidable illness and death,” Salomon told me. The death toll could be lower if COVID’s fatality rate decreased—if, say, vaccination rates suddenly rocketed up, or if every infected person could instantly access tests and treatments. But Salomon said those are very unsafe bets to make. As it stands, “the CDC policy is to not take action to reduce spread until there is a high level of death,” Raifman told me. And that’s to say nothing about the long-COVID cases and other serious impacts that would follow as well. [Read: The pandemic after the pandemic] The agency’s plan is simply too slow and too reactive, antithetical to how public health operates best—when it leans on proactive measures meant to prevent an undesirable future, says Maia Majumder, a computational epidemiologist at Harvard Medical School. The solution is acting earlier, though exactly how much earlier is unclear. Single infections have a way of branching into multiple ones, imperiling the vulnerable, including unvaccinated people; workers who are highly exposed to the virus; those who lack easy access to medical care; people marginalized by race or socioeconomic status; and the immunocompromised, who do not respond as well to vaccines. These communities have already borne the pandemic’s brunt; any future wave would disproportionately burden them again. I asked the CDC for its take on what’s up ahead. “We’re in a stronger place today as a nation with more tools to protect ourselves and our communities from COVID-19,” Jasmine Reed, an agency spokesperson, wrote in an email. “CDC’s COVID Community Levels and the corresponding prevention measures allow us to adapt and respond to new variants or a surge in cases.” Somehow that seems tough to square with the dwindling of funds to support further vaccinations, testing, and treatment—especially for the communities that most need to access them. The CDC’s new guidance is contingent on a capacity to react, and the assumption that supplies are free-flowing. They are not; they never have been; they will not be, unless more money comes through. Which means that we’re slated to start this next surge not just with porous shields but without the ability to patch the gaps. At the press briefing, White House officials underlined Congress’s failure to refresh pandemic funds, outlining again the consequences of the shortages that will result. Without resources to respond quickly to a more dangerous level of disease, our tolerance for infections should be quite low. “To prevent unequal outcomes, you have to prevent people from getting infected in the first palace,” says Lakshmi Ganapathi, a pediatric infectious-disease specialist at Boston Children’s Hospital, who has two unvaccinated sons under the age of 5. One option would simply be to return to masking and other measures much earlier; Jeremy Faust, an emergency physician at Brigham and Women’s Hospital in Boston, recently proposed a trigger of 50 cases per 100,000 people per week as a way to keep the risk of infection for immunocompromised people lower than 1 percent. (And that’s only if we assume effective monoclonal-antibody treatments are readily available, which they are not.) Most counties in the U.S., for the moment, remain below that benchmark. Salomon and others also propose the idea of more closely tracking how steeply cases are rising over the course of several days—a potentially good way to confirm that transmission is truly starting to deviate from the norm. But even our metrics are, at this point, kind of on the fritz. So much testing is now done at home that official case numbers are becoming “nearly impossible to interpret,” Scarpino told me. Wastewater, a test-agnostic approach championed by the CDC as an “early warning of COVID-19’s spread in communities,” could offer an alternative. And yet the agency doesn’t include this metric in its community-level guidance, in part because wastewater-surveillance sites remain sparse and unevenly distributed. Wastewater data can also be tricky to interpret when the total number of viral particles is very low. “There’s just more noise, and it’s more unstable,” says Megan Diamond, of the Rockefeller Foundation. [Read: Get ready for a wave of mixed infections] So the country is left playing chicken with case counts. That’s what worries experts such as Scarpino the most—not the danger posed by some scary new variant but the danger that we, in neglecting the holes in our pandemic-preparedness tool kit, pose to ourselves. In a sense, whether a bad BA.2 surge is nigh “doesn’t really matter,” he told me, “in terms of thinking about the things we should be doing now.” The to-do list isn’t short, and it’ll require the federal funds that remain in political limbo. The unvaccinated need first shots. The unboosted need boosters. Masks, tests, and treatments should be accessible to everyone, with the most vulnerable at the front of the line. Stocks must be filled while things are a bit calmer, Raifman told me, so that we’re not scrambling when danger’s already upon us. Then, when surges do come our way, our focus can be on collectively cocooning the vulnerable—masking when it’s clear that cases are going up, turning on remote-work options, ensuring that high-risk people have opportunities to safely shop for food, travel, and access the tools they need. Again, we don’t know when measures like these will need to flicker on. It could be next week. It might not be until fall or winter, perhaps when an even scarier variant might come to call. The ambiguity is actually the point: The best public-health infrastructure is flexible and comprehensive enough to protect both in peacetime and amid the throes of war. It is the system we lack now, and the one we need to build. It is the hardest path to take, but it is also, Ganapathi told me, “the path of least regret.” from https://ift.tt/Mh9tmej Check out http://natthash.tumblr.com COVID-19 tests were in such short supply during the winter’s Omicron surge that most infections—affecting up to three out of four Americans by some estimates—went entirely undiagnosed. Now, with abundant rapid tests and another looming wave of cases, we may soon confront a different problem: Large numbers of infections will be missed in the coming months because these tests are so widespread. America’s COVID-detection program has entered a novel phase. Thanks to the entrance of new over-the-counter diagnostic manufacturers and the federal government’s promise to send up to eight tests to every home, a COVID diagnosis is, at this point, far more likely to be obtained through self-swabbing than through lab-based PCR techniques. One of more than a dozen companies, iHealth, is producing 300 million rapid antigen devices per month, while all the country’s labs put together have maxed out at conducting just 2.5 million tests a day. Because rapid results are rarely reported to public-health agencies, that means our early-warning system may now be somewhat less sensitive than it was before. More important, these tests’ ubiquity could bring a wave of false-negative results in tandem with the next wave of illness—and thus a wave of missed opportunities for treatment. A sense that rapid tests might not be entirely reliable emerged during the Omicron outbreak, when Americans were just getting used to running their own makeshift personal laboratories. Asking millions of citizens to perform self-tests for the first time in the midst of the winter’s sudden, unprecedented viral tsunami turned out to be unintentionally cruel. Consumers sought out help from social media, where misinformation is rampant. Many people felt confusion and regret when their home devices missed cases, putting their friends and family at risk. The need to explain away these false negatives became almost existential. Experts composed tortuous Twitter threads taking readers through the developing science. People wondered whether rapid tests no longer worked against the Omicron variant. Speculation arose that additional throat sampling was needed on top of standard nasal swabbing, and media outlets gave instructions on how to do so—in open defiance of the FDA. [Read: Families are going rogue with rapid tests] The dust has now settled, and the answer as to why so many tests came up short is relatively straightforward: Many people received false-negative antigen results because this technology has always been likely to produce false negatives. Rapid tests are known to miss about 30 to 40 percent of infections compared with the gold-standard PCR method (which already isn’t perfect), even when patients are feeling sick; self-swabbing is also less accurate than professionally obtained samples. Meanwhile, multiple studies have confirmed that the current crop of rapid tests can indeed pick up the Omicron variant, and experiments with throat swabbing suggest that the technique might help a bit but isn’t a game changer. In other words, incorrect COVID-test results became more common during the Omicron surge only because COVID home testing itself became more common. Now both will be more common still. Rapid-test advocates have long emphasized the technology’s public-health potential: Despite the fact that these affordable devices miss many cases overall, they still diagnose the majority of actively infectious people (especially with repeated testing). The widespread screening of asymptomatic people has been encouraged to help keep public gatherings safe and break chains of transmission. Under this testing model, receiving an incorrect result wasn’t crucial, because that individual was unlikely to spread the coronavirus. But things are very different in 2022: The Biden administration is in the midst of rolling out a nationwide test-to-treat program, in which local pharmacies and health centers will provide on-site testing and immediate prescriptions for anyone who turns up positive. Early-treatment options for COVID—antiviral pills such as Paxlovid and Molnupiravir, infusions such as Remdesivir and monoclonal antibodies, and hopefully other options soon—promise to blunt some of the remaining risk from the virus among unvaccinated and high-risk vaccinated people. As these treatments must be started within five to seven days of symptom onset (depending on the therapy), eligibility requires the timely receipt of a positive result—and rapid tests will be essential. So what will happen when, as one Omicron-era study found, antigen tests start missing one in four patients whose symptoms have started in the past week? Repeated self-testing after a negative result is officially recommended. Still, some users are likely to feel misled after months of advocacy suggesting that rapid tests catch nearly 100 percent of “infectious” cases. The distinction between “infected” and “infectious”—that is, between those who are carrying the virus and those who are carrying enough of it to transmit the infection to others—will be lost on many lay consumers, but the former is all that matters for treatment. Vulnerable individuals who are experiencing COVID-like symptoms may worry less about whether they’re infectious than whether a regimen of Paxlovid would cut their risk of hospitalization or death by 88 percent. With stakes so high, a single negative rapid test won’t provide sufficient clarity. Even as rapid testing takes precedence, follow-up PCR samples should still be used to exclude the need for treatment. Repeating antigen tests over several days will also help. Health-care providers participating in the test-to-treat program can offer this type of guidance directly, but many people receiving negative diagnoses at home are bound to feel falsely reassured without more explicit scientific coaching. Better education on the use of rapid tests could be ramping up while case rates remain modest. The increasing availability of home testing is a boon for the public, as is the development of effective outpatient interventions for COVID. Yet the combination of these two advances is likely to produce a false-negative wave—whether in the coming weeks, from the BA.2 sub-variant, or later on, from some other future viral offshoot. If infections once again reach Omicron’s historic peak, then millions of treatable cases could be missed if only a single antigen test is taken each time. The official White House line is that Americans now have “all the tools we need to protect each other and treat COVID-19.” But to save every life that we can, the public must first know how to use these tools properly. from https://ift.tt/KjSs20Q Check out http://natthash.tumblr.com About 18 years ago, while delivering a talk at a CDC conference, Gregory Poland punked 2,000 of his fellow scientists. Ten minutes into his lecture, a member of the audience, under Poland’s instruction, raced up to the podium with a slip of paper. Poland skimmed the note and looked up, stony-faced. “Colleagues, I am unsure of what to say,” he said. “We have just been notified of a virus that’s been detected in the U.S. that will take somewhere between 10,000 and 15,000 lives this year.” The room erupted in a horrified, cinematic gasp. Poland paused, then leaned into the mic. “The name of the virus,” he declared, “is influenza.” Call it funny, call it mean, but at least call it true. Poland, a physician and vaccinologist at Mayo Clinic, had done little more than recast two facts his colleagues already knew: Flu is highly contagious and highly dangerous, a staggering burden on public health; and for years and years and years, Americans, even those trained in disease control and prevention, have almost entirely ceased to care. Vaccines capable of curbing flu’s annual toll have existed since the 1940s. Close to a century later, some 50 to 60 percent of Americans adults still do not bother with the yearly shot. The crux of the uptake shortfall “is this normalization of death,” Poland told me. He predicts this pattern will play on repeat, and at higher volume, with SARS-CoV-2—another devastating respiratory virus that’s tough to durably thwart with shots. [Read: How did this many deaths become normal?] COVID-19 is not the flu, and no one knows for sure exactly how often we’ll have to immunize ourselves against it. But it seems inevitable that someday, the entire American public will be asked to sign up for shots again—perhaps quite soon, perhaps every fall, as some vaccine makers would like. We have just one template for this: the flu shot. And expecting even similar levels of so-so uptake may be optimistic. “I’m guessing that flu-vaccine coverage is going to be a ceiling,” says Alison Buttenheim, a behavioral scientist at the University of Pennsylvania. “I just don’t think we’ll have 70 percent of U.S. adults saying, Oh, an annual COVID shot? Sure.” Immunization ennui is already playing out. Months into the COVID-booster-shot rollout, only half of Americans eligible for an additional injection have gotten one—that’s with the pandemic still raging, with more than 1,000 people dying each day in the United States alone. “We’re already losing the immediate motivator of, I’m afraid I’ll get sick and die,” says George Dehner, a flu historian at Wichita State University. If the future of COVID shots ends up mirroring the past and present of flu vaccines, we’ll have our work cut out for us. But many of the barriers we face now in trying to get people to sign up for their shots, not just once, not just twice, but likely many times over, don’t have to feel like uncharted territory. Flu vaccines offer “a lot of parallels,” says Tony Yang, a health-policy expert at George Washington University. Again, the two diseases aren’t at all identical. But efforts to vaccinate against either have enough overlap that they can inform each other. Our experience with flu shots reminds us that Americans, cultured to become immune to the notion of unnecessary death from disease, still have a chance to shift that perspective—and chase the kind of immunity that will instead spare them from it. Annual flu vaccines are both an old innovation and a new imperative. Originally developed in the 1940s, when World War II was still raging, the shots first went to the military, under orders from the surgeon general. By the end of the fall of 1945, “everyone in the U.S. Army was vaccinated,” Dehner told me. The shot was cleared for civilian use and soon became a regularly reformulated vaccine to keep pace with the viruses’ rapid mutational clip. The vaccine worked—flu deaths plummeted among those who received the shot. Still, only after the 1957 flu pandemic pummeled people who were over the age of 65, pregnant, or ill with a chronic disease did public-health officials begin actively recommending the vaccine for those groups. Another 45 years would pass before children six to 23 months old joined the list. And only in 2010 were annual flu vaccines recommended for everyone six months and up. More than a decade later, getting just half of American adults to nab the jab is “considered a good year,” Buttenheim told me. That level of uptake is paltry compared with the percentages of children who are, by the age of 2, up-to-date on their shots against chicken pox (90.2), hepatitis B (90.6), measles (90.8), and polio (92.6). But unlike those vaccines, flu shots are high maintenance, requiring refreshment through adolescence and adulthood, every single year. The annual vaccines have other factors working against them too. While they’re decently good at keeping people out of the hospital and the ICU, their protections against less-severe infections are relatively weak, topping out at about 60 percent effectiveness, and fast-fading. (They do far worse than that when there’s a mismatch between the vaccine’s contents and the circulating strain du jour.) “A lot of times, you still end up getting the flu even if you’ve had the vaccine”—which has given the shots a pretty bad rap, says Seema Mohapatra, a health-law expert at Southern Methodist University. [Read: How to time your second booster] And when people, especially young, healthy adults, do end up with the flu, many of them simply don’t care. The worst flu outbreak in recorded history, in 1918, carried a mortality rate of about 2.5 percent. That was devastating, given how many people were infected. But instead people have, in the decades since, internalized that most did not die. If vaccine appeal tends to toggle by three metrics—the convenience of staying current on shots, the inoculation’s effectiveness, and the pathogen’s perceived threat—flu jabs aren’t much of a contender in any arena. “There are a lot of people who are very, very pro-vaccine, except for flu,” Rupali Limaye, a vaccine-behavior expert at Johns Hopkins University, told me. They just don’t think the juice is worth the annual squeeze. COVID vaccines have already begun to follow flu shots’ problematic patterns. Set up to believe that the vaccines would instantly obliterate all infections, many people now consider the shots’ performance underwhelming, says Limaye, who has spoken with about 3,000 vaccine-hesitant people in the past two years. And since the start of the coronavirus crisis, it’s been tough to shake the false narrative in some circles that essentially “everyone” who gets the virus “seems to be just fine,” she said. In America, states with low annual flu-shot-uptake rates are near the bottom of the charts on the COVID-vaccine front as well. There’s a mirroring across demographics as well: For both flavors of shots, the elderly, the white, the wealthy, and the highly educated are more likely to be dosed up. These gaps are bound to widen, as the inequities of first doses become the inequities of boosters, and fewer and fewer people return for additional injections. “First to second, second to third, we already saw dropoff,” says Arrianna Marie Planey, a medical geographer at the University of North Carolina at Chapel Hill. We don’t have to resign ourselves to this fate. Flu shots have had their failures, but they’ve clearly had their successes too. Roughly half of American adults don’t get an annual flu shot. The other half do. “The best predictor of whether you got a flu shot this year is if you got one last year,” says Gretchen Chapman, a cognitive scientist who studies vaccine behaviors at Carnegie Mellon University. To at least a degree, we have been doing a few things right. First, when mandates are possible, they help. The military requires flu shots, for instance, as do some universities. And requirements are common across a bonanza of health-care settings—a result of intense advocacy efforts, spearheaded just over a decade ago, in part by scientists including the Mayo Clinic’s Poland. Here, the perks of mass inoculation are absolutely incontrovertible. More flu vaccines mean fewer health-care workers missing work, or coming to work sick; they mean fewer vulnerable patients being exposed to the virus and falling seriously ill. It just took an all-out requirement to get the workforce to invest: Following a wave of mandates, starting around the early- to mid-aughts, vaccine-uptake rates zoomed from about 40 percent to about 70 or 80 or more. In other settings, though, mandates are much harder, for some of the same reasons that totally voluntary uptake remains in the pits. Schools might seem an obvious venue, because they already require other shots. But most of those vaccines require just a couple of doses that are done by adolescence at the latest; trying to track annual shots, meanwhile, is a bookkeeping nightmare, my colleague Rachel Gutman reported last fall. No states currently require annual vaccines for all K–12 students (though a few ask that day cares and preschools do). Attempts to change that have ended up dead in the water; even in health-care settings, mandates were an “arduous battle,” Angela Shen, a vaccine expert at Children’s Hospital of Philadelphia, told me. [Read: Vaccinating kids has never been easy] Once people age out of the school system, they become even harder to convince and corral. Across the board, “adult immunization coverage is abysmal,” and not just for the flu, Shen told me. With the American mindset so entrained on liberty and individualism, out-and-out requirements in most industries—for flu shots, for COVID shots—feel doomed to fail. Mandates are “tremendously effective,” Chapman told me. “People just hate them.” Without mandates, shot uptake depends on the miscellany of motivation. So-called nudge tactics have sometimes worked with flu shots, especially when they’re laced with a financial incentive--gift cards, coupons, salary bonuses, and the like, Southern Methodist University’s Mohapatra told me. But they can also flop, or even backfire; the COVID era has provided plenty of evidence for that, even with a few pretty creative pot-sweeteners (boats! sports cars! free gas for 10 years!) in the mix. Some individuals may grow suspicious of the hype, worried they’re being duped. Incentives can also go overboard with cash value, and make people feel like they don’t actually have a choice in the matter at all. “You still want there to be autonomy,” Mohapatra said, so it remains a true nudge, and not a coercive shove. Really, incentives work best on people who just need an extra little push. They’re much less likely to totally overhaul someone’s sociopolitical worldview. [Read: A very simple way to get America boosted] Increasing vaccine uptake, then, isn’t just about making shots desirable. It’s also about making them convenient and, in some cases, feasible at all. For many people, getting a vaccine still represents a huge disruption—time spent away from work, or child care, or other responsibilities—especially for those who live in rural regions or don’t have reliable access to health care. Simple venue changes can help. In 2009, a policy shift that finally allowed pharmacists to administer flu vaccines became an “absolute game changer,” says Ross Silverman, a vaccine-policy expert at Temple University’s College of Public Health. Just over a decade later, more than a third of American adults receive their annual shots at pharmacies and stores. Community vaccination sites and mobile clinics, UNC’s Planey told me, can help too. (Unfortunately some of the ones that popped up during the COVID pandemic have since disappeared.) And for those who straight-up forget to get a flu shot, or hit scheduling inertia, Chapman and her colleagues have found that auto-generating appointments can help—it becomes a default option, and people tend to follow through. Decades of slips and stumbles have also made clear what other changes might help efforts to vaccinate against both flu and COVID. Eliminating financial barriers is essential—to do that, policy makers could ensure that shots of all kinds remain free of charge, regardless of insurance status, Shen told me. For those who have to travel to appointments, officials could also instate measures to ensure that their transportation costs are covered, and put paid sick leave on the table so work hours aren’t lost. Changes like these would likely help address some equity gaps in uptake, especially among essential employees and their children, who might be more exposed to infection to begin with, and need the shots that much more. “All of these barriers add up,” Planey told me, but so does chipping away at them. Still, changes that focus on nudges and logistics can go only so far when much of the public has been cultured to view vaccines as not just annoying or unneeded, but outright dangerous, immoral, or partisan. These views are part of why, even after years of scientific toil, flu-vaccine uptake is “stagnant,” Poland said. With COVID, the immunization obstinance may be even worse. Vaccination has become “a hot-button issue in a way that it has never been,” Silverman told me. [Read: Restaurant vaccine mandates were set up to fail] Here, the lessons from flu shots match the ones already clear from current COVID-vaccination campaigns: People must be met where they are. Sometimes, that’s about hearing a vaccine-enthusiastic message from the right person. George Washington’s Yang notes that a strong recommendation for a flu vaccine from a health-care provider can be enough to tip some people toward dosing up. Trusted community messengers—some of whom might even go door-to-door in some cities—are powerful motivators as well. These conversations are about compassion, not dismissal, says Limaye, who works in vaccine hesitancy at Johns Hopkins University. She’s running a study to see if tapping into Republican Party values, such as individualism, freedom, and protecting small businesses, might make headway among conservatives who remain skeptical of shots. Larger-scale cultural shifts, too, are needed—amending people’s perspective on communal risk, and the price of ignoring it, as Poland emphasized at that CDC conference. Some of those lessons can be ingrained early in children, the primary target of most shots to begin with, he told me. Decades ago, when Poland’s youngest son was in second grade, he brought home an assignment he’d filled out in science class. The page was headed with a prompt: “Flu (influenza) kills and hurts people. A flu vaccine exists. What should we do every fall?” Beneath it, Poland told me, his son had scrawled, We should get a shot. So his son did. And so he has, ever since. from https://ift.tt/ug4OwDN Check out http://natthash.tumblr.com About three weeks ago, COVID case rates in the United Kingdom made an abrupt about-face, spurred on by a more transmissible Omicron subvariant called BA.2. Case rates are rising, too, in Switzerland and Greece and Monaco and Italy and France. Given that BA.2 is already present in the United States, The Washington Post reports that epidemiologists and public-health leaders suspect that North America will be next. After all, the paper said, “in the past two years, a widespread outbreak like the one in Europe has been followed by a similar surge in the United States some weeks later.” It’s true that watching the Delta and Omicron waves in Europe last year was like peering into a crystal ball of America’s pandemic future. Cases in the U.K. started to rise in early June, peaked roughly a month later, and bottomed out in early August. In the U.S., the surge began in July, peaked in September, and reached a low point in October. Cases shot up again in the U.K. starting around December 10 and peaked on January 4; the U.S. followed on December 18 and January 10, respectively. Britain hit its post-Omicron trough at the end of February. If the pattern continues, we should be hitting ours … right about now. But this correlation hasn’t always held. If, over the past two years, some surges in European countries have been trailed by ones in the U.S., others simply haven’t been. And the wave we’re now seeing overseas may well end up among the latter. Differences between the U.S. and European nations in variant levels, previous infections, and pandemic policy could keep our case rates on a different track. “There are a number of things which tug the U.S. experience away from the European one,” Bill Hanage, an epidemiologist at Harvard, said in a press call yesterday. The fact that Europe has, at times, been two steps ahead of us might come down to chance. The most influential variants so far--Alpha, Delta, and Omicron—were each first identified in places—the U.K., India, and South Africa—that are more connected by travel to Europe than to the U.S. These variants simply arrived in Europe earlier than they arrived in the U.S., but that trend could easily reverse. “If the next variant starts in Brazil, it’s far more likely to go to the U.S. before it comes to Europe,” Graham Medley, an infectious-disease modeler at the London School of Hygiene and Tropical Medicine, told me. “We’re all following each other.” Vaccination rates, the type of vaccine used, and previous infection patterns could also have influenced the Europe-then-America trend, says Shaun Truelove, an epidemiologist at Johns Hopkins. For example, AstraZeneca’s vaccine, which was commonly used during the early phases of the U.K.’s vaccine rollout, does not ward off infection as well as Pfizer’s and Moderna’s jabs, which were the most popular shots in the U.S. from the get-go. “It’s a very complex system, so it’s hard to say exactly,” Truelove told me. Differences in policy and behavior could also drive the timing trends, and right now, policies and behaviors in Europe are, shall we say, all over the place. In England, people who test positive for the virus are no longer asked to self-isolate; meanwhile, Spain and Italy only recently dropped outdoor mask mandates. “The restrictions that have been withdrawn in a lot of European countries include restrictions which have never been in place in much of the United States,” Hanage said, which might mean that Europeans’ lives have changed more rapidly than Americans’ over the past several weeks. The U.S., on the whole, hasn’t had many COVID restrictions in place since last summer. [Read: Restaurant vaccine mandates were set up to fail] Oddly enough, America’s recent laissez-faire approach to the pandemic has made case rates easier to predict here. Throughout the pandemic, the most difficult part of modelers’ jobs has been accounting for how policy and Americans’ behavior would change, says Lauren Ancel Meyers, who directs the COVID-19 Modeling Consortium at the University of Texas at Austin. But during the winter, schools largely stayed open and Americans largely went about their lives. Suddenly, the projections Meyers and her team made were spot-on. “We’re not used to being that accurate,” she told me. But that doesn’t mean modelers are ready to say exactly what’s next for America. “What we found in the past two years is that the models have struggled at these critical change points,” Truelove told me. We’ll know if we’ve entered a trough, he said, only after it’s over and case rates climb up again. Meyers said she expects to have better predictions in a week or so. She wants more time to see whether cases start to plateau or increase in parts of the U.S. and to get more information about how long people are protected from infection or disease after a bout with Omicron. She also wants to know more about how easily BA.2 can infect people who have survived either of the two subvariants, BA.1 and BA.1.1, that have been responsible for the bulk of American cases since December. BA.2 is thought to be slightly more transmissible than BA.1, and it’s already in the U.S. That might sound ominous, considering what’s happening in Europe, and it might also suggest that a U.S. wave is coming soon, according to the pattern set by Delta and Omicron. Hanage assured me that BA.2 will almost certainly beat out other variants here, too, but that doesn’t mean that the U.S. is doomed to suffer an identical surge. When BA.2 entered Europe, it took off almost immediately. In the U.S., Hanage said, its rise has been much slower, possibly because it’s competing with both BA.1 and BA.1.1. Even if BA.2 were to start taking over in earnest tomorrow, it would be doing so during a much lower trough, and probably less virus-friendly weather conditions, than it encountered when it made its bid for dominance in the U.K. [Read: COVID sure looks seasonal now] All of that could mean that BA.2 will have less of an effect here than in Europe. It’s happened before: In the last weeks of 2020, the Alpha variant started driving the majority of cases in the U.K. and contributed to a devastating surge. (The U.S. also experienced a devastating surge around the same time, with the highest death tolls of the pandemic, but Alpha wasn’t a major player; if it had been, the winter surge would likely have been even worse.) Alpha didn’t become dominant in the U.S. until the spring, by which point the weather was warmer and Americans were getting vaccinated. That could help explain why the U.S. didn’t experience much of an Alpha bump; if anything, the curve from that period looks more like a plateau. “We dodged a bullet with that one,” as Hanage put it. If we’re lucky, we could dodge another with BA.2. Hanage said his best guess for our next few months is that some parts of the U.S. will continue on their downward trend, but at a slower pace. Other areas will probably experience a bump in cases--wastewater data suggest that may be coming soon. But for now, the size of those bumps is anyone’s guess. from https://ift.tt/tbeoHNS Check out http://natthash.tumblr.com All epidemics trigger the same dispiriting cycle. First, panic: As new pathogens emerge, governments throw money, resources, and attention at the threat. Then, neglect: Once the danger dwindles, budgets shrink and memories fade. The world ends up where it started, forced to confront each new disease unprepared and therefore primed for panic. This Sisphyean sequence occurred in the United States after HIV, anthrax, SARS, Ebola, and Zika. It occurred in Republican administrations and Democratic ones. It occurs despite decades of warnings from public-health experts. It has been as inevitable as the passing of day into night. Even so, it’s not meant to happen this quickly. When I first wrote about the panic-neglect cycle five years ago, I assumed that it would operate on a timescale of years, and that neglect would set in only after the crisis was over. The coronavirus pandemic has destroyed both assumptions. Before every surge has ended, pundits have incorrectly predicted that the current wave would be the last, or claimed that lifesaving measures were never actually necessary. Time and again, neglect has set in within mere months, often before the panic part has been over. The U.S. funds pandemic preparedness “like Minnesota snow,” Michael Osterholm, an epidemiologist at the University of Minnesota, told me in 2018. “There’s a lot in January, but in July it’s all melted.” Or, as it happens, in March. This week, Congress nixed $15 billion in coronavirus funding from a $1.5 trillion spending bill, which President Joe Biden then signed on Tuesday. The decision is catastrophic, and as the White House has noted, its consequences will unfurl quickly. Next week, the government will have to cut shipments of monoclonal-antibody treatments by a third. In April, it will no longer be able to reimburse health-care providers for testing, vaccinating, or treating millions of uninsured Americans, who are disproportionately likely to be unvaccinated and infected. Come June, it won’t be able to support domestic testing manufacturers. It can’t buy extra doses of antiviral pills or infection-preventing treatments that immunocompromised people are banking on but were already struggling to get. It will need to scale back its efforts to improve vaccination rates in poor countries, which increases the odds that dangerous new variants will arise. If such variants arise, they’ll likely catch the U.S. off guard, because surveillance networks will have to be scaled back too. Should people need further booster shots, the government won’t have enough for everyone. To be clear, these facets of the pandemic response were already insufficient. The U.S. has never tested sufficiently, never vaccinated enough people, never made enough treatments accessible to its most vulnerable, and never adequately worked to flatten global vaccine inequities. These measures needed to be strengthened, not weakened even further. Abandoning them assumes that the U.S. will not need to respond to another large COVID surge, when such events are likely, in no small part because of the country’s earlier failures. And even if no such surge materializes, another infectious threat inevitably will. As I wrote last September, the U.S. was already barreling toward the next pandemic. Now it is sprinting there. The virus is moving too. Cases are shooting up across Western Europe, auguring a similar rise in the U.S., as has happened in every past surge. (A third of the CDC’s wastewater sites have detected upticks in coronavirus samples this month, although such data are noisy and hard to interpret when levels of virus are low.) Meanwhile, mask and vaccine mandates are being lifted. Contact tracing and quarantine policies are being discontinued. The CDC’s new guidelines recast most of the country as “low risk” and left the most vulnerable individuals with the burden of protecting themselves. Some experts supported the guidelines on the grounds that testing, treatments, and other defensive tools were available—and, as promised in Biden’s recently unveiled national plan, would be strengthened even further. But those promises were always contingent on congressional funding; without it, those residual layers of protection evaporate too. For half a year, Biden, administration officials, and several prominent public-health voices have encouraged optimism because “we have the tools” to fight the virus. The first half of that catchphrase now seems doubtful. As The Washington Post and others have reported, the funding meltdown occurred because Republicans were skeptical about the need for further COVID funding. Their counteroffer was to repurpose unspent pots of money that had already been set aside for state-level pandemic responses; Democrats refused, and coronavirus aid was omitted from the bill entirely. It is reasonable to ask for accountability in spending, but this particular line of reasoning is familiar. In 2016, Barack Obama asked Congress for $1.9 billion to fight Zika, but Republicans refused, arguing that such funds should be cannibalized from a pot that was set aside for the 2015 Ebola outbreak. In 2018, Donald Trump asked Congress to rescind $252 million that was leftover in that pot, which he billed as an example of “irresponsible federal spending.” In fact, those funds were an investment, left deliberately untouched so that the U.S. could more quickly respond to future outbreaks (such as the one that began in the Democratic Republic of the Congo exactly as Trump issued his call). The U.S. clearly grasps the concept of preparedness during peacetime: It spends at least $700 billion a year on its military, more than any other country. But when thinking about infectious diseases, vital preparations for the future are routinely seen as unnecessary excesses of the present--even in the middle of a pandemic. One could argue that such thinking reflects pragmatism rather than complacency. Budgets aren’t infinite, and countries face a multitude of pressing problems. If one threat goes away, doesn’t it make sense to divert resources to others? This argument fails for three major reasons. First, and most obvious, the threat didn’t go away! Even when the coronavirus reaches endemicity (which it very much hasn’t yet), an endemic threat isn’t one that can be ignored but one that must be managed—which requires regular investment of the kind that Congress saw fit to deny. Second, preventing epidemics is far more cost-effective than dealing with their consequences, and allocating funds only when a threat is knocking on our door is economic folly. Third, many of the measures that would make a difference against COVID—better ventilation, paid sick leave, equitable health care, a stronger public-health infrastructure—would also protect people from other diseases and health problems. In this respect, even the $15 billion that the White House asked for (and now won’t get) is insufficient. And to consider such money as “COVID funding” is part of the problem—a misguided approach of tackling health problems one by one, instead of fixing the inequities that underlie them all. These dynamics might occur for many of the same reasons that I identified in a recent article about why much of the U.S. has normalized so many COVID deaths. The virus is invisible. The ruin it inflicts is hidden from public view. The pandemic has gone on for two long years, turning tragedy into routine and breeding fatalism from failure. Older, disabled, poor, Black, or brown Americans, whose excess deaths were tolerated long before COVID, have borne the brunt of the pandemic, while privileged people have had the swiftest access to medical interventions—and have been quickest to declare the crisis over. A country that so readily forgets its dead is surely prone to also forgetting the lessons of the all-too-recent past, setting itself up for further failure in an all-too-imminent future. from https://ift.tt/YKfz9wj Check out http://natthash.tumblr.com |
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