I turn 60 today, and I feel vaguely embarrassed about it, like I’ve somehow let myself go, like I’ve been bingeing on decades and wound up in this unappealing condition. Chances are, most of you haven’t crossed this border station yet, so you’d better listen up. Because if you play your cards right, it’s going to happen to you too. Here’s what it feels like to turn 60: weird. On the one hand, you’re still going to the gym and to dinner parties. Sixty-year-olds still perform surgery on people who could choose other doctors. There’s no dithering yet—the senescence is almost undetectable. But on the other hand, you have been on this Earth for a really, really long time. I have a photograph of myself at age 3, standing on the docks of Cork Harbor, about to sail to New York. When I look at the picture of that small child on her sturdy legs in the foggy past, I don’t feel any connection to her. The photograph looks like something I would discover after many days on Ancestry.com. It looks like a snapshot of my own great-aunt. There’s a reason the photograph looks like it’s from another time. Because it is from another time; it was taken more than half a century ago. How can I be in a photograph from that long ago? The math makes sense, but my own life doesn’t. When I stood on that dock, “man” hadn’t walked on the moon; Malcolm X, Martin Luther King Jr., and Bobby Kennedy were all alive; the Beatles were still playing the Cavern Club. World War II had ended less than 20 years earlier; none of the men who flew planes into the World Trade Center had been born. How can all of the things that happened since that photograph was taken have occurred in one lifetime? How can people walk around holding this much of the past inside them? How do they possibly add in another two or even three decades of experience? I’m topped up! I’m going to have to start erasing the larger files. Maybe I already have and don’t know it. [Caitlin Flanagan: I’ll tell you the secret of cancer] Don’t get me wrong: I’m feeling pretty upbeat about becoming what David Sedaris calls “officially old, the young part of old, but old, nevertheless.” Not in some sort of “active senior” way. (Gross!) I feel good about making it to 60 because almost 20 years ago, I was diagnosed with a vicious cancer, and there wasn’t an oncologist in the country who would have given me Vegas odds on five years. The thing about cancer is that there’s a wild card in every deck. And I got one: At the exact time that I was diagnosed, there were huge breakthroughs in my exact kind of breast cancer. In a sense there isn’t any such thing as cancer at all, because the disease is made up of so many unique pathologies, many of which respond to different agents. I thought these discoveries were going to be too late to help me, but they started arriving in waves, and they keep coming. Even though I currently have Stage IV cancer and will be on chemotherapy for the rest of my life, here I am. I’ve gotten to see my children grow up, and I never thought that would happen. The last year of any decade is a tough one—the odometer’s about to tick over, and you can’t stop it—but how could I complain? I envisioned turning 60 as a series of consumer decisions: Go on a Viking cruise; buy a few postsexual separates from Eileen Fisher; get one of those oxygen facials. But then it got real. One day a few weeks ago, I got old. It just suddenly happened, and there isn’t a sports car in the world I can buy to make it otherwise. One thing that doctors don’t tell you about cancer is that even if you get lucky, there’s a price: The treatments add up in your body. I don’t look sick. But things have gone wrong inside me that have nothing to do with the cancer itself. The obvious symptom is that I’m tired. “Everyone’s tired!” other people my age tell me. But I’m as tired as they are, plus decades of chemotherapy and radiation that damaged my lungs. Every time someone asks me how I’m doing, it’s like grand rounds. I’m fine, I say; fine! The big problem, when I’m out and about, is that sometimes I just really, really want to sit down. Sometimes I’d rather sit down than do anything else in the world. Airports are some of the worst places if you’re a person who needs to sit down. There are all those soulless corridors, and—a design flaw, it seems to me—the gates never seem to have as many seats as the planes. Last month I flew to see my older sister. When I finally got to my gate, it looked like I was in luck—plenty of empty seats! But when I got closer, I realized that every other chair was covered with tape, in one of those meaningless displays of pandemic safety that California is committed to. I was about to spend five hours locked in a plane with these people; was 15 minutes at the gate really going to make a difference? Anyway, I felt a tingle of panic. In my youth I spent a lot of time sitting on the floors of airports, waiting for dirt-cheap flights that were always delayed by many hours. An 18-year-old girl sitting on the floor looks like she’s on an adventure. A 60-year-old woman looks like she’s in need of assistance. I walked to the next gate, but there were no chairs there either, or at the next one. Finally I saw a mirage: three empty seats in a row. They were real, but (damn it) they were reserved for other people, people who need some extra help. I long ago promised myself that no matter what happened, I was never going to do any learning or growing from cancer. But there’s one lesson that you can’t be this sick for this long without learning: There is no such thing as other people. There’s just all of us, with our secret or public burdens, muddling through the best we can, many of us not doing an especially good job of it. There was a time when I could manage my cancer without having to understand myself as “disabled,” but at 60, that time has passed. I sat down, and my bones settled so heavily around me--and the relief was so immediate--that I knew I’d done the right thing. But I also knew that through that simple, necessary gesture, I had become old. [Caitlin Flanagan: The cancer celebrities] Some people have the idea that only in modern-day, consumerist America do people fear aging. There’s always some mystical country (usually France) where older women in sophisticated clothes are trailed by dumbstruck young suitors, and everyone runs out of nightclubs when they hear some 80-year-old is across the street, dispensing tribal wisdom. But that’s not true. People everywhere have mourned getting old. Turn to the poets. They will tell you.
Yeats, of course. He must have spent his whole life waiting to get old, because when the time came, he had the goods. Your body does become a caricature of its former self. But here are the next lines of that famous poem:
I’ve thought about sitting in that chair a lot since it happened, and I’ve actually begun to feel a bit emotional and proud. Just by staying alive, I’ve witnessed a lot of life and a lot of history. I’ve done so many things in these six decades—I’ve survived some serious shit. In many of the ways that don’t involve the mortal coil, I’m stainless steel. And on the inside, I’m still me—probably more myself than ever. In this light, that old snapshot looks different. There’s my big sister standing next to me, casting a worried, watchful eye over me as she has for 60 years; there’s a little bit of my mother—my mother! It’s been so long since I’ve heard her voice—and there’s my father, present in his absence, recording the moment with his camera. This was many years ago, of course. When my parents were still young, and when man hadn’t walked on the moon. This was when we were the only people in the world who completely understood one another. The four of us: the Flanagans. I know that girl. I am that girl. from https://ift.tt/3DaEQ9P Check out http://natthash.tumblr.com
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When I first suspected that I was losing my hair, I felt like maybe I was also losing my grip on reality. This was the summer of 2020, and although the previous three months had been difficult for virtually everyone, I had managed to escape relatively unscathed. I hadn’t gotten sick in New York City’s terrifying first wave of the pandemic. My loved ones were safe. I still had a job. I wasn’t okay, necessarily, but I was fine. Now my hair was falling out for no appreciable reason. Or at least I thought it was—how much hair in the shower drain is enough to be sure that you’re not imagining things? The second time it happened, a little more than a year later, I was sure—not because of what was in the shower drain, but because of what was obviously no longer on my head. One day, after washing and drying my hair, I looked at my hairline in the mirror and it was thin enough that I could make out the curvature of my scalp beneath it. I still had enough hair, but notably less than I’d had before the pandemic. Feeling a sense of dull panic at the no-longer-refutable idea that something might be wrong, I tipped my head forward to take a picture of my scalp with my phone’s front-facing camera. When I looked at it, the panic became sharp. I did what everyone does: I Googled my symptoms. At the very top of the search results, a colorful carousel of vitamins, serums, shampoos, and direct-to-consumer prescription services appeared; a so-small-you-could-miss-it disclosure in one corner signaled that these products weren’t real search results, but advertising. Well below them, the real results weren’t much better—WebMD, a bundle of Reddit threads, medical journals whose articles would cost me $50 a pop, factually thin blog posts, natural-health grifters touting hair-growth secrets that doctors didn’t want me to know, product reviews that weren’t labeled as ads but for which someone had almost certainly been paid. I pressed on to gather whatever reliable-looking information I could find, itself full of terms I didn’t fully understand--effluvium, minoxidil, androgenic. What I didn’t know at the time was that I had just started a quest for answers that many, many others had also undertaken in the previous year. Only a few months into the pandemic, around the same time when I first thought I might be losing either my hair or my mind, people whose hair was indeed falling out by the handful started to come forward. They showed up in Facebook groups about hair loss, in subreddits dedicated to regrowth, and in the waiting rooms of dermatologists and hair-restoration clinics. First there were a few, but then there were thousands. Some of them had had COVID-19, but others, like me, had not. At first, the fire hose of products I’d been sprayed with felt like a very American type of reassurance—not only was my problem apparently common, but it was also widespread enough to be profitable, and therefore maybe it had a solution. In hindsight, the products feel more like a warning. This story isn’t about a medical mystery. The pandemic was a near-perfect mass hair-loss event, and anyone with the most basic understanding of why people lose their hair could have spotted it from a mile away. The actual mystery, instead, is why almost no one has that understanding in the first place. Hair loss, I eventually learned from my diligent Googling, can be temporary or permanent, and it has many causes—heredity, chronic illness, nutritional deficiency, daily too-tight ponytails. But one type of loss is responsible for the pandemic hair-loss spike: telogen effluvium. TE, as it’s often called, is sudden and can be dramatic. It’s caused by the ordinary traumas of human existence in all of their hideous variety. Any kind of intense physical or emotional stress can push as much as 70 percent of your hair into the “telogen” phase of its growth cycle, which halts those strands’ growth and disconnects them from their blood supply in order to conserve resources for more essential bodily processes. That, in time, knocks them straight off your head. The pandemic has manufactured trauma at an astonishing clip. Many cases of TE have been caused by COVID-19 infection itself, according to Esther Freeman, a dermatologist and epidemiologist at Harvard Medical School and the principal investigator for the COVID-19 Dermatology Registry, which collects reports of COVID-19’s effects on skin, nails, and hair. That doesn’t necessarily have anything to do with something unique about the disease, she told me—any illness that comes with a high fever can cause a round of TE, including common illnesses such as the flu. Among the millions of Americans who have been infected by the coronavirus, hair loss has been a common consequence, she said, both for patients whose symptoms resolve in a couple of weeks and for those who develop long COVID. Researchers do not yet know exactly how prevalent hair loss is among COVID-19 patients, but one study found that among those hospitalized, 22 percent were still dealing with hair loss months later. [Read: Yes, the Pandemic Is Ruining Your Body] COVID-19 infections are only part of the picture. Throughout the pandemic, millions more Americans have suffered devastating emotional stress even if they’ve never gotten sick: watching a loved one die, losing a job, going to work in life-threatening conditions, bearing the brunt of violent political unrest. Feelings can have concrete, involuntary physical manifestations, and these traumas are exactly the kinds that leave people staring in horror at the handfuls of hair they gather while lathering up in the shower. All of these factors have led to what Jeff Donovan, a hair-loss dermatologist in Whistler, British Columbia, described to me as a “mountain” of new hair-loss patients since the pandemic began. What exacerbates the difficulty of dealing with hair loss for many patients, he and the other doctors I spoke with told me, is just how little good, if any, information on the condition the people coming into their offices are able to assemble, even if they broached the issue with other kinds of doctors in the past. “They don’t know what's going on, they don’t know why they’ve spent so much money, and they’re just so confused," Maryanne Makredes Senna, a co-director of Massachusetts General Hospital’s hair-loss clinic, told me. “It’s like, ‘I don’t know what to believe, and I went to this doctor and they made me feel like I was crazy.’” The doctors I spoke with said that their patients typically come to them after having seen at least a handful of other practitioners, and sometimes as many as 15. This level of confusion—including my own—is, frankly, infuriating. Eighty percent of men and about half of women experience some form of hair loss in the course of their life. TE was first described in the 1960s, and it has long been a predictable side effect of surgery, changing medications, crash dieting, childbirth, bankruptcy, and breakups. The way TE resolves for almost everyone who doesn’t already have chronic hair-loss issues is that the hair eventually grows back—plain and simple. You would think, at some point, that someone would tell you not to panic if you lose some hair after something intense happens—that even if you shed for months, it will grow back eventually, and there’s no need to do anything but wait. For several reasons, many people don’t get much straightforward information on any type of hair loss, TE and beyond. For one, hair loss doesn’t really lend itself to the format of the modern American doctor appointment. Finding the right diagnosis can be a detailed, time-intensive process. “You cannot do everything for a hair-loss patient in a 15-minute visit,” Senna said, and that’s all the time many doctors get to have with their patients. Seeing a dermatologist who specializes in hair loss, she said, is more likely to get patients a visit of at least 30 to 45 minutes and a more detailed, empathetic evaluation—if a patient can figure out to go to such a dermatologist in the first place. Moreover, hair loss typically isn’t a particularly urgent problem for practitioners who may have many other types of health concerns coming into their office. Most hair loss that isn’t triggered by some kind of trauma is caused by androgenic alopecia, or AGA, often known as male or female pattern hair loss. It’s passed on genetically and has no cure, although some safe treatments are widely available. Doctors busy with other things may shrug their shoulders at patients who have incurable conditions that aren’t physically dangerous or painful. And for panicking patients who hear “Wait it out” or “Buy some Rogaine,” that recommendation may feel dismissive or inadequate, even if it is correct. Some causes of hair loss vary along ethnic lines, so getting answers can be even harder for certain patients. Susan Taylor, a dermatologist at the University of Pennsylvania and the founder of the Skin of Color Society, told me that Black patients usually land in her office with more advanced hair loss than their non-Black counterparts, which can make treatment less effective. Black patients are more likely to have a type of hair loss called central centrifugal cicatricial alopecia, or CCCA. According to Taylor, many practitioners know little about CCCA, and their advice to patients suffering from it can be especially dismissive. “For Black women in particular, they’re told, ‘Stop your relaxers; don’t straighten your hair,’” Taylor said. “And then they say to me, ‘But Dr. Taylor, I always wear my hair natural. I don’t relax my hair.’” [Read: When ‘Good Hair’ Hurts] What makes all of this harder is that hair loss—TE in particular—is a long game played on a wonky, counterintuitive timeline. It’s a nightmare for people trying to distinguish correlation and causation on their own. TE is temporary for almost everyone, but because of the vagaries of hair’s growth cycle, the shedding generally doesn’t start until two to four months after the stressor that triggered it occurred. By then, people are no longer thinking about the flu they had months ago—a new shampoo or medication might get the blame instead. And many people who experience TE have no idea whether their hair will ever come back; the shedding can go on for months before slowing down, and regrowth can take several more months to become visible to the naked eye. By the time people notice their hair growing back, a year may have passed since the process was set into motion. Once it starts, the only effective treatment is patience. If you’ve never gone from normal hair to bald spots in a matter of weeks, you might be tempted to dismiss this as vanity. But people value their hair because the society they live in tells them it’s important. Women in particular have been told for centuries that their hair is their glory, which paraphrases a biblical edict about long hair as a demonstration of righteousness before God. A full head of hair, Donovan, the Whistler dermatologist, pointed out, is still a crude, unscientific shorthand for youth, for healthy living, for vitality. Losing it can send people into a profound depression, or make them ashamed to leave the house. So people do what I did. They turn to the internet. Waiting for them is a booming market for nonmedical health products, ranging from the dubiously effective to the obviously scammy. Never does a new product look more promising than when you’re trying to solve a problem you don’t understand. In America, where competent medical care can be hard to access even for simple problems, hair loss—extremely common, highly emotional, absolutely confounding—is a case study in how much money there is to be made in this mixture of desperation and hope. When I first began my own search for answers, the avalanche of hair-loss products under which Google immediately buried me was disorienting and overwhelming. It wasn’t just the beautiful, full-color photos of luxuriously packaged pills and oils that Google threw at me up front, but how the internet kept the score, using the admission that I was losing my hair to stalk me across time and platforms in a way seemingly designed to wear down my defenses. For months on end, those products and many more followed me around the internet, interrupting my friends’ Instagram stories of their latest cooking projects and slipping between my extended family’s Facebook posts about their kids’ first day of school. At first glance, many of these products seem promising. Vegamour, a start-up that describes its shampoos and scalp serums as a “holistic approach to hair wellness,” can become practically inescapable if you use the internet to look at mainstream fashion and beauty products. It has a website and social-media presence befitting any luxury cosmetic, complete with videos of models tossing around their impossibly thick hair and promises of clinical proof that its products will grow yours. This clinical proof is not included on the site for scrutiny. (A spokesperson for Vegamour did not respond to questions about its products and website.) Similarly omnipresent are brands of slickly packaged hair-growth supplements, such as SugarBearHair, whose Tiffany-blue gummy-bear vitamins can be found between the lips of celebrities such as the Kardashian-Jenner sisters in sponsored Instagram posts. Social-media influencers are common in this game. Wellness products are a marketing sweet spot for a class of celebrities who are supposed to be more relatable than traditional stars, because they seem to offer a behind-the-scenes look at what it takes to be beautiful, but without really revealing anything at all. They are a simple way to assure an audience that you got hot through clean living, good nutrition, and a little self-care—that your entire deal isn’t one big, carefully stage-directed feminine farce. The catch, of course, is that the professionally beautiful absolutely do not rely on these types of products to ensure that their hair looks thick and luxurious. Celebrities, as Senna told me, generally don’t have incredible hair. Instead, they have incredibly expensive hair extensions and lace-front wigs. (SugarBearHair did not respond to multiple requests for comment.) In the United States, cosmetics and dietary supplements occupy a separate legal category from drugs. Their efficacy claims are far less regulated, which allows the manufacturers of nonmedical hair-growth products to make enticingly vague promises that would be more heavily scrutinized and caveated when made by a pharmaceutical company. Paradoxically, this freedom from regulatory surveillance can lead potential customers to assume that these products must be superior overall. The difference can seem implicit in the distinction from pharmaceuticals—if this class of products weren’t safer, more natural, and just as effective, wouldn’t the same level of governmental caution be applied to them? Can’t we infer something from its absence? These assumptions and their attendant fears are explicitly encouraged by many supplement and cosmetic companies as a way to more effectively market their own products. Vegamour’s website, for example, includes a list of medical-grade ingredients that its products do not include, alongside context-free lists of the most unpleasant side effects that have ever been attributed to those ingredients, even if those side effects are quite rare. The site does not mention any potential side effects of its own products. Drug manufacturers are legally required to track and disclose side effects, but cosmetic companies are not. You can see the effect anywhere that health problems are being discussed online, especially in spaces dedicated to regrowing hair. In one Facebook group with nearly 30,000 members, the same discussion plays out again and again: A new member asks for help, alongside photos of her thinning hair. Well-meaning people post links to buy the vitamins or essential oils that they’re currently using. They suggest a megadose of biotin, which has never been linked to hair growth in those without a biotin deficiency. They recommend an iron-supplementation protocol with its own Facebook group, even though taking iron supplements can be dangerous if you’re not deficient. Suggesting minoxidil can be controversial, even though it’s one of the only effective treatments for hereditary hair loss, has been studied for decades, and is widely available over the counter in cheap generics. People express a fear of side effects without getting more specific about what scares them. The most common side effect of minoxidil is scalp irritation. When wading through the sludge of the internet’s hair-loss advice, if you’re lucky, you come across someone like Tala, whose last name I’m not using in order to protect her privacy. She’s a 39-year-old moderator of the Reddit forum r/FemaleHairLoss, which has grown from about 3,000 subscribers to more than 14,000 during the pandemic. The subreddit is a relative rarity on the internet: a place to crowdsource information about a tricky health problem where discussions tend to stay based in reality. People post lots of pictures of their head, either to ask whether it looks like they’re losing more hair than they should be or to show before-and-after photos of treatment plans that really work. They talk about minoxidil and finasteride. They trade hair-war stories about scalp injections and laser helmets, and tell newbies how to find a specialist who can actually help them. Tala has AGA, the hereditary kind of hair loss, and has been losing hair since she was 30, but she considers herself lucky—she lives in an area with lots of good doctors and she can afford to see them, which means she has access to quality information. Passing on as much of it as possible feels important to her and the subreddit’s other moderators because of how vulnerable many of the group’s new members are. “I can't tell you how many suicidal people come to this group,” Tala told me. “To know that somebody is suffering that much because they lost their hair, it breaks my heart.” Maintaining a safe, truthful environment is an uphill battle. “To keep this group running and to keep it free from shills and people who are trying to take advantage of it and spammers, it's a lot of work,” Tala said. She and the other mods walk a difficult line: For the group to be helpful to as many people as possible, it has to feel welcoming and nonjudgmental, and it has to be free of people who might be trying to sell something. For the group to actually help, the moderators and regular commenters have to find ways to tell people who have spent so much money on “natural” cures that they maybe have been duped, without making them feel stupid or defensive. They teach people the basics of hair’s growth cycle, what to look out for when evaluating a scientific study, and which treatments are known to be effective for the type of hair loss they suspect they have. Several of the doctors I spoke with think that communities like r/FemaleHairLoss, which encourage rigor and evidence-based treatment options, provide a useful port in the storm of internet health marketing and misinformation. Nonmedical products, the doctors said, are basically all useless for expediting the growth of existing hair—which is not possible in already healthy individuals—or reviving dormant follicles. Dietary supplements themselves can be useful, Senna said, but only for patients whose hair loss is caused by a nutritional deficiency, which is rarely the case for people eating a standard American diet. If you’re not medically deficient, more isn’t better—and it can certainly be worse. Senna mentioned biotin, large doses of which are extremely common in hair-growth supplements. Too much biotin can lead to an incorrect thyroid-disease diagnosis, she said. Thyroid disease can also cause hair loss, so the misdiagnosis can send doctors on a wild-goose chase. The whole problem becomes bigger than if you never took the supplements in the first place. The myths commonly passed on as facts in some online hair-loss groups are a constant impediment to getting patients on treatment regimens that actually have some chance of helping their hair. “It can be very, very challenging to convince the patient that the diagnosis that she came up with from the internet is not the correct one,” Taylor, the University of Pennsylvania dermatologist, told me. With some types of chronic hair loss, the time that people spend trying things that don’t work is precious—the longer someone goes without effective treatment, the less effective they can expect that treatment to ultimately be. In the case of TE, hair loss’s timeline is on the side of the wellness industry. Think about how all of this feels to the average person, who has no idea what’s happening to them or why, and who may not even realize that dermatologists treat hair loss—I didn’t. After a couple of months of shedding, they may get worried enough to start looking for remedies as their scalp becomes more visible. They pick up a bottle of hair vitamins and a vial of scalp oil, with the understanding that results will take a few months to see. Down the line, when they spot short little hairs filling back in around their hairline, they’ll attribute that regrowth to the things they bought, not their natural hair-growth cycle. Suddenly, they’re evangelists for their vitamins and oils, which seem like a miracle cure but did nothing at all. The pandemic likely put this process into motion thousands—if not millions—of times. It’s a challenge that the supplement and cosmetic industries were well positioned to meet; beauty supplements and topical cosmetics are now often sold alongside each other, not just in luxury department stores and beauty emporiums such as Sephora and Ulta, but at Target or via Amazon’s recommendation algorithm. That these products don’t work matters very little to their profitability. In that way, this is a story that predates the pandemic by at least a century. When real, reliable information is hard to come by—in this case, when it is cut off from the general public by the structural limitations of the American health-care system—there will always be a market for new products with hollow promises. from https://ift.tt/3wNR85B Check out http://natthash.tumblr.com A couple weeks ago at my local CVS, I spied them in the wild for the very first time—Abbott BinaxNOWs, currently America’s most sought-after rapid, at-home coronavirus test, piled neatly behind the counter. With the fall and winter holidays on the way, I figured it was a good opportunity to stock up. But after I asked for a few tests to cover my multi-person household, the pharmacist plucked just a single box off the stack. “One box per customer,” she told me, shaking her head as if she’d already had this conversation four or five times that day. “Sorry, but we can’t keep these tests on the shelves.” She paused. “I mean,” she added, “there’s two tests in this box.” I left the store clutching my lone, overpriced purchase ($23.99! For one box!) to my chest like contraband, feeling frustrated. As the weather cools and people flock indoors, tests, when combined with other measures such as vaccines, ventilation, and masks, could help make our upcoming festivities safer—we’ve known that for a very long time. But nearly two years into the pandemic, America still hasn’t bothered to prepare for the tough months ahead. Cheap, at-home coronavirus tests have been in short supply, and although their availability is slowly ticking up, a crush of demand around Thanksgiving will almost certainly make the search difficult again. This year, tests, not turkeys, might turn out to be the most expensive, prep-heavy fixtures of many a Thanksgiving table. The power of tests depends on people being able to access and afford them, and use them correctly and frequently enough. But scarcity could prompt people to use the tests in nonideal ways, as my pharmacist was verging on advising me to do. “A box of two tests is really meant to be used on one person,” Jennifer Nuzzo, a senior scholar at the Johns Hopkins Center for Health Security, told me. The goal here is serial testing, particularly if the first result is negative. Tests offer snapshots, not forecasts, and a virus that’s at first sparse in the airway can rocket up to high levels in a matter of hours or days, especially if it’s a speedster like the Delta variant. The BinaxNOW actually spells this out in the instruction manual: “A positive result is highly accurate, but a negative result does not rule out infection.” Other types of coronavirus tests, including PCR tests, typically need just one try to detect the virus. (Of course, no test is perfect.) Those tests repeatedly xerox SARS-CoV-2’s genetic material, so they can pick up the pathogen even when it’s not abundant. Antigen tests such as the BinaxNOW, however, simply scan for the bits of coronavirus proteins that are already there. They’ll probably catch most dense infections—ones that saturate the airway with virus, as tends to happen when people are quite contagious—but an early, low-level infection could be easily missed. The tests are also best at spotting the virus in the few days after symptoms first appear; when they’re used to screen people who feel healthy, including people who were very recently exposed, the results can be a bit more mixed. Those imperfect results wouldn’t be such a big deal if we could say that people carrying less virus didn’t pose a huge transmission risk. But “we still don’t know how much virus you need to transmit,” Esther Babady, a clinical microbiologist at Memorial Sloan Kettering Cancer Center, told me. A negative result can’t guarantee that someone won’t spread the virus. To buoy accuracy, Abbott tells users to take a second test 36 to 72 hours after the first—that’s how the product can provide “the best coverage,” Mary Rodgers, a principal scientist in Abbott’s diagnostics business, wrote in an email. Say I split a box of two tests between my spouse and me; the confirmation goes away, and the products lose punch. [Read: The wrong way to test yourself for the coronavirus] After my disappointing CVS encounter, I wanted the security of having more tests around. But when I checked, CVS was sold out of the tests online too, as well as a very similar product, the Quidel QuickVue. So was Walgreens. And Walmart. Amazon had the QuickVue in stock—if I was willing to buy 45 two-packs for $1,079.55 (and swaddle myself in swabs while my bank froze my credit to investigate aberrant spending). It’s no wonder that several experts told me they’d started stockpiling tests for the holidays weeks, if not months ago, long before most Americans were even thinking about preordering their birds. Even when not purchased in bulk, the tests quickly add up in cost: For Thanksgiving, for example, I’d ideally want a two-pack for myself, so I could take one in advance, a day or two before the dinner, and then a second one right before the event. Then I’d want another two-pack that I’d start about three days after, to make sure that I hadn’t caught the virus while celebrating. Multiply that by eight people—a totally reasonable size for a Turkey Day soiree—and I’d be looking at 32 tests, packaged into 16 boxes, and close to a $400 bill, if we’re talking standard-price BinaxNOWs. (Consider: A budget turkey, buxom enough to feed eight people, can go for about $15; even truly bougie birds don’t often cost more than $150.) Even absent a shortage, that’s way out of reach for most American families, including many of the ones who most need access to fast and easy tests. The Biden administration has, in recent months, taken big steps to juice up the manufacture and distribution of rapid tests in the United States, including invoking the Defense Production Act, and pledging some $3 billion in federal funds to the cause. Dozens of these products already have an emergency green light from the FDA; more will follow. Mara Aspinall, an expert in biomedical diagnostics at Arizona State University, told me that she expects tests to be significantly more available through November and December. (Aspinall is on the board of OraSure Technologies, one of several companies that manufactures rapid coronavirus tests.) Not all of those tests will be headed straight to drugstore shelves, though. Many will end up in doctor’s offices and other health-care settings, to be used as point-of-care alternatives to slower laboratory tests; others will be bought by businesses hoping to screen people at conferences or workplaces, perhaps to comply with a mandate. The Biden administration’s pledge to produce more “rapid” tests is also a catchall—every test that falls into this category is fast, but not all are intended for easy, at-home, over-the-counter use. A few require a prescription; a few need a telehealth proctor to supervise the process. Their design and price tags vary too; some, like the BinaxNOW, look for antigens, while others, such as the Lucira, are sped-up PCR-like tests. Those latter ones also tend to cost a lot more, many upwards of $50 a pop. The administration has said that about 200 million at-home rapid tests could be available to Americans each month by the end of the year, but in a country with 330 million residents, that will go only so far. [Read: The nonsensical loophole in Biden’s vaccine mandate] I’ve been intermittently checking online retail sites since the CVS incident, and the tests do seem to have become more available. My CVS is still limiting purchases, but in the past couple of days, I was told once that I could now buy two boxes and another time that I could buy four. Even so, several experts told me they’re worried about the surge in demand that could come in the few days before Thanksgiving. “Trying to get those tests the week of will be an unmitigated disaster,” Susan Butler-Wu, a clinical microbiologist at the University of Southern California’s Keck School of Medicine, told me. The best move will probably involve nabbing some tests well before the turkey starts defrosting or brining. Aspinall also recommends taking a “test agnostic” approach. Serially administering antigen tests is great; so is scoring a no- or low-cost PCR swab at a community site, if there’s time to wait for results. If needed, families with no recent exposures, who are headed into low-risk gatherings—at which everyone’s vaccinated and meeting outdoors, for instance—might be able to get away with antigen-testing just once. Shortcutting tests, though, gets riskier when entering crowds of strangers or places where the virus is surging, or mingling with uninoculated people, sans masks or indoors. “Then you should be doing two [at-home rapid] tests,” Aspinall said. (She and her husband always test twice before visiting their young grandson.) And no matter how or how often negative results are produced, they aren’t insta-armor against SARS-CoV-2, Babady told me. Tests offer none of the protection that vaccines do, and work best when accompanied by other measures that actively prevent infection from taking hold. But tests can be such a powerful partner to shots and masks that they’re worth seeking out. After spending some quality time with my laptop this weekend, I was able to find several retailers selling at-home antigen tests at $14 per two-pack (about as cheap as they come in the United States); I finally bought enough to keep my household supplied through our expected December gatherings. Even testing at home drains time and resources. More supply will hopefully solve the first problem and help with the second—but for now, adequate testing remains a privilege reserved for those who can afford it. from https://ift.tt/3F44FJ6 Check out http://natthash.tumblr.com When I first received the invitation to the wedding where I would eventually get COVID, I was on the fence about attending at all. My best friend had gone through a tough divorce and was remarrying. I was thrilled for him. His wedding had been put off repeatedly because of COVID, and this was the couple’s second try at a real ceremony. As a bonus, the wedding would take place in New Orleans, where my friend lives. I hadn’t seen him since before the pandemic. New Orleans is a miraculous place, and my favorite city to visit in America. The notion of a trip there shone out of the fog and dreariness of this whole era of history. The downside, of course, was the risk of exposure to COVID. Sure, I’m vaccinated—two shots of Pfizer—and the wedding’s other attendees would all be vaccinated too. But breakthrough cases happen, and we’d be in New Orleans in October, a place where cases were still high and vaccination was inconsistent. One could not expect to not get exposed to COVID. But then I reasoned both with myself and with my wife. COVID was unlikely to kill me, a vaccinated 39-year-old endurance athlete. I would be fine, and even if I gave the coronavirus to any of my family members, they too would almost certainly be fine. My wife is vaccinated, and our young children’s risk of serious illness, while not nonexistent, is very low. I went back and forth, looking at flights and realizing that I’d probably have to travel through Las Vegas and have a considerable layover. I put off RSVPing one way or the other, and thought I would end up passively not going, the slow slide into a never-booked flight. But for some reason, one morning in early October, I got the “last call” email about the wedding and I revisited the prospect. Everything was beginning to seem more and more normal. The radio station where I host a show was encouraging people to come back into the office. I saw laughing, maskless people in my social-media feeds and in restaurant windows. The Delta-variant surge was easing in most places. Cases were coming down. The really vulnerable were getting boosters. Kid vaccinations were on the horizon. Filled with a surge of love for my friends and New Orleans and a sense that, you know what, I’m ready to nose out into a new tier of risk, I booked a flight; I’d be going solo. [Read: How easily can vaccinated people spread COVID?] As the day approached, my wife and I had not run through every scenario. I still was not precisely sure how the wedding would work, COVID-wise. My friend is a doctor, and I knew the crowd would mostly be New York and California people. There would be no anti-vaxxers among the guests, and the invitation said they’d follow the local public-health protocols. And I think I didn’t want to know too much. If I’m honest with myself, once I decided to go, it felt like I’d committed to taking on some risk. At the same time, my wife and I had been in lockstep on COVID stuff for so long that I don’t think I had the courage to really say: Hey, I want to go to this wedding, and it’s probably going to be maskless and … are we really okay with that? I don’t think she wanted to be the one to say no to seeing such good friends, if I was willing to do it. And so I boarded my flight without the kind of real conversation and—as important—return plan that we should have made. I spent hours in an N95 mask in the Las Vegas airport and on planes before arriving in Louisiana and heading to the welcome drinks. I walked in and saw that people were all inside, fairly densely packed in a big room. No one was wearing a mask. Everyone was celebrating like people who haven’t seen one another for a long time, ready for a wedding weekend in the greatest city in America. For some reason, I was shocked. I don’t know why I didn’t expect it to look like that. Maybe I thought we’d be in a garden under some nice string lights, mostly keeping masks on, in that maybe it helps way. I almost turned around and begged off the night of drinks, figuring that the next day would be less risky. But I’d come all that way. Here were my friend’s family and closest friends, the woman he’d fallen in love with. I just couldn’t do it. And all the everyone is vaccinated reasoning started to play in my head. I ordered a tequila and soda, pushed breakthrough infections out of mind, made some new friends, and had a great time. The wedding was maskless too. But in a huge, airy, gorgeous building. There was a second line through the streets, and people danced and waved white handkerchiefs with the names of the bride and groom. We wore tuxedos and listened to old-time music at Preservation Hall and made jokes and got a little drunk, mostly hanging around outside. When that part ended, a bunch of people went next door to a huge party spot, but I left as soon as I saw the piano-bar-and-club scene there. My wife was rightfully getting worried. It seemed not unlikely that I’d get exposed to COVID. Had we really been thinking clearly? Had we really wanted to take on that level of risk? Honestly, once I’d been in the situation, the realness started to unfurl. Outside the wedding events, I’d followed our protocols from home, staying outside, masking inside, etc. But attending the wedding was much riskier than I’d wanted to admit before I’d done it. Walking back across the city, the energy of wanting things to be normal was thick. I felt it too. After spending so much of my time studying COVID, being a part of the response with the COVID Tracking Project, and writing many stories about the pandemic, I was over it. I was done. I don’t know that I could have admitted that to myself, but I just wanted it all to go away. And there in New Orleans, for a few days, it seemed like it had. Just look at all those people singing at the piano bar, dancing to Lizzo, arm in arm with friend and stranger alike. [Read: Don’t be surprised when vaccinated people get infected] The next day, away from the wedding and visiting with my best friend, it became more and more obvious. My wife and I needed a plan for my return. I’d do a rapid PCR test at the airport. At least that would get me somewhere. My kids were so happy to see me, and after my negative result came back, to hug me. Was I actually safe? No, I knew I was not. I should have quarantined. But I had stuck my wife with the kids for four days, and I wanted to get back in the mix and help. That seemed like the right thing to do. On Monday, I felt fine, but I took an antigen test anyway (negative). I scheduled a PCR test for the next day. By the time my appointment arrived, I’d started to have some postnasal drip and what felt like a possibly psychosomatic tickle in my throat. Tuesday night—four days after the wedding—my PCR result came back negative, and despite having what felt like a cold, I figured I was pretty close to being in the clear. The next day, my symptoms were about the same. I did an intense Peloton workout and it felt fine, though maybe my legs were a little slow. I wasn’t eager to test again; a negative PCR test seemed good enough. But my wife heard me cough—one of only maybe 20 coughs throughout my whole sickness—and said, “Couldn’t you take another antigen test?” I was on the phone with a young geographer, talking about doing research at Bay Area libraries, and kind of absentmindedly did the swabbing. When I looked down a few minutes later, I had tested positive. Maybe a false positive? I immediately took another antigen test and the little pink line was practically red, it was so dark. Wrapping up the call, I packed my things quickly, texted my wife the result, walked outside with an N95 mask on, and waited for all hell to break loose. I was able to find a long-term rental on our block thanks to an angelic neighbor. I set my bags down inside and tried to figure out what I had to do. The worst-case scenario that I’d imagined was that I’d get sick, mildly, as I did. I ended up taking one day off from work, and even that was more of a precaution. I felt pretty sick, like when you have a cold, but I’ve probably been sicker 15 times as an adult. As someone who has thought so much about COVID science, it was almost interesting to experience: Oh! That’s what losing your smell is like. [Read: Your vaccinated immune system is ready for breakthroughs] But the real worst-case scenario was everything that happened to the people around me. My kids had to come out of school and isolate with my wife. A raft of tests had to be taken by everyone I’d had even limited contact with. (I was one of at least a dozen people at the wedding who got sick.) I had been with several older people, including my mother-in-law. For my wife and children, the tests went on for days and days, each one bringing a prospective new disaster and 10 to 14 more days of life disruption or worse. But for me, the very worst part was my children. They knew, cognitively, that I was vaccinated and unlikely to get really sick. That said, COVID-19, for them, is a terrible thing. The past year and a half of their lives has been disrupted by this virus. They take precautions every single day not to have this happen. They reacted in different ways. My nonbinary 8-year-old was so mad and maybe so scared that they could barely look at me. My 5-year-old daughter proved her status as the ultimate ride-or-die kid. She brought a chair down the street so she could sit 20 feet away from me outside in her mask, as I sat on the porch in an N95. I’m not sure which reaction was more heartbreaking. It was as if one never wanted to see me again and the other didn’t want to let me out of her sight. These vaccines are amazing. I was and am fine. But as The Atlantic’s Sarah Zhang described in her recent article “America Has Lost the Plot on COVID,” we have developed the least logical system around them. “The least vaccinated communities have some of the laxest restrictions, while highly vaccinated communities … tend to have some of the most aggressive measures aimed at driving down cases,” Zhang writes. In the communities where ignoring the pandemic is the norm, COVID testing may not be standard—and even when testing takes place, the required isolation and quarantining procedures are sometimes ignored. As I’ve found, you really are on your own to set the limits of what you do. And given the requirements and difficulties of isolating, I can imagine that few people are willing and able to follow the letter of the law. A positive test sets in motion huge hassles and anxieties for anyone you’ve been in contact with. This is how we slow the spread, right? It makes sense. And also, families and businesses and schools and event venues are trying to return to normal. Perhaps the risks of going into an office every day are far less than those of going to a wedding in New Orleans. But in the course of actual normal life in the places that have fought this virus the hardest, there will be more positive tests. Just in the past few weeks, I’ve seen more and more of them around me here in the Bay Area. For people pondering edging back into normal life, or trying to jump in headfirst as I did, it’s easy to do the risk calculation only about physical health; that’s really what this was about for so long. But the vaccines changed that, and we need to update our mental spreadsheets. The life disruption—the logistical pain you cause those around you—is now a major part of any bad scenario. As I write this, I’m now 10 days past my first symptoms, but I continue to test positive on antigen tests, and so I have not returned home. I haven’t hugged my kids for 10 days. They missed a whole week of school, and my wife’s work life got turned upside down—even though they never tested positive or got sick. I blame no one but myself for this. We cannot will this pandemic to be over. Lord knows I tried. I understand that my scenario is far better than could or would have played out in a pre-vaccination world. So many communities were hit hard. I have enjoyed tremendous privilege to keep my risk low before now. We got lucky that I didn’t infect anyone vulnerable. I’m so grateful my wife insisted that I take just one more test. In social worlds like mine, though, where most people do work from home, where people have minimized risk and gotten vaccinated, we’re at a weird moment. Things aren’t likely to change that much for quite some time. Even after however many kids get vaccinated, there will still be breakthrough infections. Other variants could spread. Maybe we’re in this space for another year or two or three. One way to put the question of endemicity is: When do we start treating COVID like other respiratory illnesses? [Read: The coronavirus is here forever. This is how we live with it.] I don’t know the answer. And I’m not even sure who should be trying to answer the question. There are many outstanding mysteries about long COVID. There are still so many unvaccinated Americans, and that number seems unlikely to shift a lot anytime soon. Right now most policies appear designed to make life seem normal. Masks are coming off. Restaurants are dining in. Planes are full. Offices are calling. But don’t be fooled: The world’s normal only until you test positive. from https://ift.tt/3C3RHJw Check out http://natthash.tumblr.com For many, many months now, 7-year-old Alain Bell has been keeping a very ambitious list of the things he wants to do after he gets his COVID-19 shot: travel (to Disneyworld or Australia, ideally); play more competitive basketball; go to “any restaurants that have french fries, which are my favorite food,” he told me over the phone. These are very good kid goals, and they are, at last, in sight. On Tuesday evening, about as early as anyone in the general public could, Alain nabbed his first dose of Pfizer’s newly-cleared pediatric COVID-19 vaccine. The needle delivered “a little poke,” he said, but also a huge injection of excitement and relief. Since his father, a critical-care physician, was vaccinated last December (the first time I interviewed Alain), “I’ve been impatient,” Alain said. “I really wanted to get mine.” Now he is finally on his way to joining the adults. When he heard on Tuesday that his shot was imminent, he let out a scream of joy, at “a pitch I have never heard him use before,” his mother, Kristen, told me. There’s an air of cheer among the grown-ups as well. “It’s cause for celebration,” says Angie Kell, who lives in Utah with her spouse and their soon-to-be-vaccinated 6-year-old son, Beck. Their family, like many others, has been reining in their behavior for months to accommodate their still-vulnerable kid, unable to enjoy the full docket of post-inoculation liberties that so many have. Once Beck is vaccinated, though, they can leave mixed-immunity limbo: “We might have an opportunity to live our lives,” Kell told me. [Read: Five big questions about COVID vaccines for kids] The past year has been trying for young children, a massive test of patience—not always a kid’s strongest skill. And there’s yet another immediate hurdle to clear: the plodding accumulation of immunological defense. Alain has another 15 days to go until his second dose; after that, it’ll be two more weeks before he reaches a truly excellent level of protection. Only then, on December 7, will he count as fully vaccinated by CDC standards and be able to start adopting the behavioral changes the agency has green-lit. In the intervening weeks, he and the many other 5-to-11-year-olds in his position will remain in a holding pattern. Their wait isn’t over yet. The timing of this semi-immune stretch might feel particularly frustrating, especially with the winter holidays approaching: At this point, no young kids are slated to be fully vaccinated by Thanksgiving or Hanukkah, except the ones who were enrolled in clinical trials. One shot can offer a level of protection, but experts advise waiting to change behavior for a reason—the extra safeguards that set in about two weeks after the second shot really are that much better, and absolutely worth sitting tight for. “It takes time for immune cells to get into a position where they’re ready to pounce,” Gigi Gronvall, a senior scholar at the Johns Hopkins Center for Health Security, told me. COVID-19 vaccines teach immune cells to thwart the coronavirus, a process that, like most good boot camps, takes many days to unfold. The second shot is essential to clinch the lesson in the body’s memory, encouraging cells to take the threat more seriously for longer. Immune cells also improve upon themselves over time—the more, the better in these early stages. Gronvall’s own 11-year-old son is also about to get his first shot, and she doesn’t want to risk stumbling so close to the finish line. “I can’t know exactly what his immune system is going to do” after the first dose alone, she said. [Read: You’re not fully vaccinated the day of your last dose] Evidence from Pfizer’s original clinical trial, conducted only in adults, hinted that a first, decent defensive bump takes hold after the first shot. Kit Longley, Pfizer’s senior manager of science media relations, pointed to those data when I asked how kids at various points along the vaccination timeline should be approaching behavioral change. “Protection in the vaccinated cohort begins to separate from the placebo arm as early as 12 to 14 days after the first dose,” he told me. The adult clinical-trial data were collected last year, though, long before the rise of the Delta variant. A more recent study, conducted in the United Kingdom, showed that one dose of Pfizer reduced the risk of symptomatic COVID-19 by only 35.6 percent when the cause was Delta, and by only 47.5 percent with Alpha. (And remember those numbers apply best on a population scale—not for a single, individual child.) After adding a second dose, though, effectiveness rocketed up to about 90 or 95 percent against either variant. “You really need two doses for adequate, good protection,” Samuel Dominguez, a pediatric-infectious-disease specialist at Children’s Hospital Colorado, told me. Immunity is so far looking strong in young kids: In a recent trial of thousands of children ages 5 to 11, Pfizer’s vaccine was more than 90 percent effective at blocking symptomatic cases of COVID-19, including ones caused by Delta. Longley said Pfizer expects that the timing of protection will be similar between children and adults—a first dose should lower everyone’s risk to some degree. But the company’s pediatric trial picked up only a few COVID-19 cases; none of them occurred until about three weeks after the first dose was given, or later. So it’s hard to say anything definitive about when “enough” immunity really kicks in for kids. Some parents are counting on a level of early protection from one shot, including my cousin Joanne Sy, whose 8-year-old son, Jonah, received his first injection on Friday. “He will have good immunity after one dose,” she told me, hopefully enough to guard him on a trip they’re taking to New York for Thanksgiving two weeks from now. “We’re still going to be cautious,” Sy told me: They’ll be watching the Macy’s Thanksgiving Day Parade from a hotel room rather than the streets, and wearing masks, at least on the plane. “But we just need to move forward.” The calculus is playing out differently for Christy Robinson of Arlington, Virginia, who will again be “hunkering down” with her husband and two daughters, June and Iris, 7 and 5, respectively, this Thanksgiving. The kids got their first Pfizer shot on Saturday, setting their household up for full, full vaccination by mid-December, just in time to hold an indoor gathering with their aunts, uncles, and cousins for Christmas. (Some quick arithmetic: To be fully vaccinated by December 25, a kid would need their first dose by November 20.) June’s also eager to “see my friends inside, because it’s cold outside,” she told me—plus go to movie theaters, and Build-A-Bear, and a trampoline park, and IHOP, and the nail salon. By the end of this conversation, Robinson looked amused and maybe a little regretful that my question had prompted such an extravagant list. As their mother, she’s especially excited for the possibility of no longer having to quarantine her daughters after viral exposures at school. Heftier decisions are ahead too. She and her husband are still weighing whether to bring their daughters into closer, more frequent indoor contact with their grandparents, who are vaccinated but could still get seriously sick if someone ferries the virus into their midst. And that risk—of transmitting the virus—is worth keeping in mind, with so much SARS-CoV-2 “still circulating around,” cautions Tina Tan, a pediatrician and infectious-disease specialist at Northwestern University. Immunized people are at much lower risk of picking up the virus and passing it on. There still aren’t enough of them, though, to reliably tamp down spread; uptake of shots among young kids, too, is expected to be sluggish in the months to come. Even fully vaccinated families won’t be totally in the clear while our collective defenses remain weak. [Read: COVID-vaccine mandates for kids are coming] That doesn’t mean Thanksgiving has to be a bust—or even a repeat of 2020, before the vaccines rolled out. The Bells will be cautiously gathering with a few loved ones; all the adults in attendance will be immunized and everyone will get tested beforehand. “Then they can come inside the house, mask off,” Taison Bell, Alain’s father, told me. None of those measures is completely reliable on its own; together, though, they’ll hopefully keep the virus out. The road ahead might feel a little bumpy for Alain, who’s celebrating his 8th birthday at the end of November, a few days after his second shot. (He’s getting the gift of immunity this year, his father joked.) The Bells will do something special “around when he hits full vaccination,” Kristen said, “with something Alain hasn’t gotten to do in the last two years.” But Alain, who has asthma, which can make COVID-19 worse, knows that his own injections won’t wipe the slate clean for him, or those around him. Some people in his neighborhood have caught the virus even after getting vaccinated, and he understands that he could too.
from https://ift.tt/3qiiWxN Check out http://natthash.tumblr.com COVID-19 vaccination for 5-to-11-year-olds is finally a go. But even as the emergency-use-authorization process unfolded, so too did arguments over whether kids should (or would soon) be forced into getting shots. School mandates for new vaccines tend to lag behind CDC recommendations by about half a decade, but COVID-19 shots appear to be in the express lane. The Los Angeles Unified School District—the nation’s second-largest—will require students 12 or older to be vaccinated by mid-December if they want to continue attending in-person classes. The entire state of California plans to mandate shots for all of its public- and private-school students as soon as vaccines are fully approved for them, and New York City’s mayor-elect has said that he supports the same idea. The implementation of any statewide K–12 school mandates may still be a while off, given the expected delay before the FDA gives full approval of shots for kids—for reference, the same process for the adult vaccines took eight months. In the meantime, parents, pediatricians, and public-health officials will be left to ponder the pros and cons. COVID-19 may be an unprecedented disease prompting an unprecedented vaccination effort to match. But how, exactly, does the case for mandating COVID vaccines in schools compare to the one for all the other shot requirements—such as those for polio, chickenpox, and measles—that are already in place throughout the country? When state regulators are deciding whether to mandate a given vaccine, they generally consider the risks and benefits—just like the FDA and CDC do when deciding whether to green-light a vaccine—but also how those risks and benefits relate to a school environment, says Mary Anne Jackson, an infectious-disease pediatrician at University of Missouri at Kansas City’s Children’s Mercy Hospital. In addition to being safe and effective, a vaccine should be easy to distribute and well accepted among the medical community and the public. Under these conditions, school vaccination mandates can provide “a safety net for vaccine policy,” says Jason Schwartz, a vaccine-policy expert at the Yale School of Public Health. They help bring up immunization rates when other methods of persuasion have failed. The most important benefit of mandatory COVID vaccination, as far as parents are concerned, would be its potential to prevent death. COVID-19 has, up to this point, caused relatively few deaths in children ages 5 to 11--66 from October 2020 to October 2021. But we routinely vaccinate schoolkids against diseases that were even less deadly before their respective vaccines were available. Chickenpox, for example, killed an average of 16 5-to-9-year-olds a year in the early 1990s; now all 50 states (as well as the District of Columbia) require that elementary schoolers be vaccinated against it. Chickenpox, Jackson told me, used to kill “a certain subset of kids”—mostly those who were immunocompromised. The same is true today of COVID-19. [Read: Five big questions about COVID vaccines for kids] Besides warding off death, COVID vaccines for kids also promise to prevent and mitigate sickness, the long-term effects of which remain unclear in children and adults alike. In data that Pfizer provided to the CDC, the company’s little-kid dose was 90.9 percent effective at staving off symptomatic infections. (Keep in mind, though, that the vaccine’s effectiveness may change over time, as it has for adults.) This level of protection is comparable to that provided by vaccines mandated for elementary schoolers in all 50 states: polio (99 percent), measles (97 percent), chickenpox (94 percent), and pertussis (84 percent). It’s also important to consider how likely kids are to contract the disease to begin with. The Delta variant appears to be less transmissible among children than chickenpox, measles, and pertussis, and about as transmissible as polio. But we have very little data on how rapidly the Delta variant spreads among schoolchildren in particular, and how much more rapidly it would do so if precautions such as masks and social distancing were removed from schools. To sum up the benefits: The kid-size COVID vaccine fights a disease that is about as dangerous as others for which schools regularly require vaccination, and, at least for now, it appears to be about as effective as these other vaccines, while the disease it prevents appears to be slightly less transmissible. [Read: Why are we microdosing vaccines for kids?] Now for the risks. The main concern with the Pfizer kid vaccine is myocarditis, a condition in which the heart muscle becomes inflamed, leading to symptoms such as chest pain and shortness of breath in children. Non-vaccine-caused myocarditis tends to be rarer in young children than in teens and young adults, and Pfizer’s little-kid trial didn’t result in any recorded cases among its roughly 3,000 vaccine recipients. But among older boys and young men who have received a second dose of an mRNA vaccine, myocarditis has been observed in roughly one in 10,000. How does this rate compare to rates of the most troubling side effects from school-mandated vaccines? COVID-vaccine-induced myocarditis occurs less often than febrile seizures do after the measles, mumps, and rubella vaccine (about one in 2,500 doses), but more often than a bruising condition called immune thrombocytopenia purpura (one in 30,000). The myocarditis cases are also more common than cases of anaphylaxis after the Hepatitis B vaccine (one in 1.1 million), which is required for elementary schoolers in all but a handful of states. But the rate of COVID-vaccine-induced myocarditis doesn’t tell us that much on its own. “The question is, how severe is myocarditis?” says Daniel Salmon, who directs the Johns Hopkins Institute for Vaccine Safety. We still don’t really know. According to the CDC, most patients with post-vaccine myocarditis “felt better quickly,” and “can usually return to their normal daily activities after their symptoms improve.” But no one can say yet whether a bout of vaccine-induced myocarditis now would harm someone’s health in a year, or 10 years, or 50. Salmon told me he wouldn’t support a kids’ mandate until researchers are able to rigorously follow kids who get myocarditis for a year or two, and find no related serious health problems. [Read: America has lost the plot on COVID] Waiting a year or two would also give regulators a chance to see how Americans learn to live with SARS-CoV-2 as an endemic virus, which has its own implications for any potential mandates. Lainie Ross, a pediatrician and bioethicist at the University of Chicago, told me that right now, “what makes this disease unique is that everybody is sort of a virgin” to the virus that causes it. If it doesn’t continue to transform into new and more dangerous variants, and if the vaccines (or natural immunity left by previous infections) remain protective against it, then COVID-19 will likely start to resemble measles or chickenpox: It will become a childhood disease, because every living adult will already have been exposed. That makes the case for childhood mandates much easier. But if, as some experts (and pharmaceutical-company CEOs) have predicted, the virus changes so much that we’ll need to get a new shot once or twice a year, mandates for schoolchildren would suddenly get a lot more complicated. Most schools track routine vaccinations at particular entry points, like enrollment in kindergarten or middle school, says Seema Mohapatra, a visiting law professor at Southern Methodist University, and they have practiced systems for doing so. Should the COVID vaccine become an annual shot, “that’s a whole different story,” she told me. The paperwork, she said, would be a nightmare. Consider the flu vaccine. During the 2019–20 season, 112 children ages 5 to 17 died of flu, yet no state mandates annual flu shots for K–12 students. (Massachusetts announced a mandate in August 2020, then dropped it in January after the flu season turned out to be mild.) In contrast, an average of three children and teens a year died of Hepatitis A in the five years before the two-doses-and-that’s-it vaccine for that disease was licensed. Yet Hepatitis A vaccines are mandatory in grade schools in one-third of states. True, the Hepatitis A vaccine is significantly more effective than the annual flu shot, but the flu arguably presents a much more formidable danger to kids. [Aaron E. Carroll: Many parents won’t vaccinate their kids. Here’s why.] The miraculous speed at which the COVID vaccines were developed has only made these questions harder to work out. By the time the first emergency use authorization was issued for Pfizer’s adult shots last year, humankind had had only about 13 months of experience with the new coronavirus. The first American polio epidemic occurred decades before Jonas Salk began work on his famous vaccine; measles was around for centuries before an effective inoculation was discovered. If we’d had that kind of time with COVID-19 before vaccines were introduced, a lot more kids would probably have gotten sick or died from the disease, but we’d also know a lot more about how rapidly the virus mutates over time, the exact degree to which kids spread and get infected by it, and the rate at which it causes chronic symptoms. Likewise, any scraps of information that can be gathered in the next few months will be of use in deciding whether to mandate the vaccine for kids. The approaches taken by mayors, governors, and regulators so far suggest that most intend to wait until the FDA grants its full approval for the shots. By then, we should have some more to go on. from https://ift.tt/3BQhPY6 Check out http://natthash.tumblr.com Back in the winter, when the COVID-19 vaccines were fresh and his immune system was unenlightened, Mike Ford knew his marching orders: Don’t gather in crowds, or socialize unmasked; do stay at home, and get the jab when asked. Then came the end of March, and the first of his two Pfizer shots. Once vaccinated, Ford, a Ph.D. student studying historical musicology at Columbia University, began to ease up on masking, as the CDC told him he could; he started to hang out much more with others indoors, as the CDC told him he could. “I even took a short trip,” he told me. After a year or so of cloistering himself, he said, the changes felt bizarre, even “drastic.” But at least the rules were clear. Now Ford, like so many others, has nabbed a booster, and he says the shot will, like his first two, “open up possibilities for me that I didn’t even consider before.” He’ll have his wedding, then a honeymoon, his post-nuptial schedule packed with travel and indoor socializing. He won’t worry about infecting his mom, who’s flying in from South Africa for the big day—a trip that, pre-booster, would have been “out of the question.” The shot’s still the catalyst for change, but this time Ford is the one making up the postinjection rules. In deciding what’s next, “I haven’t even thought about CDC guidance,” he said. That’s not surprising, considering that specific guidance doesn’t exist. For months, the CDC has been updating its hefty page on what people can do once they’re fully vaccinated (which, by the way, is still defined as two weeks after the second Pfizer or Moderna dose, or two weeks after the one-and-done Johnson & Johnson). But no such instruction manual exists for the pre-to-post-boost transition, which some 120 million Americans will be eligible to make in the next few months. I asked the CDC if those recommendations might appear soon. “Not at this time,” Kristen Nordlund, an agency spokesperson, told me in an email. For now, “people who have received a booster should continue to follow CDC’s fully vaccinated guidance.” (Nordlund did clarify that people shouldn’t consider themselves boosted until two weeks post-jab. They just aren’t being told to, you know, behave any differently at that point.) On a strictly scientific level, that conservative approach seems to check out with what a lot of experts are saying: “We’re still learning about what boosters mean, and what they can do,” Saskia Popescu, an infection-prevention expert at George Mason University, in Virginia, told me. She’s gotten a booster, she said, and hasn’t changed her behavior. But on another level—one that’s more emotional, more intuitive, and, let’s face it, more appealing—a different strain of booster logic holds: If two shots gave us so much freedom, shouldn’t a third do the same? Truly, no one knows. “Honestly, I’m confused on this myself,” Whitney Robinson, an epidemiologist at the University of North Carolina at Chapel Hill, told me. Ford and others are now charting their own post-booster paths, freelancing in the advisory vacuum the government has left behind. Gerald Pao, a biologist, told me that nabbing a booster emboldened him to visit his elderly aunt in Vancouver. Dianne Jennings, in Boston, says that her booster has made her feel ready to take a delayed vacation to see family members in the Midwest, including an unvaccinated cousin. Ace Robinson, an infectious-disease expert in California, boosted his way into a trip to Egypt and a belated birthday party for his 95-year-old grandmother (also boosted). My own mother, who’s 71, told me that she feels like her Moderna booster is her ticket to traveling overseas; she’s also eager to dine indoors and spend more time with her unvaccinated great-nephew, who’s 8. She feels cooped up, she said over the phone: “It’s been too long.” [Read: The pandemic is still making us feel terrible.] These booster mavericks aren’t acting unreasonably. (Nothing but respect, Mom.) In those with less robust immunity, additional shots do seem to make a difference, at least for a time: Once boosted, people seem better protected against infection and symptomatic cases of COVID-19, and they might be less likely to pass on the coronavirus. And while many people are eager to push their newly boosted boundaries, none of the dozen or so individuals I spoke with said they were abandoning other measures, including wearing masks. What they’re pursuing is well within the bounds for people whose bodies have been repeatedly taught to recognize the virus and have a great chance at fending it off. The whole pattern fits with a more general attitude toward behavioral taxes: taking precautions “so we can engage in something fun or rewarding,” like when we slather on sunscreen in advance of a beach party, says Gretchen Chapman, a behavioral scientist at Carnegie Mellon University who studies how people approach vaccines. That same calculus is part of what made the first vaccine rollout so appealing. The benefits of vaccination, though, always work best on a community level—not as a personal super-shield. Popescu said she’s worried that some people will significantly overestimate the benefits of boosting; she’s already heard from at least one person who’s getting the shot so they can go back to clubbing. Frequent, heavy exposure to the virus can still overwhelm vaccines’ best defenses—no number of doses will ever rocket anyone up to “bulletproof protection.” But people might be more likely to behaviorally overshoot post-boost when they’re forced to intuit which activities are probably, likely safe, and shirk the ones that aren’t. The last time we were at such a juncture, making the transition from unvaccinated to fully vaccinated, the calculations were simpler: We were all ending up in pretty similar, COVID-safe spots. Privileges were spelled out in intense detail on the CDC’s website; folks were told, point-blank, that they could “resume activities that you did prior to the pandemic.” This time around, though, the thinking’s much less binary—in part because boosters are being asked to play such different roles, depending on who’s getting them and when, Robinson pointed out. For the immunocompromised, for instance, whose bodies have a tougher time responding to vaccines, additional doses are meant to generate protection that might have been mostly absent before; the CDC doesn’t even call these jabs “boosters” at all. The booster-made gains in protection can also be big for the oldest among us. This group started out at higher risk of getting severe COVID-19, and for them, post-vaccination protection against infection of all flavors seems to be on a bit of a decline. More shots can shore up those defenses—that’s what I’m hoping a booster will do for my mother, whose age and health conditions put her at high risk. The younger, healthier contingent of the booster-eligible still seems pretty well guarded against COVID-19, but people in this group might work or live in places that up their chances of catching and transmitting the virus. Many experts think that members of this group really might not need additional shots at all, at least not yet: The benefits seem a bit unclear—like topping off a tank that’s already near-overflowing—and could be totally transient. For them, the boost is more like a hedge against the risks they’re already taking; it’s not intended to be an incentive to take on new ones. The matrix that covers all of these scenarios is head-spinning, and no universal rule book can accommodate all of them. People’s risk budgets have also been different: Many never took advantage of all that being “fully vaccinated” allowed, and are finally starting to; others engaged in those behaviors, then dropped them during the summer of Delta, and now want to reclaim them. That’s a thorny landscape for any CDC guidance to wade into, especially when green-lighting activities for people who are boosted would also mean excluding many who are not and yet who remain, officially, fully vaccinated. [Read: America has lost the plot on COVID.] In one sense, boosters could be seen as helping level the playing field, adding protection where it was incomplete. Immune protection, once built, isn’t static; time and viral mutations do tend to erode it away. More shots for individuals can shuttle people back up the spectrum of defense. But that’s still just among the already vaccinated. The power of a booster still pales in comparison with that of a first shot. “It’s almost like we’re increasing the inequality in immunity,” Jennifer Dowd, an epidemiologist at Oxford University, told me. “Some now have supercharged immunity, some have none, and everywhere in between.” A best-case scenario is one in which more people are vaccinated, the virus doesn’t run as rampant, and we end up needing the shots less, not more.
from https://ift.tt/2YbjJF2 Check out http://natthash.tumblr.com “How we feelin’ out there tonight?” Bo Burnham asks an imaginary audience during his comedy special Inside, which he self-filmed from a single room over the course of a year. “Heh, haha, yeahhhhh,” he says to himself. “I am not feeling good.” Following the special’s release this past May, TikTok users pounced on the clip. The sound has been used in more than 71,000 videos, amassing millions and millions of plays. Everyday users and creators alike can be found lip-synching along—sometimes gesturing to a specific stressor in their life, other times just conveying a general sense of malaise. It’s a pretty fitting time capsule of this moment in American life. Just like Bo said: We are not feeling so good. And even after all this time—you can still blame the coronavirus. You can tell from the numbers. In a recent national poll by NPR, the Robert Wood Johnson Foundation, and the Harvard T. H. Chan School of Public Health, half of U.S. households polled said someone within the home was experiencing serious problems with depression, anxiety, or stress—or sleep issues. You can tell from the recent streak of bad behavior in airports and other public spaces. And you can tell from the surge of interest in self-help books on trauma and anxiety. The latest wave of coronavirus cases is receding at last, and we may feel a bit of relief. But this past summer’s false start of hope has given way to a nasty sense of whiplash and unease, particularly as winter approaches. Humans generally do not like ambiguity, experts warned me, and we’re deep in it right now. “That jerking around is very, very stressful,” Pauline Boss, a professor emeritus at the University of Minnesota, told me, “because it’s full of uncertainty.” Some individuals tolerate ambiguity better than others, but Americans in particular don’t tolerate it well, Boss explained. “We are a mastery-oriented society. We like to put a helicopter on Mars,” she said. “And suddenly we get this virus that can’t be controlled and hasn’t been now for such a long period of time.” On the off chance you didn’t notice, 2020 was a banner year for uncertainty. We lived through ever-extending shutdowns, fluctuating day-to-day guidance, and unpredictable surges. But by the spring of 2021, we’d won back a bit of control: Vaccines offered answers and an exit ramp. Then Delta swooped in with more uncertainty—you know, for good measure. The variant not only disrupted summer plans, but scuttled a lot of our hard-earned knowledge about the coronavirus and made us rethink our personal risk calculus. Any bits of certainty we’d managed to reclaim over the course of a year living with this virus evaporated. All of this can have real consequences for a person’s psyche. “It’s called the burden of accumulated adversity,” Steven Taylor, a professor at the University of British Columbia, in Vancouver, who wrote a 2019 book on the psychology of pandemics, told me. Though outbreaks affect different people in different ways, “the more stresses you pile upon people, the greater their risk of developing psychological problems.” (And the stresses are piling on: The NPR poll also documented financial distress, fears of children falling behind in school, and worries about being attacked or threatened because of race and ethnicity.) Taylor expects that, as this pandemic stretches on, people’s moods will continue to worsen, particularly if we experience more setbacks. These moods could manifest as irritability, or as more serious mental-health problems. Since April 2020, the Census Bureau has been keeping track of the estimated number of Americans reporting signs of anxiety or depression using its biweekly Household Pulse Survey. In the first half of 2021, the survey reflected a general sense of optimism: The number of people reporting such symptoms was generally on the decline. It fell from its 2021 peak of 41 percent, around the end of January, to 29 percent by the Fourth of July. But since then, the number has begun to creep back up, hovering around 32 percent in the most recent reporting periods. Think of it this way: About one in every three people in the country is feeling fragile, in some way, right now. Two of the experts I spoke with worried that compounding stress is responsible for the angry outbursts we’re seeing in public places. Kenneth Carter, who teaches psychology at Oxford College at Emory University, describes himself as an optimist. But even he worries that, after so much loss and suffering, some of us “may be near the bottom of our well of compassion.” That could translate into feeling numb or being unable to show up for those in pain—even if we feel guilty about it, he says. This “compassion fatigue”—combined with the kind of people who are creating messy, angry scenes in public—“doesn’t make the world feel like the warm hug that we want it to be.” The good news is that people are resilient. Boss believes some of us have “increased our tolerance” for ambiguity over the past year and a half. And ultimately, this period will pass. Some people will continue to struggle, but most will bounce back. “It’s a no-brainer,” Taylor said, pointing out that humanity has survived two dozen pandemics over the past two centuries. “That’s what humans do.” Until then, either get comfortable with uncertainty—or outsource the job to TikTok. Recently, users have become enamored of a 13-year-old pug named Noodle with a penchant for prediction. Each morning, the dog’s owner delicately lifts the drowsy pup into a sitting position, then tests if he stays upright or slumps back into canine slumber. It’s Groundhog Day meets horoscopes meets pandemic blues: If the pug finds his bones, it’s a good day; if he doesn’t, you’re encouraged to call in sick and wear soft pants. The dog’s daily forecasts might not be all that scientifically accurate, but if you’re having a bad day, you can always blame Noodle. Or, you know, the compounding uncertainty of the once-in-a-lifetime pandemic you’re, yes, somehow still living through. from https://ift.tt/3CCE3y4 Check out http://natthash.tumblr.com Do you know what’s going on inside your teeth? I had never even contemplated the matter until April, when one of my molars began its revolt and my teeth became the only things I was capable of contemplating. As anyone who’s been in this position knows, the quaint discomfort that the word toothache implies doesn’t capture the incredible misery that a toothache can produce; sometimes, the pain was so bad that it was difficult to use my laptop. After a week’s worth of inconclusive X-rays, a futile round of antibiotics, and fistfuls of an ibuprofen-acetaminophen cocktail recommended by the internet, I was finally shuffled to an endodontist—a specialist who treats dental pain—to confront my tormenter. I had cracked a tooth, which the endodontist was finally able to locate with a CT scan. Moments later, I was being shot up with novocaine, and after a few minutes of drilling, the endodontist asked me if I wanted to see the source of all my agony. “Yeth,” I said, mostly through my nose. He held up his forceps, and dangling from the end was what looked like a tiny, leaf-bare tree rendered in the vivid red of fresh blood. It looked too perfect, its edges too discrete, like something created for a movie instead of an ordinary blob of human viscera. Nothing about this was going how I’d expected. When a tooth cracks, the oft-recommended treatment is one of the most commonly feared procedures in modern medicine: a root canal, so famously terrible that its name has long been a popular metaphor for a lengthy tour through agony itself. That’s what I was in the chair for that day—to have my tooth drilled open and its nerves and vasculature scooped out. After the CT scan, I’d pleaded with the specialist to root-canal me right then and there, while I was feeling the bravery of absolute desperation, instead of making me come back the next day. That’s when things got weird: The procedure was fast, and it was painless enough for me to make noises of surprised approval upon sight of the newly removed chunk of my face. When the endodontist told me we were all finished, I thought he might be joking—pop culture had spent years steeling me for an experience that apparently no longer existed. A few hours later, once the local anesthetic had worn off, I ate dinner like nothing had happened. My story is a not-uncommon one from the past year and a half. Through some combination of intense stress, new medication, and what had previously been a mild predisposition toward grinding my teeth in my sleep, I joined lots of other Americans in what seems to be a pandemic tooth-cracking bonanza. According to a February survey by the American Dental Association, almost two-thirds of dentists reported seeing more cracked teeth in their practices during the pandemic than before it, and 71 percent reported higher rates of bruxism, which is the involuntary grinding that can lead to cracks. My endodontist said as much: The root-canal business was booming. [Read: Yes, the Pandemic Is Ruining Your Body] Asgeir Sigurdsson, the chair of the NYU Department of Endodontics, told me that that’s still the case, six months after my own procedure. Not only are people stressed, but many people whose problems would have been spotted during a routine visit in 2020 skipped their checkups, for financial reasons or because of a fear of COVID-19 infection. Then, as Americans began getting vaccinated, dentists’ appointment books began to fill up quickly, which may have helped further dissuade some patients from getting a cleaning on the calendar. Checkups are easy to put off—even the most basic dental care is expensive and, at best, physically uncomfortable, and about a third of American adults don’t have insurance that covers any part of it. Submitting to a cleaning opens up the possibility that you’ll be told that you need an expensive, painful procedure, and there are some unscrupulous practitioners who take advantage of patients’ inability to evaluate their own oral health. People who need a root canal tend to know they need it, or know they need something. Cracks, infections, and severe decay make themselves apparent in no uncertain terms. Teeth are extremely sensitive; each tooth has 1,500 to 2,000 nerve fibers at its core, according to Sigurdsson, and most of them are a type of receptor that only feels pain. (If you’ve never considered the total absence of tooth pleasure from your life, well, there you go.) It’s perhaps not surprising, then, that at some point in the not-too-distant past, getting all of those nerve fibers scooped out of your tooth really hurt—enough to create an understanding of the root canal that has endured far beyond its own accuracy. Thank God for advances in medicine and technology. Except that when it comes to root canals, there haven’t been many significant advances. Sigurdsson has been performing the procedure regularly for 30 years, and it’s basically the same now as when he learned it in dental school. “What I think has changed maybe more is the way we teach our students to approach it,” he said. “To have more empathy for your patient, wait until the anesthesia has truly kicked in, and then give additional anesthetics if needed.” If you got a root canal a couple of decades ago and the pain scarred you for life, it probably didn’t have to—your dentist or endodontist might just have been an old-school rub-some-dirt-on-it type who didn’t really care if it did. [Read: The truth about dentistry] None of this means that every single patient’s procedure now is pain-free, even if everything is done correctly. The novocaine injections are themselves pretty uncomfortable, and can be terrifying for patients who fear needles. Some patients with additional complications, such as severe nerve inflammation, won’t fully respond to the available anesthetics, Sigurdsson noted. And some evidence suggests that people with intense anxiety about their procedure are more difficult to anesthetize, maybe because their fight-or-flight response or some other neurochemical reaction inhibits the anesthetic’s effectiveness. But, Sigurdsson promised me, the majority of his patients are “pleasantly surprised.” If decades of dental students have been taught to fully numb their root-canal patients instead of diving right into their pulp, then why does the procedure’s reputation persevere? It might be because, for most people, root canals are mercifully rare. Many people who will need more than one in their lifetime go decades between procedures, unaware that their next one won’t be so bad. For people who’ve never had a root canal, they may remember their parents complaining about a particularly bad one. Or millions of people may have been misled simply by growing up in the 1990s. According to Google Ngram, which tracks the popularity of words in books and newspapers over time, the phrase was particularly omnipresent in media during that decade. Joking about root canals does fit in with the what’s-the-deal-with-airplane-food comedy of the era; an episode of Seinfeld even features the specter of Jerry’s future root canal and the procedure’s seriousness as a reason he fights with Elaine. But as better-trained dentists enter the field and more people have uncomfortable but uneventful root canals, the same Google data show that the procedure’s ability to strike fear in our hearts, at least metaphorically, may be waning. The comedians of the 2020s will have to find a different way to tell you how comparatively agonizing it is to go to the DMV. from https://ift.tt/2ZGv54i Check out http://natthash.tumblr.com We know how this ends: The coronavirus becomes endemic, and we live with it forever. But what we don’t know—and what the U.S. seems to have no coherent plan for—is how we are supposed to get there. We’ve avoided the hard questions whose answers will determine what life looks like in the next weeks, months, and years: How do we manage the transition to endemicity? When are restrictions lifted? And what long-term measures do we keep, if any, when we reach endemicity? The answers were simpler when we thought we could vaccinate our way to herd immunity. But vaccinations in the U.S. have plateaued. The Delta variant and waning immunity against transmission mean herd immunity may well be impossible even if every single American gets a shot. So when COVID-related restrictions came back with the Delta wave, we no longer had an obvious off-ramp to return to normal—are we still trying to get a certain percentage of people vaccinated? Or are we waiting until all kids are eligible? Or for hospitalizations to fall and stay steady? The path ahead is not just unclear; it’s nonexistent. We are meandering around the woods because we don’t know where to go. What is clear, however, is that case numbers, the metric that has guided much of our pandemic thinking and still underlies CDC’s indoor-masking recommendation for vaccinated people, are becoming less and less useful. Even when we reach endemicity—when nearly everyone has baseline immunity from either infection or vaccination—the U.S. could be facing tens of millions of infections from the coronavirus every year, thanks to waning immunity and viral evolution. (For context, the flu, which is also endemic, sickens roughly 10 to 40 million Americans a year.) But with vaccines available, not every case of COVID-19 is created equal. Breakthrough cases are largely mild; 10,000 of them will cause only a fraction of the hospitalizations and deaths of 10,000 COVID cases in the unvaccinated. The more highly vaccinated a community is, the less tethered case numbers are to the reality of the virus’s impact. So if not cases, then what? “We need to come to some sort of agreement as to what it is we're trying to prevent,” says Céline Gounder, an infectious-disease expert at New York University. “Are we trying to prevent hospitalization? Are we trying to prevent death? Are we trying to prevent transmission?” Different goals would require prioritizing different strategies. The booster-shot rollout has been roiled with confusion for this precise reason: The goal kept shifting. First, the Biden administration floated boosters for everyone to combat breakthroughs, then a CDC advisory panel restricted them to the elderly and immunocompromised most at risk for hospitalizations, then the CDC director overruled the panel to include people with jobs that put them at risk of infection. On the ground, the U.S. is now running an uncontrolled experiment with every strategy all at once. COVID-19 policies differ wildly by state, county, university, workplace, and school district. And because of polarization, they have also settled into the most illogical pattern possible: The least vaccinated communities have some of the laxest restrictions, while highly vaccinated communities—which is to say those most protected from COVID-19—tend to have some of the most aggressive measures aimed at driving down cases. “We’re sleepwalking into policy because we’re not setting goals,” says Joseph Allen, a Harvard professor of public health. We will never get the risk of COVID-19 down to absolute zero, and we need to define a level of risk we can live with. Scientific experts have been reluctant to make that call themselves. For one, there is real scientific uncertainty ahead. We don’t know how much immunity may continue to wane, how long the effects of a booster last, the exact incidence of long COVID in the vaccinated, or if a new variant will upend even the best-laid plans. But the level of COVID-19 risk we can live with is also not an entirely scientific question. It is a social and political one that involves balancing both the cost and benefits of restrictions and grappling with genuine pandemic fatigue among the public. China, for example, has been brutally effective at suppressing COVID cases with strict lockdowns: Residents are barred from leaving locked-down neighborhoods; planes, trains, buses, and taxis in and to locked-down cities are being suspended; even vaccinated travelers are subject to mandatory quarantine. But are we willing to go that far? Currently, no. “This is the point at which we then have to start looking at ourselves and asking the hard question: Exactly how hard do we want to work to help how many people?” says Bill Hanage, an epidemiologist at Harvard. By we, he means all of us and, in particular, the public officials who represent us. “I can give you a policy, and I can tell you, okay, if you do that, I think you will have that outcome,” he says, but public officials need to first define what that policy is supposed to achieve. One plausible goal is to focus on minimizing COVID-19’s impact on hospitals. A collapsed health-care system means more people will die, not just of COVID-19 but from other treatable diseases and injuries. Elsewhere in the world, like in the U.K. and Germany, leaders have explicitly tied their policies to containing hospitalizations rather than all cases. But in addition to hospitalizations, Gounder suggests we should also consider the risk of long COVID. “I think for people that is the big question. We just don’t know enough,” she says. Preliminary data suggest vaccines do reduce the risk of long COVID, but exactly how much is unclear given the uncertainties in diagnosing it. Once we’ve defined what we are trying to prevent, we can define thresholds for lifting and, if necessary, reinstating COVID-19 measures. This can actually be quite tricky if the goal is minimizing hospitalizations, a lagging indicator that gives you a picture of the past rather than the present. By the time hospitalizations start to rise, a bigger increase may already be baked in with people already infected but not yet sick enough to see a doctor. What to track instead? Here are some answers I got from scientific experts: hospitalizations and deaths, but stratified by age and vaccination status; a combination of vaccination rate and local transmission; a combination of vaccination rate and hospitalizations; a combination of long-COVID cases, hospitalizations, and deaths; a combination of case growth rate, testing uptake, vaccination rate, and hospitalizations. If this seems confusing, why not consider a real-life example? San Francisco and seven other Bay Area counties recently set three-pronged criteria for lifting indoor mask mandates: (1) Community transmission is moderate, as defined by the CDC, for at least three weeks, (2) hospitalization numbers are low and stable, and (3) 80 percent of the total population is fully vaccinated or eight weeks have passed since COVID-19 vaccines have been available for kids age 5 to 11. If we are in fact going to try keeping hospitalizations stable, one reason to define this goal now is to untangle this mess of what data to track. Then, we can get to outlining specific tactics in the weeks and months ahead. In the absence of a coherent strategy, our attention has focused on a policy change we know is coming: vaccines for kids under 12. COVID shots for kids 5 to 11 were authorized last week, and data for those ages 2 to 4 are expected before the end of the year. For some families, this will bring real relief and soon. Vaccinated parents, living with vaccinated children, who have vaccinated grandparents, can worry that much less about the virus’s worst impacts, and start behaving less cautiously. But on a population level, as policy makers should be thinking, tying pediatric vaccinations to the end of restrictions doesn’t necessarily make sense, if we are trying to keep hospitalizations down. Vaccinating kids will protect them individually and help dampen transmission from and among them—but this policy lever simply has limited impact on hospitalizations. To prevent hospitals from being overwhelmed, the key group we need to vaccinate is really the elderly. The risk of hospitalizations for an unvaccinated person over 80 is 25 times that for an unvaccinated person under 18. A Financial Times analysis of data from the U.K. found vaccinating 25,000 children had the same effect on hospitalizations as vaccinating just 800 adults over age 60. Unvaccinated elderly adults are just that much more likely to become severely ill with COVID-19. You can’t compensate for a low vaccination rate among older adults by vaccinating more people in younger groups, says Müge Çevik, a virologist at the University of St. Andrews. The U.S. still has too many unvaccinated elderly people—or rather, parts of the U.S. do. States such as Vermont and Hawaii have done well, given almost 100 percent of people over 65 immunized at least one dose. But in Idaho, Arkansas, and Mississippi, the percentage is languishing in the 80s. Even small differences in this percentage can have an outsize impact on hospitalization outcomes. For example, two communities with a 90 versus 99 percent of the elderly vaccinated actually have a tenfold difference in the number of people at risk for hospitalization. “You don’t need a lot of infections in the unvaccinated over 65 to give you a problem,” Hanage says. During the summer wave in the U.S., the community vaccination rate in people over 65 correlated with hospitalization trends. The trend, he says, is “extremely clear.” One country that has excelled at vaccinating its elderly population is Denmark. Ninety-five percent of those over 50 have taken a COVID-19 vaccine, on top of a 90 percent overall vaccination rate in those eligible. (Children under 12 are still not eligible.) On September 10, Denmark lifted all restrictions. No face masks. No restrictions on bars or nightclubs. Life feels completely back to normal, says Lone Simonsen, an epidemiologist at Roskilde University, who was among the scientists advising the Danish government. In deciding when the country would be ready to reopen, she told me, “I was looking at, simply, vaccination coverage in people over 50.” COVID-19 cases in Denmark have since risen--under CDC mask guidelines, the country would even qualify as an area of “high” transmission where vaccinated people should still mask indoors. But hospitalizations are at a fraction of their January peak, relatively few people are in intensive care, and deaths in particular have remained low. Crucially, Simonsen said, decisions about COVID measures are made on a short-term basis. If the situation changes, these restrictions can come back—and indeed, the health minister is now talking about that possibility. Simonsen continues to scrutinize new hospitalizations everyday. Depending on how the country’s transition to endemicity goes, it could be a model for the rest of the world. Even when the coronavirus is endemic, it will still make people sick and it will still cause deaths and hospitalizations. That means our fight against COVID-19 is not over, and we might consider strategies sustainable over the long term. Better ventilation, for example, can make indoor spaces safer against all respiratory viruses, not just COVID-19. And even without mask mandates, people who feel at risk can still voluntarily mask up. In the longer term, Çevik says, we also need less focus on policies that work by “reducing small risks among many” and more on policies targeted at the people most affected by COVID-19. During the pandemic, the virus has disproportionately sickened people who are poor, who are less likely to be able to work from home, and who are less likely to have space to isolate from their family at home. When COVID-19 becomes endemic, it will likely, as many diseases are, continue to be correlated with poverty. “Pay much more attention to who and why people are at risk,” says Stefan Baral, an epidemiologist at Johns Hopkins University. Baral says public health needs to go back to its traditional roots, where tackling disease also means reforming the living and working conditions that make people more susceptible. For example, universal paid sick leave and free voluntary isolation spaces can help minimize the impact of COVID-19, as well as many other diseases. Hard questions lie ahead, and the answers require political will. But first, we have to stop avoiding them. We need a goal. from https://ift.tt/3mwHXmu Check out http://natthash.tumblr.com |
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