A glance at the U.S. vaccine dashboard, courtesy of the Centers for Disease Control and Prevention, shows how far we have come in ten months of an epic immunization odyssey:

•  213.5 million people ages 12 and older have received at least one COVID-19 shot. That’s 75.3% of the vaccine-eligible population.
•  183.9 million people 12 and older are fully vaccinated. That’s 64.9% of the vaccine-eligible population

The glass is more than half-full. The Kaiser Family Foundation has estimated vaccination rates by race and ethnicity, drawing on data from the states. The percentage who have received at least one dose of COVID-19 vaccine include:

•  69% of Asian Americans
•  53% of Whites
•  49% of Hispanics
•  45% of Blacks

When it comes to booster shots, however, it’s reasonable to ask if the tail is wagging the dog.

The hubbub and hullabaloo over COVID-19 booster shots are drowning out the voices of public health officials who insist that vaccinating the unvaccinated remains job number one.

The two are, of course, interrelated – birds of a feather, two peas in a public health pod. Let’s think of them as occupying opposite sides of a split screen, a technique moviemakers have put to imaginative use for more than 100 years. See Life of an American Fireman (1903), Indiscreet (1958) and Kill Bill: Volume 1 (2003), among many others.

In 2021, the left side of the split screen shows that, in the United States, we have fully vaccinated 56% of the total population, 65% of the vaccine-eligible population (12 and older), 45% of adolescents aged 12 to 17, 67% of all adults and 83% of seniors 65+.

Worldwide, the left side of the screen offers a more sobering picture. The Global Dashboard for Vaccine Equity reports that as of September 22, 61.5% of people in high-income countries, but only 3.3% in low-income countries, had received at least one dose of COVID-19 vaccine.

On the right side of the split screen, the U.S. and a few other Western nations are busily mobilizing their booster efforts. In the U.S., people who ”should” receive a booster shot of the Pfizer/BioNTech vaccine, at least six months after their second dose, include anyone 65 or older, anyone living in a long-term care facility and adults ages 50 to 64 who have medical conditions that put them at high risk for severe COVID-19.

But wait, there’s more. Also eligible, based on an assessment of individual risk and benefits, are people ages 18 to 64 in jobs putting them at high risk for COVID-19 (frontline workers across a variety of occupations) and people 18 to 49 with underlying medical conditions, who have been encouraged to consult with their healthcare provider.

Call it coincidence, but last week a split screen would have shown the Food and Drug Administration and Centers for Disease Control and Prevention issuing booster recommendations on the one side while the United Nations General Assembly and World Health Organization on the other wrestled with the matter of global vaccine inequity.

The U.S. and other countries, meeting virtually in a vaccine summit, pledged to donate millions of doses in an effort to vaccinate 70% of the world’s population by September 2022. But we can do more and sooner, argue Georgetown professors Lawrence Gostin (also director of WHO’s Collaborating Center on National and Global Health Law) and Eric Friedman. Writing in Medpage Today, they note that the Biden administration’s original plan to give boosters to the entire U.S. population was “tone-deaf to global suffering.”

The booster parade

•  The booster decision has generated considerable debate throughout the scientific community. The FDA and CDC advisory committees were not entirely in sync, but the subsequent recommendations of their respective leadership are essentially in agreement.

•  Lecia Bushak explores the booster conundrum in MM+M, noting how difficult it is to conduct scientific discussions under the glare of 24/7 public scrutiny. Unclear or inconsistent communication only magnifies the challenges.

•  Most people now seeking boosters won’t care much about the context; the arm wants what the arm wants. Pharmacies, hospitals, long-term care facilities, home care agencies and others are rolling out the invitations to roll up the sleeves for shot number three.

•  Although the booster recommendation is specific to the Pfizer/BioNTech vaccine, vaccination sites following CDC’s guidance will allow individuals to self-attest to their eligibility for a booster. In other words, it’s an honor system and you are responsible for your own “truthiness.” 

•  For those who didn’t receive the Pfizer vaccine or received it less than six months ago, public health officials are advising folks to be patient, wait your turn and it will come. Moderna has submitted its initial booster paperwork and is trying to be patient as well. J&J is somewhere en route.

•  It almost makes you nostalgic for those long-gone days of – what, 10 months ago? – when the initial vaccine rollout spelled out the priorities. Remember groups 1a, 1b and 1c?

•  Meanwhile, POTUS got his booster SHOTUS on Monday.

•  The upshot, pardon the expression, is to leave on the table a number of pertinent questions, including:

– Will the advent of boosters change the definition of what it means to be “fully vaccinated”? For now, the official response is “nope.”

– Will boosters make the vaccine-hesitant even more so? A Kaiser Family Foundation survey notes that the booster discussion has been a net positive for the vaccinated but a net negative for the unvaccinated, 71% of whom view boosters as a sign that the vaccines are not working.

– How soon will children under 12 be vaccine-eligible? Pfizer/BioNTech have now submitted data to the FDA for children 5 to 11 years of age. The past five weeks have seen more than 1 million new cases of COVID-19 among children and adolescents in the U.S., according to the American Academy of Pediatrics and Children’s Hospital Association.

– Will there be enough doses available to handle the demand for boosters and the next wave of shots for kids newly eligible? For now, the official answer is “yes indeed.

Source: Getty Images.

Still job number 1

Moving the needle into the arms of the unvaccinated is supposed to be the A-side of the record. The B-Side is for boosters.

•  The current vaccination rate among nursing home staff – 64.4%, nationally – is not good enough to protect residents from outbreaks of infection, Danielle Brown reports in McKnight’s Long-Term Care News.

•  Brown notes that the federal government has come up with a new tool that makes it easier for consumers to compare vaccination rates among nursing home staff and residents. The old tool was somewhat user-hostile.

•  Ohio, the first state to offer a lottery for the vaccinated, has a new incentive for the youngest: The Vax-2-School program will give away five scholarships of $100,000 and 50 scholarships of $10,000. Adolescents and young adults ages 12 to 25 (46% of whom have been vaccinated) are eligible. The money can be used for college or vocational school.

•  The National Hockey League expects that 98% of players will have their COVID-19 vaccine by the time the season opens on October 12. That would leave just 10 to 15 players unvaxxed. The vaccine is by far the lightest piece of protective equipment for players who skate around with 25 pounds of gear (double that for goalies).

•  One key to improving the vaccination rate is to find the group dubbed “unvaccinated but willing,” which describes 44% of the unvaccinated according to a federal government report. The group includes people who continue to wait and see and others who are ready to roll up their sleeves but face logistical obstacles, such as getting time away from work, having family care responsibilities or finding transportation to a vaccination site.

•  The National Rural Health Association has launched a Rural Vaccine Confidence Initiative to help improve lagging COVID-19 vaccination rates. The association is turning to rural hospital CEOs to champion the campaign in concert with local business, nonprofit and faith leaders. Central to the effort is a vaccine confidence communications toolkit.

•  The NRHA is also enlisting the aid of home health agencies to educate and vaccinate, Diane Eastabrook reports in McKnight’s Home Care Daily. NRHA president Alan Morgan identifies the rural communities hardest hit by COVID-19 as African Americans in the Southeast, Latin Americans in the Southwest, Native Americans and Native Alaskans. ”We want to make sure we are reflective of what is actually happening in the rural context,” Morgan said. “We don’t want to throw up a picture of an old white guy leaning up against a tractor with a mask on. It just doesn’t resonate.”

•  In MM+M, Lecia Bushak spotlights five “Get the Shot” campaigns that resonate, including Black Doctors Read COVID Tweets, a PSA nudged into a segment of Family Guy and the “Don’t get vaccinated” funeral van.

•  In the latest Kaiser Family Foundation poll, more than one-third of the “recently vaccinated” (since June 1) said their major motivating factors were the surge in cases caused by the Delta variant, reports of hospitals and ICUs filling up with COVID-19 patients, and knowing someone who became seriously ill or died of the disease. Another major motivator was needing vaccination to travel, go to a gym or attend concerts or sporting events. One in five (19%) said their employer required vaccination and 19% cited social pressure from family and friends.

The challenges

•  FDA’s approval of the Pfizer/BioNTech vaccine not only failed to persuade vaccine-hesitant senior caregivers, it actually strengthened their opposition to vaccination, Kimberly Bonvissuto reports in McKnight’s Senior Living. Caring.com partnered with Pollfish to survey 2,000 unvaccinated private and professional caregivers of people 55 and older. After FDA approval, 31% said they would refuse the shot, up from 26% who felt that way before approval; 35% have concerns about COVID-19 vaccine safety and testing, up from 29% pre-approval; and 14% believe COVID is a hoax, up from 11%.

•  Jennifer Avila, executive director at Chicago-based Custom Home Care, said that FDA approval “really hasn’t changed the fear of the vaccine.” Her agency was able to achieve 100% compliance with a staff vaccination mandate by arranging “a lot of one-on-one conversations with knowledgeable, educated health professionals. We spent the time to talk with caregivers about their fears and related our experiences with getting the vaccine ourselves.”

•  The last thing PRWeek’s Diana Bradley expected when she took her son to the dentist was an unsolicited anti-vax diatribe from the hygienist. “If someone is in a position of authority and can influence people’s medical decisions, the fact that they are spreading misinformation should be alerted to their superiors. Period,” she writes.

•  The Federation of State Medical Boards said recently that “physicians who generate and spread COVID-19 vaccine misinformation are risking disciplinary action by state medical boards, including the suspension or revocation of their medical license.” The Board notes that doctors “possess a high degree of public trust and therefore have a powerful platform in society.” Spreading inaccurate COVID-19 information “threatens to further erode public trust in the medical profession and puts all patients at risk.”

Source: Getty Images.

Movement on mandates

•  It’s a tumultuous week in the Empire state and the Big Apple. Monday was the deadline to comply with two vaccination mandates, one for hospital and nursing home workers throughout the state and another for teachers and other school employees in New York City. Governor Kathy Hochul is ready to bring in medically trained National Guard personnel and healthcare professionals licensed in other states to take the place of unvaccinated workers. Judges upheld the school mandate and NYC Mayor Bill de Blasio set a new compliance deadline of Friday.

•  The tumult in New York is likely to echo elsewhere as mandates take effect in California, Rhode Island and Connecticut.

•  U.S. athletes won’t be allowed to compete in the 2022 Olympic and Paralympic Games in Beijing next February and March unless they show proof of COVID-19 vaccination or obtain an exemption. In the Tokyo summer games, vaccination was encouraged but optional.

•  Police and firefighter unions are among the most vocal opponents of vaccination mandates, judging by news coming out of San Jose, Los Angeles, Newark, Charlotte and other locations. The State Police Association of Massachusetts filed a lawsuit seeking to delay implementation of a vaccination mandate for all state employees, but a judge refused to issue an injunction.

•  All adults working or volunteering in Washington, DC schools and state-licensed day care centers must be vaccinated against COVID-19 by November 1, according to an order from Mayor Muriel Bowser. The vaccination mandate also applies to students age 12 and older who take part in school-based extracurricular sports.

The vaccine dashboard

•  Sanofi is not pursuing further development of an mRNA COVID-19 vaccine, but is working with GSK on a recombinant protein vaccine that could see duty as a COVID booster.

•  Generic drug companies, including Teva, want to license COVID-19 vaccine technology from Pfizer, Moderna and J&J to help increase production worldwide, Axios reports. So far, no takers.

•  A CDC study of 1,613 pregnant women who received COVID-19 vaccine (30% in the second trimester and 70% in the third trimester) found no increase in the expected risk of miscarriage or birth defects.

•  Go Give One is a fundraising program of the WHO Foundation, supporting COVID-19 vaccination in lower-income countries. The campaign is asking individuals to donate $5 for a single vaccine and hoping to generate 50 million such donations.

Source: Getty Images.

The rest

•  A CDC study in Arizona found that schools without mask mandates had rates of pediatric COVID-19 3.5 times higher than rates in schools that had mask mandates in place at the start of the school year.

•  Antibodies from llamas and camels could prove to be an effective treatment for COVID-19, Alicia Lasek reports in McKnight’s Long-Term Care News. Antibodies – or more precisely, nanobodies – from a llama named Fifi were successful in treating hamsters. If the approach works in the human animal, early COVID-19 might be treatable with nebulizers.

•  But don’t nebulize this: The Asthma and Allergy Foundation of America issued a strong warning against using hydrogen peroxide in a nebulizer to treat or prevent COVID-19, yet another “cure” circulating on social media channels. The AAFA calls it a “concerning and dangerous trend.”

•  New Mexico reported two deaths from misguided use of the antiparasitic ivermectin to treat COVID-19. The patients were 38 and 79 years old.

•  Kidney disease is a particular risk for people who develop “long COVID,” even those whose initial COVID-19 infection was mild and did not require hospitalization, John Schieszer reports in Renal & Urology News.

•  Broadway hosted the first Tony Awards in 27 months. They could have called it Come From Away.

Parting shot

“We can give boosters to people, but that’s not really the answer to this pandemic,” said Dr. Helen Keipp Talbot, associate professor of medicine at Vanderbilt and a member of the CDC’s vaccine advisory committee. “Hospitals are full because people are not vaccinated. We are declining care to people who deserve care because we are full of unvaccinated COVID-19 patients.”

Dr. Talbot’s concern comes at a time when the daily pace of new vaccinations in the U.S. is at its lowest since tracking began in January. With 689,000 COVID-19 deaths, we are averaging more than 1,000 a day for the duration of the pandemic.

In West Virginia, COVID-19 deaths during September (more than 400) exceeded the toll in the state’s (and country’s) worst mining disaster, a 1907 explosion at the Monongah mine that killed 362 men and boys. Governor Jim Justice wondered aloud why such comparisons don’t motivate more residents to get their shots. “We can stop this if we’ll just get vaccinated,” he said.

… and some B-sides that became hits

Hound Dog, Elvis Presley

Ruby Tuesday, The Rolling Stones

We Will Rock You, Queen

Unchained Melody, The Righteous Brothers

Good Riddance (Time of Your Life), Green Day

Black Water, The Doobie Brothers

Thank you for joining us as September winds down. See you back here next week. Be well, stay safe.