Imagine a digital COVID-19 “weather map” of the United States. You hover your computer mouse over a certain area and it shows you what’s going on, whether calm skies, gathering storm systems or disasters in progress.

Hover over IdahoAlaska and Montana and you’ll see health systems applying “crisis standards of care”—in other words, rationing. Overwhelmed by COVID-19 patients in extremis, hospitals and ICUs must allocate limited resources and decide who receives care and who must wait.

Hover over Arizona, where state Attorney General Mark Brnovich is suing the Biden administration over the “get vaccinated-or-get-tested” policy for businesses. In South Carolina, Governor Henry McMaster vows to fight vaccination mandates “to the gates of hell to protect the liberty and livelihood of every South Carolinian.” Republican attorneys general in 24 states have sent a letter to the White House threatening legal action against the employer mandate, Kathleen Steele Gaivin reports in McKnight’s Senior Living.

Hover over Mississippi to learn that seven babies have been delivered by bedside emergency C-section in the ICU while their mothers lay incapacitated by COVID-19. Some of the mothers did not live to see their newborns.

Hover over New Jersey and discover that officials plan to re-open vaccination megasites at malls and convention centers in anticipation of a rush for COVID-19 booster shots. They may have to retool a bit after a Food and Drug Administration advisory committee recommended that boosters, at least for now, be limited to seniors 65+, healthcare workers, and people at high risk for severe disease.

Now hover over the headquarters of the FDA in Silver Spring, MD and the Centers for Disease Control and Prevention in Atlanta, soon to be pondering reams of new data on the long-awaited first shots for children under 12 years of age, the last segment of the population to become eligible for COVID-19 vaccination.

Pfizer/BioNTech revealed their top-line data on vaccination of kids 5 to 11 earlier this week, and Moderna and J&J will follow in hot pursuit.

Time to remember

We’ve now had two springs and two summers of a global pandemic. Today we begin our second autumn heading toward our second winter. It has been a roller coaster ride with more downs than ups. 

The US death toll of 678,000 (Johns Hopkins numbers) eclipses that of the 1918 influenza pandemic. COVID-19 has taken the lives of 1 in 500 Americans, compared to 1 in 150 in 1918, when no vaccine was available to stem the tide of infection.

Early on in this worldwide health crisis, in March 2020, Dr. Anthony Fauci estimated that COVID-19 could claim 100,000 to 200,000 American lives. We reached the 100,000 mark by Memorial Day 2020 and 200,000 on the first day of fall, one year ago today.

Hundreds of thousands of small white flags commemorating those we have lost to COVID-19 now spread across 20 acres on the National Mall in Washington, DC. The display, titled “In America: Remember,” by Maryland artist Suzanne Brennan Firstenberg, opened last Friday and will remain until October 3. Visitors may personalize a flag for a loved one. Dedications can also be posted on a website and a flag will be planted. It is the largest participatory art exhibit on the Mall since the AIDS Quilt blanketed the entire area in October 1996.

Worldwide, the COVID-19 death toll stands at 4.7 million, with more than one third of the total coming from three countries—the US, Brazil and India.

Source: Getty Images.

One country, divisible

As if fighting a deadly pandemic were not challenging enough, the vaccination effort has become entangled in politics at all levels, an issue generating sharp, edgy differences of opinion and belief.

In an August survey of 956 unvaccinated US adults, two thirds said that requiring proof of vaccination to travel or enter public spaces poses a greater personal threat than the possibility of being exposed to COVID-19 in a public space. In the poll, conducted by Morning Consult for the de Beaumont Foundation, 79% said freedom to choose or reject vaccination is a higher priority than requiring vaccination to prevent the spread of COVID-19—and 77% said they don’t trust the federal government’s guidance on vaccines.

“When unvaccinated adults say personal freedom is a higher priority than public safety, the time for education campaigns has passed,” said Brian C. Castrucci, president and CEO of the de Beaumont Foundation. “As much as they may dislike it, for many Americans vaccine mandates are the only thing that will persuade them.”

The latest report from the COVID States Project, a coalition of university-based researchers, notes that safety concerns remain top of mind for the unvaccinated, along with a growing lack of trust in institutions. Concerns about vaccine safety and effectiveness “are linked to a lack of confidence in messages coming from the government, health officials, and the mainstream media,” said co-author Katherine Ognyanova. “Lack of trust is a more important challenge at this point than the remaining logistic problems that people experience.”

When it comes to COVID-19 vaccination, the “trusted local messenger” may be someone sitting at the family dinner table. According to The Harris Poll, 76% of vaccinated Americans worry about their unvaccinated family members, and 67% have made an effort to change minds. Conversations have had mixed results: 18% said persuasion worked, 25% said the relative is receptive and reconsidering, 16% reported that the discussion led to an argument, and the rest (41%) found some common ground without altering attitudes. One third of the vaccinated say they have cut ties in some way with unvaccinated friends, family or acquaintances.

A new PSA from the Ad Council and COVID Collaborative shows young adults having difficult conversations with loved ones who are undecided or doubtful about the vaccine. Two other PSAs encourage parents who are on the fence to talk to a pediatrician or healthcare provider about protecting their children. Sabrina Sanchez has details in Campaign.

The vaccine dashboard

•  Pfizer/BioNTech on Monday released topline results from their trial of COVID-19 vaccine in children ages 5 to 11 and said they will submit the data to the FDA and overseas regulatory agencies “as soon as possible.” Children in the trial received two vaccinations 21 days apart, at a dose of 10 µg, or one-third the dose used in the vaccine for people 12 and older. The companies say the vaccine was safe, well-tolerated and produced a robust immune response.

•  Pfizer/BioNTech data on younger children—study cohorts of 2 to 5 years of age and 6 months to 2 years—are expected as soon as Q4.

•  A CDC study reports that Moderna’s vaccine was 93% effective in preventing COVID-19 hospitalizations in adults without immunocompromising conditions. Pfizer/BioNTech took the silver at 88% and J&J the bronze at 71%. The CDC considers all to be winners. The study covered the period from March 11 to August 15.

•  In July and August, if every state had vaccinated as efficiently as the state with the highest vaccination rate (which for most of that period was Vermont), more than 16,000 deaths could have been prevented. Researchers from Weill Cornell Medical College and Northwestern Feinberg School of Medicine shared their analysis in a New York Times op-ed.

•  In a study of 1,069 cancer patients, the relative risk of developing COVID-19 was 21.5 times higher for unvaccinated patients, Jen Smith reports in Cancer Therapy Advisor. The research, presented at the 2021 Congress of the European Society for Medical Oncology, noted that 0.4% of vaccinated patients and 8.9% of unvaccinated patients developed COVID-19. Most vaccinated patients had no or only mild side effects from the vaccine and were able to continue cancer treatment as normal.

•  Black and Hispanic people are more likely to be hospitalized not just with COVID-19 but also with flu. As flu makes its seasonal return, the Center for Sustainable Health Care Quality and Equity, a division of the National Minority Quality Forum, has developed a toolkit that primary care teams, healthcare systems and community organizations can use to improve vaccination rates in underserved, at-risk communities. An added benefit: The outreach experience gained with the flu program is helping to inform and inspire local COVID-19 vaccination efforts.

•  America is suffering from a case of vaccinopia, “an inability to look beyond shots in arms when considering how to manage the pandemic,” Eric Topol and Daniel Oran argue in STAT. They say that rapid tests for the SARS-CoV-2 virus could help control the pandemic and ultimately reduce the spread of disease to levels that render it more of a nuisance than a national emergency. Topol, a cardiologist, is director and founder of the Scripps Research Translational Institute.

Source: Getty Images.

Boosters—what’s new and what’s next

•  The FDA’s Vaccines and Related Biological Products Advisory Committee rejected the concept of boosters for people 16 and older by a vote of 16-2 but unanimously recommended boosters for a more targeted population of seniors (65+) and people at high risk of severe COVID. FDA leadership will act as early as today on the committee’s advice.

•  In lockstep, the CDC’s Advisory Committee on Immunization Practices is meeting today and tomorrow to discuss boosters and make its own recommendations.

•  “Communication and messaging [for boosters] will be a challenge compared to a scenario where everyone could just get a vaccine,” Jason Schwartz, a public health professor at Yale, told Axios.

•  J&J on Tuesday released new booster data for its single-dose vaccine. A booster two months after the first shot was 94% effective in preventing symptomatic COVID-19 and 100% effective against severe disease. Protection may be better if the booster comes six months rather than two months after the first jab.  

•  In the UK, invitations for booster shots are now going out to people over 50, frontline healthcare and social workers, residents of care homes for older adults and people ages 16 to 49 with medical conditions that put them at risk for severe COVID-19.

•  Vaccinating the world against COVID-19 is high on the agenda of the United Nations General Assembly, meeting this week virtually and in New York City. The seven fully vaccinated, South Korean K-pop megastars known as BTS, who are designated UN youth envoys, paid a visit (see songs, below). 

Works in progress

•  Certified nursing assistants remain the least vaccinated workers in nursing homes, Danielle Brown reports in McKnight’s Long-Term Care News. The average COVID-19 vaccination rate among CNAs was 49.2%, researchers noted in JAMA Internal Medicine, compared to 61% for RNs and LPNs, 70.9% for therapists and 77.3% for physicians and independent practitioners.

•  A New York judge has blocked a vaccine mandate for health workers in the state because it doesn’t allow for religious exemptions. Brown reports that religious exemptions are becoming a “widely used loophole” for workers who don’t want the vaccine.

•  A five-year partnership between the CDC and AMDA—The Society for Post-Acute and Long-Term Care Medicine—seeks to improve vaccination rates among residents and staff for COVID-19, flu, shingles and pneumonia. Kimberly Bonvissuto has details in McKnight’s Senior Living.

•  In March, Rutgers became the first major university to announce a COVID-19 vaccine mandate for students. In September, 98% of its 71,000 students are vaccinated.

•  Even before the White House announced its wave of vaccination mandates, 18 states and the District of Columbia had already issued vaccine mandates for public sector workers, and 21 had issued mandates for healthcare workers, according to the Pew Charitable Trusts.

•  United Airlines reports that 95% of its US-based management and 90% of staff are vaccinated ahead of a September 27 deadline.

•  The military branches have set deadlines for COVID-19 vaccination of active-duty members: November 2 for the Air Force, November 28 for the Navy and Marines, and December 15 for the Army. Later deadlines apply to reservists.

•  The Buffalo Bills are now requiring fans 12 and older to show proof of vaccination to get into the stadium. Management made the decision after the first home game, where thousands of fans ignored earnest guidance on mask-wearing. Call it a facemask violation.    

•  NBA referees have agreed to a mandatory COVID-19 vaccination policy for the coming season. Not so for players. Would seem to be a slam-dunk.

•  The US is lifting restrictions on international travel into the US that have been in place for a year and a half, but will require foreign nationals heading this way to be fully vaccinated come early November.

•  Nevada Governor Steve Sisolak has mandated COVID-19 vaccines for workers in state correctional facilities as well as adult and youth psychiatric and juvenile detention centers. The vaccination rate among Nevada corrections workers is 43%, and more than 1,100 of the 2,700 prison employees have tested positive for the virus.

Photo Credit: @klanca50

The rest

•  The big words on the truck circling Charlotte’s Bank of America Stadium before Sunday’s Panthers-Saints game said “Don’t get vaccinated.” The smaller words below said “Wilmore Funeral Home.” A photo soon went viral on Twitter. As Lecia Bushak reports in MM+M, the funeral home is a concoction. The website shown on the truck is “a mostly blank page featuring a ‘Get vaccinated now’ box; clicking on it takes users to Charlotte provider StarMed Healthcare and a page providing credible vaccine information.”

•  The FDA has expanded emergency use authorization for the monoclonal antibody cocktail of bamlanivimab plus etesevimab (Lilly) to include postexposure (but not pre-exposure) prevention of COVID-19 in people 12 and older who are at risk for progression to severe disease. The combination is not a substitute for vaccination and is intended for people who are not fully vaccinated or are not expected to mount a sufficient immune response to complete vaccination. Brian Park has more in MPR.

•  More than one in four employees say they would be willing to take a pay cut if it means they could continue to work remotely. The finding comes from a survey of 2,000 workers by Indeed, Francis Churchill reports in People Management.

Parting shot

Ron Burger would have resisted the notion that he was a health-care hero. He was just doing his job, devoted to public health, emergency preparedness and disaster response throughout a 35-year career with the CDC. Time and again he made a beeline to the scene of natural and manmade calamities—hurricanes, floods, earthquakes, the Legionnaires’ disease outbreak in Philadelphia, a smallpox vaccination campaign in Bangladesh, the Mount St. Helens eruption, Ground Zero chaos at the World Trade Center, the 2002 anthrax attacks, the Flint water crisis, a Zika epidemic in Puerto Rico. His preference was to prevent rather than respond to public health crises.

I lost track of Ron after we graduated from high school in Lancaster, PA many moons ago, where he was a stalwart on the football team, and learned of his passionate devotion to public health years later, mostly through Facebook posts. He officially retired but inevitably found a way to stay busy, serving as a Florida-based regional coordinator for the Department of Homeland Security’s Biowatch program. Throughout the pandemic, he has been on the move across the country as a volunteer with the National Disaster Medical System. Characteristically, he was on assignment with the NDMS, tapping into his inexhaustible supply of effort and energy, responding to the surging Delta variant in Mississippi and setting up a field hospital when he died last month at 73. His light continues to shine.

… and some songs

Permission to Dance, BTS, performed at the UN and shown to the UN General Assembly

September, Earth Wind and Fire

Try to Remember, Harry Belafonte

We Are Family, Sister Sledge

Teach Your Children, Crosby Stills and Nash

Reason to Believe, Rod Stewart

Thanks for joining us on this first day of fall. Here’s to a season of better health for all. We’ll be back next Wednesday.