Implementing a long overdue vaccine mandate

https://mailchi.mp/60a059924012/the-weekly-gist-september-10-2021?e=d1e747d2d8

There's a Lot That Can Go Wrong With 'Vaccine Passports'

Declaring that “our patience is wearing thin” with Americans who refuse to be vaccinated against COVID-19, President Biden announced sweeping new plans to implement vaccine mandates on Thursday.

Businesses that employ more than 100 people must require their employees to get vaccinated or face weekly COVID testing, federal workers and contractors must be vaccinated or face disciplinary measures, and all healthcare organizations that receive Medicare or Medicaid funds must ensure 100 percent employee vaccination as a condition of continued participation in those federal payment programs. The healthcare component of the mandate will impact about 17 million workers, including those at hospitals, surgery centers, dialysis facilities, and home health agencies. The Centers for Medicare & Medicaid Services (CMS) already requires nursing home workers to be vaccinated, and yesterday announced plans to release a new regulation by October 1st, implementing the expanded mandate. According to Fierce Healthcare, at least 172 hospital systems have already announced some form of vaccine mandate, but others have expressed concerns that forcing workers to get vaccinated might exacerbate labor shortages and result in employees seeking work elsewhere.
 
Responding to President Biden’s announcement, the American Hospital Association (AHA) echoed those concerns, citing “the critical challenges that we are facing in maintaining the resiliency of our workforce.” In our view, that concern pales in comparison to the imperative to protect patients by reducing the potential for exposure by unvaccinated caregivers. If anything, the national healthcare mandate should provide cover for those hospitals and care providers that have shied away from mandates, letting other organizations take the lead. Once universal healthcare mandates are implemented, vaccine resistant workers will find few employment alternatives left, significantly dampening the risk of widespread resignations. If you don’t want to take the necessary precautions to keep patients safe, you shouldn’t be working in healthcare in the first place. Yesterday’s mandate announcement, while aggressive, is overdue.

CDC: Unvaccinated 11 times more likely to die from COVID-19

https://thehill.com/policy/healthcare/571706-cdc-covid-vaccines-remain-highly-effective?rnd=1631294709

The Centers for Disease Control and Prevention (CDC) announced results from a study Friday that found unvaccinated individuals were 11 times more likely to die from COVID-19 than fully vaccinated people. 

The research, spanning more than 600,000 people in 13 jurisdictions, also determined that unvaccinated populations were over 10 times more likely to be hospitalized — figures that underscore COVID-19 vaccines protect recipients from deaths and hospitalizations.

The study also showed that unvaccinated people were 4 1/2 times more likely to contract COVID-19 than the fully vaccinated. 

The studies come just one day after President Biden announced a new rule that would require private companies with 100 employees or more to mandate vaccinations or frequent coronavirus testing.

The Biden administration as a whole has pushed for the use of vaccines as the best way to combat the pandemic. 

CDC Director Rochelle Walensky on Friday made the case for vaccines yet again, citing the study along with two others and stating that COVID-19 shots still work to protect recipients from the worst of the disease amid the rampant spread of the delta variant. 

“As we have shown study after study, vaccination works,” Walensky said during the briefing. “CDC will continue to do all we can do to increase vaccination rates across the country by working with local communities and trusted messengers and providing vaccine confidence consults to make sure that people have the information they need to make an informed decision.”

“The bottom line is this: We have the scientific tools we need to turn the corner on this pandemic,” Walensky said. “Vaccination works and will protect us from the severe complications of COVID-19. It will protect our children and allow them to stay in school for safe in-person learning.”

The agency and Biden administration are promoting the data behind the vaccine effectiveness in their bolstered push to get the unvaccinated shots.

The U.S. has made progress with vaccinations, reaching 75 percent of adults who have had at least one dose earlier this week.

But the portion of unvaccinated people continues to affect the U.S.’s trajectory in the pandemic, with the unvaccinated making up almost all of the growing hospitalizations and deaths.

The other two studies in the CDC’s Morbidity and Mortality Weekly Report (MMWR) released Friday focused on the vaccine’s effectiveness against hospitalization.

One involving five Veterans Affairs Medical Centers found the mRNA vaccines’ overall effectiveness against hospitalization reached 86.8 percent.

Another similarly calculated that effectiveness at 86 percent among patients in emergency departments, urgent cares and hospitals across nine states. 

However, the studies also provided some evidence that the effectiveness of the vaccines are starting to wane among the older population, prompting the researchers to call for further investigation.

For the patients in emergency departments, urgent cares and hospitals across nine states, the effectiveness among those aged 75 and older was 76 percent, while among those aged 18 to 74, effectiveness reached 89 percent. 

But researchers urged caution, with the report saying “this moderate decline should be interpreted with caution and might be related to changes in SARS-CoV-2, waning of vaccine-induced immunity with increased time since vaccination, or a combination of factors.”

The study involving Veterans Affairs facilities determined that the mRNA vaccine effectiveness among those aged 65 and older was 79.8 percent, compared to 95.1 percent among those aged 18 to 64.

More than 82 percent of those aged 65 and older are considered fully vaccinated, according to CDC data.

Surgeon General Vivek Murthy said Friday the administration is aiming to get “as close to 100 percent as possible” through expanded outreach.

“We know that every senior matters in terms of getting them vaccinated as a potential life saved,” he said, adding that booster vaccinations “will likely be helpful” for the older population. 

The Biden administration had announced it planned to start administering additional shots to recipients on Sept. 20 beginning eight months after their second shot.

But the plan led to criticism from some experts who said the administration was getting ahead of the review process at the Food and Drug Administration (FDA), although officials say the strategy depends on FDA approval.

Delta variant ignites new mask debate

https://thehill.com/policy/healthcare/561039-delta-variant-ignites-new-mask-debate?userid=12325

Delta variant ignites new mask debate | TheHill

Health officials are grappling with how to prevent potential COVID-19 outbreaks from the delta variant that is spreading rapidly across the U.S.

Concern over the highly transmissible delta strain prompted Los Angeles County this week to recommend that all people wear masks indoors, even if they’re vaccinated. The World Health Organization (WHO) has also encouraged fully vaccinated people to continue using masks.

But the Centers for Disease Control and Prevention (CDC) has not signaled any plans to revise its mask guidance, with Biden administration officials and some experts say that fully vaccinated Americans are safe from all existing COVID-19 variants.

“If you have been vaccinated, the message we’re conveying is you’re safe,” White House press secretary Jen Psaki said Wednesday. “Vaccines are effective, and that is something we want to be very clear with the public about.”

Still, the move by officials in Los Angeles County raises the prospect that mask recommendations and even mandates could make a return to certain parts of the country.

The CDC projected the delta variant made up more than a quarter of cases in the U.S. in the most recent two-week period, ending June 19 — a jump from 10 percent the previous two weeks.

Los Angeles County issued a statement Monday saying it “strongly recommends” all people wear masks in indoor settings where they don’t know everyone’s vaccination status.

Barbara Ferrer, director of the county’s Department of Public Health, told The Hill that officials want to take time to get more people vaccinated as research is conducted on delta variant transmission from the fully vaccinated.

“While we’re doing that work with building confidence, we’re going to go ahead and offer as much protection as possible for everyone,” she said.

Leana Wen, an emergency physician and public health professor at George Washington University, praised the county’s decision as the “right move,” saying she hopes other jurisdictions follow suit to protect both vaccinated and unvaccinated residents.

“People who are fully vaccinated are still at risk, albeit a low risk, from those who are unvaccinated,” Wen said.

“Fully vaccinated people can be around others who are fully vaccinated without any limitations,” she added. “However, if they’re going to be around unvaccinated people or vaccination status is not being checked, then those could be high-risk settings” where masks should be worn.

For now, Los Angeles County is an outlier as cities and states continue to loosen mask requirements. Washington’s King County, home to Seattle, and Pennsylvania were the latest jurisdictions to end their mandates, taking that step this week.

CDC Director Rochelle Walensky told NBC’s “Today” on Wednesday that the agency’s guidance that fully vaccinated people don’t need masks in most settings has not changed. She said the WHO has given conflicting instructions, saying the international organization is focused on the global community, which has a lower vaccination rate than the U.S.

“We have always said that local policymakers need to make policies for their local environment,” Walensky said. “But those masking policies are not to protect the vaccinated, they’re to protect the unvaccinated.”

So far, the delta strain has not led to any changes in masking policies at the White House or the Capitol.

The White House does not require masks if a person is vaccinated, although the administration is not checking to see whether all maskless people have gotten their COVID-19 shots.

In recent weeks, the House has ended its universal mask requirement, and few people in the Capitol continue to wear them. The overwhelming majority of lawmakers in both parties have shed masks and freely gather in large groups on the House floor.

The Senate, which never had a mask requirement since nearly all senators voluntarily wore facial coverings when it was recommended, has also relaxed its pandemic restrictions.

But the delta variant threat is influencing other activities in the House. Speaker Nancy Pelosi (D-Calif.) announced this week that proxy voting would be extended through Aug. 17, and House Majority Leader Steny Hoyer (D-Md.) said that was due to the global spread of the delta variant.

“As we know, there are some countries in the world that are seeing a virulent resurgence of this new variant of the COVID-19. Israel is a perfect example of that,” Hoyer told reporters, referring to Israel reimposing its indoor mask mandate despite having one of the world’s highest vaccination rates. “But even in Israel, where they have the vaccine available, they’re seeing a resurgence.”

“So, the Speaker correctly, along with the medical advice that she’s gotten, determined that there was still justification for staying on guard,” Hoyer said.

Recent studies have found that COVID-19 vaccines are effective against the strain. Both doses of Pfizer-BioNTech were found to be 88 percent effective against symptomatic disease.

There is “less data” on how Johnson & Johnson performs, Walensky said Wednesday, but “right now we have no information to suggest that you need a second shot after J&J, even with the delta variant.”

Jen Kates, senior vice president and director of global health & HIV policy at the Kaiser Family Foundation, said research shows the CDC guidance “still stands,” although she acknowledged the agency needs to be prepared to adjust.

Kates expressed concern that the resurgence of the mask debate could affect the vaccination effort, noting the variant is spreading mostly among unvaccinated people.

“The worst outcome, I think, is that people choose not to get vaccinated because they think the vaccines aren’t as effective against variants,” she said.

As most Americans have gotten vaccinated, COVID-19 cases, hospitalizations and deaths have declined significantly. But the U.S. is expected to fall short of President Biden’s goal to have 70 percent of adults receiving at least one vaccine dose by the Fourth of July.

The White House still plans to move forward with Independence Day festivities. The administration sent 1,000 invitations for people to gather at 1600 Pennsylvania Ave. on Sunday, with vaccinated people allowed to go without masks. All guests were instructed to get tested one to three days before arriving.

“We certainly feel comfortable and confident moving forward with our event here at the White House and individuals having barbecues in their backgrounds this week to celebrate the Fourth of July,” Psaki said on Wednesday.

The Worst-Case COVID-19 Predictions Turned Out To Be Wrong. So Did the Best-Case Predictions.

http://www.reason.com/2021/06/22/

CrystalBallDoctorDreamstime

An argument for humility in the face of pandemic forecasting unknown unknowns.

“Are we battling an unprecedented pandemic or panicking at a computer generated mirage?” I asked at the beginning of the COVID-19 pandemic on March 18, 2020. Back then the Imperial College London epidemiological model’s baseline scenario projected that with no changes in individual behaviors and no public health interventions, more than 80 percent of Americans would eventually be infected with novel coronavirus and about 2.2 million would die of the disease. This implies that 0.8 percent of those infected would die of the disease. This is about 8-times worse than the mortality rate from seasonal flu outbreaks.

Spooked by these dire projections, President Donald Trump issued on March 16 his Coronavirus Guidelines for America that urged Americans to “listen to and follow the directions of STATE AND LOCAL AUTHORITIES.” Among other things, Trump’s guidelines pressed people to “work or engage in schooling FROM HOME whenever possible” and “AVOID SOCIAL GATHERINGS in groups of more than 10 people.” The guidelines exhorted Americans to “AVOID DISCRETIONARY TRAVEL, shopping trips and social visits,” and that “in states with evidence of community transmission, bars, restaurants, food courts, gyms, and other indoor and outdoor venues where people congregate should be closed.”

Let’s take a moment to recognize just how blindly through the early stages of the pandemic we—definitely including our public health officials—were all flying at the time. The guidelines advised people to frequently wash their hands, disinfect surfaces, and avoid touching their faces. Basically, these were the sort of precautions typically recommended for influenza outbreaks. On July 9, 2020, an open letter from 239 researchers begged the World Health Organization and other public health authorities to recognize that COVID-19 was chiefly spread by airborne transmission rather than via droplets deposited on surfaces. The U.S. Centers for Disease Control and Prevention (CDC) didn’t update its guidance on COVID-19 airborne transmission until May 2021. And it turns out that touching surfaces is not a major mode of transmission for COVID-19.

The president’s guidelines also advised, “IF YOU FEEL SICK, stay home. Do not go to work.” This sensible advice, however, missed the fact that a huge proportion of COVID-19 viral transmission occurred from people without symptoms. That is, people who feel fine can still be infected and, unsuspectingly, pass along their virus to others. For example, one January 2021 study estimated that “59% of all transmission came from asymptomatic transmission, comprising 35% from presymptomatic individuals and 24% from individuals who never develop symptoms.”

The Imperial College London’s alarming projections did not go uncontested. A group of researchers led by Stanford University medical professor Jay Bhattacharya believed that COVID-19 infections were much more widespread than the reported cases indicated. If the Imperial College London’s hypothesis were true, Bhattacharya and his fellow researchers argued, that would mean that the mortality rate and projected deaths from the coronavirus would be much lower, making the pandemic much less menacing.

The researchers’ strategy was to blood test people in Santa Clara and Los Angeles Counties in California to see how many had already developed antibodies in response to coronavirus infections. Using those data, they then extrapolated what proportion of county residents had already been exposed to and recovered from the virus.

Bhattacharya and his colleagues preliminarily estimated that between 48,000 and 81,000 people had already been infected in Santa Clara County by early April, which would mean that COVID-19 infections were “50-85-fold more than the number of confirmed cases.” Based on these data the researchers calculated that toward the end of April “a hundred deaths out of 48,000-81,000 infections corresponds to an infection fatality rate of 0.12-0.2%.” As I optimistically reported at the time, that would imply that COVID-19’s lethality was not much different than for seasonal influenza.

Bhattacharya and his colleagues conducted a similar antibody survey in Los Angeles County. That study similarly asserted that COVID-19 infections were much more widespread than reported cases. The study estimated 2.8 to 5.6 percent of the residents of Los Angeles County had been infected by early April. That translates to approximately 221,000 to 442,000 adults in the county who have had the infection. “That estimate is 28 to 55 times higher than the 7,994 confirmed cases of COVID-19 reported to the county by the time of the study in early April,” noted the accompanying press release. “The number of COVID-related deaths in the county has now surpassed 600.” These estimates would imply a relatively low infection fatality rate of between 0.14 and 0.27 percent. 

Unfortunately, from the vantage of 14 months, those hopeful results have not been borne out. Santa Clara County public health officials report that there have been 119,712 diagnosed cases of COVID-19 so far. If infections were really being underreported by 50-fold, that would suggest that roughly 6 million Santa Clara residents would by now have been infected by the coronavirus. The population of the county is just under 2 million. Alternatively, extrapolating a 50-fold undercount would imply that when 40,000 diagnosed cases were reported on July 11, 2020, all 2 million people living in Santa Clara County had been infected by that date.

Los Angeles County reports 1,247,742 diagnosed COVID-19 cases cumulatively. Again, if infections were really being underreported 28-fold, that would imply that roughly 35 million Angelenos out of a population of just over 10 million would have been infected with the virus by now. Again turning the 28-fold estimate on its head, that would imply that all 10 million Angelenos would have been infected when 360,000 cases had been diagnosed on November 21, 2020.

COVID-19 cases are, of course, being undercounted. Data scientist Youyang Gu has been consistently more accurate than many of the other researchers parsing COVID-19 pandemic trends. Gu estimates that over the course of the pandemic, U.S. COVID-19 infections have roughly been 4-fold greater than diagnosed cases. Applying that factor to the number of reported COVID-19 cases would yield an estimate of 480,000 and 5,000,000 total infections in Santa Clara and Los Angeles respectively. If those are ballpark accurate, that would mean that the COVID-19 infection fatality rate in Santa Clara is 0.46 percent and is 0.49 percent in Los Angeles. Again, applying a 4-fold multiplier to take account of undercounted infections, those are both just about where the U.S. infection fatality rate of 0.45 percent is now.

The upshot is that, so far, we have ended up about half-way between the best case and worst case scenarios sketched out at the beginning of the pandemic.

The Beginning of the End of the American Pandemic

A tree branch emerging out from the shadows to the light with blooms and bird perched on top.

The country is reopening. What does the future hold?

The story of the American pandemic has unfolded in three chapters. The first began last January, when the coronavirus emerged and the world was plunged into uncertainty about how covid-19 could be treated, how the virus spread, and when it might be defeated. The second started on the morning of November 9, 2020, when Pfizer-BioNTech announced the extraordinary efficacy of its vaccine. Those results made clear that this pandemic would end not through infection but vaccination. Our goals shifted from merely slowing the spread to beginning immunization as quickly as possible. In America, much of the past half year has been devoted to administering vaccines and gathering evidence on how well they work in the real world.

Earlier this month, the Centers for Disease Control and Prevention ushered in the American pandemic’s third chapter. The agency announced that vaccinated people could go without masks or social distancing indoors and outside, in crowds large and small. It carved out a few exceptions—for hospitals, public transportation, and the like—and noted that people still needed to obey federal and local laws. But the broad message was that vaccinated Americans could resume their pre-pandemic lives. The C.D.C. is an agency known for caution, and its new guidance shocked many public-health experts; just two weeks earlier, it had issued far more restrictive recommendations. During the same period, a survey of nearly six hundred epidemiologists found that more than three-quarters of them believed that indoor mask-wearing might remain necessary for another year or more. Still, immediately after the announcement, a number of states lifted their mask mandates. Others will surely follow, as the pressure to return to normal grows. America is now moving swiftly toward reopening.

Despite the C.D.C.’s early stumbles on communication, masks, and tests, it remains perhaps the world’s preëminent public-health agency. Its recommendations carry unparalleled scientific force in the U.S. and beyond. Ultimately, the C.D.C.’s decision reflects real shifts in the weight of the evidence on several fundamental epidemiological questions: Are the vaccines as effective as they were in the trials? Can they protect us against the coronavirus variants? And do they prevent not just illness but transmission? The answers to these questions give us good reason to think that the pandemic’s newest chapter will be its last. Read The New Yorker’s complete news coverage and analysis of the coronavirus pandemic.

On the first question, the nationwide rollout of covid-19 vaccines has proved, beyond any doubt, that they are astonishingly effective at preventing serious illness, even for the most vulnerable people. So-called breakthrough infections, in which the virus weaves its way around some of an individual’s immune system, do occur. But such infections are extremely rare, and—because a person almost always has some effective antibodies and other immune-system defenses—they usually cause mild or no symptoms. In one study, the C.D.C. examined post-vaccination infections among nearly fifteen thousand nursing-home residents and staff members, and discovered only two covid-19 hospitalizations and one death. Another study, involving half a million health-care workers from around the country, found that getting two shots reduced the risk of a symptomatic infection by ninety-four per cent. Moving forward, we should expect to continue seeing breakthrough infections from time to time—but, for the most part, we shouldn’t worry about them. (At the same time, the covid vaccines have proved exceptionally safe. Few dangerous side effects have been linked to the vaccines from Pfizer-BioNTech or Moderna, and the over-all risk of concerning blood clots after receiving Johnson & Johnson’s vaccine is rare—as of last week, when more than nine million doses had been administered, there were thirty confirmed cases.)

The most striking vaccine-efficacy statistic draws on data shared by state governments. Around a hundred and thirty million Americans are fully vaccinated, and the C.D.C. has said that it has received reports of fewer than fourteen hundred covid-19 hospitalizations and three hundred deaths among them. This means that, after vaccination, one’s chances of dying of covid-19 are currently about two in a million, with the likelihood of being hospitalized only slightly higher. Statistics reported by hospitals tend to be accurate; still, even if state governments have missed a few cases here and there, the results are staggeringly good. “The evidence on vaccines just keeps getting better and better,” Robert Wachter, a physician and the chair of medicine at the University of California, San Francisco, told me. “When the trial results first came out, I thought, They can’t actually be this good. The real world is always messier than the trials. What we’ve learned since then is that the vaccines are probably even more spectacular than we initially believed.”

The answer to the second questionwhether the vaccines work against the major coronavirus variants—is also now clear. Earlier this month, a study conducted in Qatar, where the B.1.1.7 and B.1.351 variants predominate, found that the Pfizer-BioNTech vaccine was ninety-seven per cent effective at preventing severe disease. Vaccines from Moderna and Johnson & Johnson also appear to be highly effective against the variants; in fact, these vaccines are already successfully fighting them here in the United States. The B.1.1.7 variant, which is vastly more contagious than the original virus and caused a devastating surge in the U.K. this past winter, now accounts for three-quarters of new U.S. cases—and yet, largely thanks to vaccination, daily infections in this country have fallen by nearly ninety per cent since their peak in January, and are now lower than at any point in the past eight months. The existence of more contagious variants isn’t a reason to doubt the vaccines but to vaccinate people as quickly as possible.

As for the final questionwhether vaccinated people can spread the virus to others, especially unvaccinated people, including children—the evidence is similarly encouraging. Because vaccinated people are unlikely to contract the virus, the vast majority won’t be passing it on. And even the small number of vaccinated people who experience breakthrough infections have much less of the virus circulating in their bodies, and may be less infectious. Real-world data from Israel, which has mounted one of the world’s fastest and most effective vaccination campaigns, is instructive. The country’s progress in immunizing its adults has been linked to significant declines in infections among unvaccinated people; according to one preliminary estimate, each twenty-percentage-point increase in adult vaccination rates reduces infections for unvaccinated children by half. When vaccinated people remove their masks, they pose little threat to others, and they face little peril themselves.

The shift toward reopening is not without risk. The first issue is timing. Less than half of Americans have received even one shot of a covid-19 vaccine, and only around four in ten have been fully vaccinated. This means that the majority of the country remains susceptible to infection and disease. Meanwhile, the pace of vaccinations has slowed: in April, the U.S. was routinely vaccinating about three million people per day, but the daily average is now nearly two million. It’s unclear whether the new guidance will encourage or deter unvaccinated Americans from getting immunized. In a recent survey, unvaccinated Republicans said that they would be nearly twenty per cent more likely to get the shots if it meant that they wouldn’t have to wear a mask anymore. We’ll now find out how they really feel.

Vaccine hesitancy is only part of the picture. Some thirty million Americans—a group larger than anti-vaxxers or the vaccine-hesitant—say that they want to get immunized but haven’t yet done so. Some face language barriers, or fear immigration problems; others have difficulty navigating the health system, or can’t take time off from work. Many of the willing-but-unvaccinated are working-class Americans; four in five don’t have a college degree. The Biden Administration has sent billions of dollars to health centers serving low-income populations, offered tax credits to businesses that provide paid time off for employees to get immunized, and helped assemble thousands of volunteers—known as the covid-19 Community Corps—to assist with vaccine outreach to underserved populations. States, too, are trying to reduce barriers to vaccination, and offering incentives—including payments in Maryland, a lottery in Ohio, and a “Shot and a Beer” program in New Jersey—for residents who remain on the fence. There are, in short, real efforts under way to sway the vaccine-hesitant and make vaccines more accessible.

Still, the new C.D.C. guidance makes these efforts even more urgent. Until now, unvaccinated people have been shielded from high levels of viral exposure by government mandates and social norms that have kept their friends, neighbors, and colleagues masked and distanced, to varying degrees. But, in the coming weeks, those protections will likely erode. For unvaccinated Americans, this could be the most dangerous moment in the pandemic. In most contexts, there is no reliable mechanism for verifying who has and hasn’t been vaccinated. Inevitably, against the C.D.C.’s advice, many unvaccinated people will resume normal life, too, threatening their own health and that of others. When asked how businesses are to know which customers can enter unmasked, Anthony Fauci, the nation’s top infectious-disease expert, told CNN, “They will not be able to know. You’re going to be depending on people being honest enough to say whether they were vaccinated or not.”

“Unvaccinated people are now going to have much higher levels of exposure,” Wachter told me. “That’s especially true in places with lots of community spread and in places where more contagious variants are circulating.” Wachter suggested that the C.D.C. could be making an epidemiological bet. The move “will cause some additional covid cases that otherwise would not have occurred,” he said—but, “if it leads to even a small uptick in vaccination, it will save lives in aggregate.”

Since the start of the pandemic’s second chapter, public-health officials have been working to prevent a catastrophic collision between the ship of reopening and the iceberg of the unvaccinated. By slowing the speed of the ship or shrinking the size of the iceberg, we have sought to reduce the force of the collision. But barring a hundred-per-cent vaccination rate, or something close to it—an outcome that the U.S. was never likely to achieve—a crash of some sort has been inevitable. India’s collision has been titanic—it reopened with a population of more than a billion, even though hardly anyone was vaccinated. In the U.S., the situation is different. Our iceberg has been melting, and we’ve been approaching it slowly. Now we’re taking off the brakes.

The C.D.C. issues guidance, not laws; there are several quantitative measures that states, counties, cities, companies, and individuals can consult in pacing their reopening and squaring the agency’s broad recommendations with local realities. A community’s immunization rate is perhaps the most obvious statistic to track. Experts have argued for meeting a seventy-per-cent immunity threshold before relaxing masking and distancing requirements. No states have got there yet, although some, such as Vermont and Maine, are well on their way. The Biden Administration has said that it hopes to hit the seventy-per-cent target for first shots by the Fourth of July.

Because the vaccines prevent almost all cases of severe covid-19, the number of covid-19 hospitalizations is another good metric to watch. “With vaccines, cases become uncoupled from severe disease,” Monica Gandhi, an infectious-disease doctor at the University of California, San Francisco, who has studied asymptomatic coronavirus transmission, told me. Gandhi was among the first researchers to show that masks protect not just others but wearers, too; when we spoke, before the C.D.C.’s announcement, she said that, in her view, most precautions could end when half of Americans had received their first shot and covid-19 hospitalizations had fallen below sixteen thousand nationally, or about five per hundred thousand people. (At the peak of most flu seasons, the U.S. records five to ten influenza hospitalizations per hundred thousand.) Hospitalizations appear to be falling, unevenly, across the country. However, there are currently thirty thousand Americans hospitalized with covid-19—roughly a quarter of the January peak, but still about twice Gandhi’s threshold.

Herd immunity offers a third benchmark for reopening. The idea is that, once about eighty per cent of the population has been vaccinated or infected, the virus will struggle to spread. Recently, some experts have argued that we might never get to herd immunity because of variants, vaccine hesitancy, and the fact that children under twelve, who make up some fifteen per cent of the U.S. population, are unlikely to be immunized for some time. But the C.D.C.’s recommendation could change the equation. As states lift restrictions and unvaccinated people face higher levels of exposure, more of them are likely to get infected, pushing us closer to the herd immunity threshold. In all likelihood, the U.S. will be able to reach sixty-per-cent vaccination in the coming weeks; meanwhile, perhaps a third of Americans have already been infected. Even assuming significant overlap between the two groups, the combination of vaccination and infection is likely to make it harder for the virus to find new hosts. Marc Lipsitch, the director of Harvard’s Center for Communicable Disease Dynamics, emphasized that, because some parts of the country may reach herd immunity, or something close to it, before others—Connecticut’s current covid-19 immunization rate, for instance, is nearly twice Mississippi’s—unvaccinated adults will face different levels of risk depending on where they live. “There won’t be one national end,” Lipsitch told me. “We’re going to see a fundamental change in terms of what it means to live in this country, but there’s also going to be a lot of local variation.”

Covid-19 deaths give us another way of tracking the pandemic. Experts have argued that the U.S., with a population of three hundred and thirty-two million, should aim for fewer than a hundred coronavirus deaths daily—roughly the toll of a typical flu season. Right now, America is seeing about six hundred covid-19 deaths each day; according to the Institute for Health Metrics and Evaluation, which generates one of the country’s most widely cited pandemic models, that number will likely fall to about a hundred in August. “Things will look very good this summer,” Christopher Murray, the director of the I.H.M.E., told me. “A lot of people will think that we’re done, that it’s all over. But what happens in the fall is the tricky part.” Murray believes that a confluence of factors—the spread of variants, in-person schooling, meaningful numbers of still-unvaccinated people, and the seasonality of the virus—will produce a small winter spike, concentrated in communities with low vaccination rates. It won’t be the apocalyptic surge of New York City in the spring of 2020—or, more recently, those of India or Brazil—but, each week, several thousand unvaccinated Americans could die.

It’s possible, given all this, to imagine a plausible scenario for the conclusion of the American pandemic. The coronavirus disease toll continues to fall throughout the summer. States do away with mask mandates and capacity restrictions; people increasingly return to bars, spin classes, and airports, then to stadiums, movie theatres, and concerts. By midsummer, in communities with high vaccination rates, covid-19 starts to fade from view. In those places, even people who remain unvaccinated are protected, because so little of the virus circulates. But, in other parts of the country, low immunization rates combined with reopening allow the disease to register again. Hospitals aren’t overwhelmed—there’s no need to build new I.C.U.s or call in extra staff—but the collision between ship and iceberg is forceful, and each week thousands of people fall ill and hundreds die. Some victims are vaccine-hesitant; others were unable, for whatever reason, to get vaccinated. Still, perhaps unfairly, these outbreaks come with an aura of culpability: to people in safe parts of the country, the ill seem like smokers who get lung cancer.

In the fall, many unvaccinated children return to school. Scattered infections among them capture headlines, but serious illnesses are exceedingly rare; the overwhelming majority of children remain safe, and, with time, they, too, are immunized. The U.S. approaches something like herd immunity. Some people may still fall ill and die of covid-19—perhaps they are immunocompromised, elderly, or just unlucky—but, by and large, America has gained the upper hand. Meanwhile, in poor nations with few vaccines, the pandemic continues. As crisis wanes in one country, catastrophe ignites in another. Every so often, we learn of a new variant that’s thought to be more contagious, lethal, or vaccine-resistant than the rest; we rush to institute travel bans, only to learn that the variant, or a close cousin, is already circulating in the U.S. and has been largely subdued by the vaccines, as all previous variants have been. In the fall, Americans line up for covid booster shots alongside flu vaccines. The pandemic’s final chapter comes to a close not through official decree but with the gradual realization that covid-19 no longer dominates our lives.

Reopening a country after a pandemic isn’t like flipping a giant switch. It’s more like lighting a series of candles, illuminating one part, then another, until the whole place shines. Many states, counties, cities, and businesses will further loosen their restrictions; others will wait. Communities and individuals will approach the end of the crisis differently, as they’ve approached the rest of it. Some unvaccinated people have already been forgoing precautions; on the other hand, I’ve been vaccinated for months and, since the C.D.C. announcement, have yet to leave my mask behind—whether because of a lingering, irrational fear or simply to avoid dirty looks, I can’t say. Social norms take time to change, even when one of the world’s most respected public-health agencies is telling you to change them.

The pandemic has created not just chaos and suffering but uncertainty. It’s easy, therefore, to be doubtful about the fortunate position in which we seem to find ourselves now. As a physician, I spent the early months of the pandemic caring for covid-19 patients in New York City; they streamed into the hospital day after day, deathly ill. We raced to build covid wards, I.C.U.s, and hospice units. At the time, we had little to offer. There were no proven therapies, and certainly no vaccines. There were weeks when thousands of New Yorkers died, many of them alone in their final moments, while more people were dying across the world. I felt fear, anxiety, and sometimes despair. The scale of the damage—the lives lost, businesses shuttered, dreams shattered, children orphaned, seniors isolated—was crushing, and the path forward was both frightening and unknown.

As good news began to arrive, I greeted it with a blend of guarded skepticism and cautious optimism. First came evidence that outdoor transmission was unlikely. Then we learned that contaminated surfaces rarely spread disease; that some patients can breathe better simply by lying on their bellies; that P.P.E. works; that dexamethasone saves lives. We discovered that immunity lasts many months, perhaps years; that repeat infections are unlikely; and that variants present a surmountable challenge.

Now, study after study, in country after country, has shown that the vaccines are capable of transforming a lethal pathogen into a manageable threat. Examining and reëxamining the vaccine results, I’ve gone through stages, too—caution, hope, and, finally, clarity. We really are that close. The beginning of the end is here.

Reaching ‘Herd Immunity’ Is Unlikely in the U.S., Experts Now Believe

Reaching 'Herd Immunity' Is Unlikely in the U.S., Experts Now Believe - The  New York Times

Widely circulating coronavirus variants and persistent hesitancy about vaccines will keep the goal out of reach. The virus is here to stay, but vaccinating the most vulnerable may be enough to restore normalcy.

Early in the pandemic, when vaccines for the coronavirus were still just a glimmer on the horizon, the term “herd immunity” came to signify the endgame: the point when enough Americans would be protected from the virus so we could be rid of the pathogen and reclaim our lives.

Now, more than half of adults in the United States have been inoculated with at least one dose of a vaccine. But daily vaccination rates are slipping, and there is widespread consensus among scientists and public health experts that the herd immunity threshold is not attainable — at least not in the foreseeable future, and perhaps not ever.

Instead, they are coming to the conclusion that rather than making a long-promised exit, the virus will most likely become a manageable threat that will continue to circulate in the United States for years to come, still causing hospitalizations and deaths but in much smaller numbers.

How much smaller is uncertain and depends in part on how much of the nation, and the world, becomes vaccinated and how the coronavirus evolves. It is already clear, however, that the virus is changing too quickly, new variants are spreading too easily and vaccination is proceeding too slowly for herd immunity to be within reach anytime soon.

Continued immunizations, especially for people at highest risk because of age, exposure or health status, will be crucial to limiting the severity of outbreaks, if not their frequency, experts believe.

“The virus is unlikely to go away,” said Rustom Antia, an evolutionary biologist at Emory University in Atlanta. “But we want to do all we can to check that it’s likely to become a mild infection.”

The shift in outlook presents a new challenge for public health authorities. The drive for herd immunity — by the summer, some experts once thought possible — captured the imagination of large segments of the public. To say the goal will not be attained adds another “why bother” to the list of reasons that vaccine skeptics use to avoid being inoculated.

Yet vaccinations remain the key to transforming the virus into a controllable threat, experts said.

Dr. Anthony S. Fauci, the Biden administration’s top adviser on Covid-19, acknowledged the shift in experts’ thinking.

“People were getting confused and thinking you’re never going to get the infections down until you reach this mystical level of herd immunity, whatever that number is,” he said.

“That’s why we stopped using herd immunity in the classic sense,” he added. “I’m saying: Forget that for a second. You vaccinate enough people, the infections are going to go down.”

Why reaching the threshold is tough

Once the novel coronavirus began to spread across the globe in early 2020, it became increasingly clear that the only way out of the pandemic would be for so many people to gain immunity — whether through natural infection or vaccination — that the virus would run out of people to infect. The concept of reaching herd immunity became the implicit goal in many countries, including the United States.

Early on, the target herd immunity threshold was estimated to be about 60 to 70 percent of the population. Most experts, including Dr. Fauci, expected that the United States would be able to reach it once vaccines were available.

But as vaccines were developed and distribution ramped up through the winter and into the spring, estimates of the threshold began to rise. That is because the initial calculations were based on the contagiousness of the original version of the virus. The predominant variant now circulating in the United States, called B.1.1.7 and first identified in Britain, is about 60 percent more transmissible.

As a result, experts now calculate the herd immunity threshold to be at least 80 percent. If even more contagious variants develop, or if scientists find that immunized people can still transmit the virus, the calculation will have to be revised upward again.

Polls show that about 30 percent of the U.S. population is still reluctant to be vaccinated. That number is expected to improve but probably not enough. “It is theoretically possible that we could get to about 90 percent vaccination coverage, but not super likely, I would say,” said Marc Lipsitch, an epidemiologist at the Harvard T.H. Chan School of Public Health.

Though resistance to the vaccines is a main reason the United States is unlikely to reach herd immunity, it is not the only one.

Herd immunity is often described as a national target. But that is a hazy concept in a country this large.

“Disease transmission is local,” Dr. Lipsitch noted.

“If the coverage is 95 percent in the United States as a whole, but 70 percent in some small town, the virus doesn’t care,” he explained. “It will make its way around the small town.”

Uneven Willingness to Get Vaccinated Could Affect Herd Immunity

In some parts of the United States, inoculation rates may not reach the threshold needed to prevent the coronavirus from spreading easily.

How insulated a particular region is from the coronavirus depends on a dizzying array of factors.

Herd immunity can fluctuate with “population crowding, human behavior, sanitation and all sorts of other things,” said Dr. David M. Morens, a virologist and senior adviser to Dr. Fauci. “The herd immunity for a wealthy neighborhood might be X, then you go into a crowded neighborhood one block away and it’s 10X.”

Given the degree of movement among regions, a small virus wave in a region with a low vaccination level can easily spill over into an area where a majority of the population is protected.

At the same time, the connectivity between countries, particularly as travel restrictions ease, emphasizes the urgency of protecting not just Americans but everyone in the world, said Natalie E. Dean, a biostatistician at the University of Florida in Gainesville. Any variants that arise in the world will eventually reach the United States, she noted.

Many parts of the world lag far behind the United States on vaccinations. Less than 2 percent of the people in India have been fully vaccinated, for example, and less than 1 percent in South Africaaccording to data compiled by The New York Times.

“We will not achieve herd immunity as a country or a state or even as a city until we have enough immunity in the population as a whole,” said Lauren Ancel Meyers, the director of the Covid-19 Modeling Consortium at the University of Texas at Austin.

If the herd immunity threshold is not attainable, what matters most is the rate of hospitalizations and deaths after pandemic restrictions are relaxed, experts believe.

By focusing on vaccinating the most vulnerable, the United States has already brought those numbers down sharply. If the vaccination levels of that group continue to rise, the expectation is that over time the coronavirus may become seasonal, like the flu, and affect mostly the young and healthy.

“What we want to do at the very least is get to a point where we have just really sporadic little flare-ups,” said Carl Bergstrom, an evolutionary biologist at the University of Washington in Seattle. “That would be a very sensible target in this country where we have an excellent vaccine and the ability to deliver it.”

Over the long term — a generation or two — the goal is to transition the new coronavirus to become more like its cousins that cause common colds. That would mean the first infection is early in childhood, and subsequent infections are mild because of partial protection, even if immunity wanes.

Some unknown proportion of people with mild cases may go on to experience debilitating symptoms for weeks or months — a syndrome called “long Covid” — but they are unlikely to overwhelm the health care system.

“The vast majority of the mortality and of the stress on the health care system comes from people with a few particular conditions, and especially people who are over 60,” Dr. Lipsitch said. “If we can protect those people against severe illness and death, then we will have turned Covid from a society disrupter to a regular infectious disease.”

If communities maintain vigilant testing and tracking, it may be possible to bring the number of new cases so low that health officials can identify any new introduction of the virus and immediately stifle a potential outbreak, said Bary Pradelski, an economist at the National Center for Scientific Research in Grenoble, France. He and his colleagues described this strategy in a paper published on Thursday in the scientific journal The Lancet.

“Eradication is, I think, impossible at this stage,” Dr. Pradelski said. “But you want local elimination.”

The endpoint has changed, but the most pressing challenge remains the same: persuading as many people as possible to get the shot.

Reaching a high level of immunity in the population “is not like winning a race,” Dr. Lipsitch said. “You have to then feed it. You have to keep vaccinating to stay above that threshold.”

Skepticism about the vaccines among many Americans and lack of access in some groups — homeless populations, migrant workers or some communities of color — make it a challenge to achieve that goal. Vaccine mandates would only make that stance worse, some experts believe.

A better approach would be for a trusted figure to address the root cause of the hesitancy — fear, mistrust, misconceptions, ease of access or a desire for more information, said Mary Politi, an expert in health decision making and health communication at Washington University in St. Louis.

People often need to see others in their social circle embracing something before they are willing to try it, Dr. Politi said. Emphasizing the benefits of vaccination to their lives, like seeing a family member or sending their children to school, might be more motivating than the nebulous idea of herd immunity.

“That would resonate with people more than this somewhat elusive concept that experts are still trying to figure out,” she added.

Though children spread the virus less efficiently than adults do, the experts all agreed that vaccinating children would also be important for keeping the number of Covid cases low. In the long term, the public health system will also need to account for babies, and for children and adults who age into a group with higher risk.

Unnerving scenarios remain on the path to this long-term vision.

Over time, if not enough people are protected, highly contagious variants may develop that can break through vaccine protection, land people in the hospital and put them at risk of death.

“That’s the nightmare scenario,” said Jeffrey Shaman, an epidemiologist at Columbia University.

How frequent and how severe those breakthrough infections are have the potential to determine whether the United States can keep hospitalizations and deaths low or if the country will find itself in a “mad scramble” every couple of years, he said.

“I think we’re going to be looking over our shoulders — or at least public health officials and infectious disease epidemiologists are going to be looking over their shoulders going: ‘All right, the variants out there — what are they doing? What are they capable of?” he said. “Maybe the general public can go back to not worrying about it so much, but we will have to.”

Entering a new phase of the vaccine rollout

https://mailchi.mp/da8db2c9bc41/the-weekly-gist-april-23-2021?e=d1e747d2d8

Why some Americans are hesitant to receive the COVID-19 vaccine - Vital  Record

With more than 222M Americans having received at least one dose of COVID vaccine, and 27.5 percent of the population now fully vaccinated, we are now nearing a point at which vaccine supply will exceed demand, signaling a new phase of the rollout.

This week, for the first time since February, the daily rate of vaccinations slowed substantially, down about 11 percent from last week on a seven-day rolling average. Several states and counties are dialing back requests for new vaccine shipments, and the New York Times reported that some local health departments are beginning to shutter mass vaccination sites as appointment slots go unfilled.

On Friday, the White House’s COVID response coordinator, Jeff Zients, said that the Biden administration now expects “daily vaccination rates will fluctuate and moderate,” after several weeks of accelerating pace. In every state, everyone over the age of 16 is now eligible to be vaccinated, but experts expect that demand from the “vaccine-eager” population will run out over the next two weeksnecessitating a more aggressive campaign to distribute vaccines in hard-to-reach populations, and to convince vaccine skeptics to get the shot.

Vaccine hesitancy, like so many other issues related to the COVID pandemic, has now become starkly politicized—one recent survey found that 43 percent of Republicans “likely will never get” the vaccine, as opposed to only 5 percent of Democrats. Another 12 percent of those surveyed, regardless of party identification, say they plan to “see how it goes” before getting the vaccine, a subset that will surely be unnerved by continued doubts about the safety of the Johnson & Johnson (J&J) vaccine.

An expert advisory panel on Friday recommended that use of the J&J shot be resumed, but advised that a warning be included about potential risk of rare blood clots in women under 50. The first three months of the COVID vaccination campaign have been a staggering success—but getting from 27 percent fully vaccinated to the 80 percent needed for “herd immunity” will likely be a much tougher slog.

A quarter of the country won’t get the coronavirus vaccine

We’re a year into the coronavirus pandemic, so the math that undergirds its risks should by now be familiar. We all should know, for example, that the ability of the virus to spread depends on it being able to find a host, someone who is not protected against infection. If you have a group of 10 people, one of whom is infected and nine of whom are immune to the virus, it’s not going to be able to spread anywhere.

That calculus is well known, but there is still some uncertainty at play. To achieve herd immunity — the state where the population of immune people is dense enough to stamp out new infections — how many people need to be protected against the virus? And how good is natural immunity, resistance to infection built through exposure to the virus and contracting covid-19, the disease it causes?

The safe way to increase the number of immune people, thereby probably protecting everyone by limiting the ability of the virus to spread, is through vaccination. More vaccinated people means fewer new infections and fewer infections needed to get close to herd immunity. The closer we get to herd immunity, the safer people are who can’t get vaccinated, such as young children (at least for now).

The challenge the world faces is that the rollout of vaccines has been slow, relatively speaking. The coronavirus vaccines were developed at a lightning pace, but many parts of the world are still waiting for supplies sufficient to broadly immunize their populations. In the United States, the challenge is different: About a quarter of adult Americans say they aren’t planning on getting vaccinated against the virus, according to Economist-YouGov polling released last week.

That’s problematic in part because it means we’re less likely to get to herd immunity without millions more Americans becoming infected. Again, it’s not clear how effective natural immunity will be over the long term as new variants of the virus emerge. So we might continue to see tens of thousands of new infections each day, keeping the population at risk broadly by delaying herd immunity and continuing to add to the pandemic’s death toll in this country.

But we also see from the Economist-YouGov poll the same thing we saw in Gallup polling earlier this month: The people who are least interested in being vaccinated are also the people who are least likely to be concerned about the virus and to take other steps aimed at preventing it from spreading.

In the Economist-YouGov poll, nearly three-quarters of those who say they don’t plan on being vaccinated when they’re eligible also say they’re not too or not at all worried about the virus.

That makes some perverse sense: If you don’t see the virus as a risk, you won’t see the need to get vaccinated. Unfortunately, it also means you’re going to be less likely to do things like wear a mask in public.

Or you might be more likely to view as unnecessary precautions such as avoiding close-quarter contact with friends and family or traveling out of state.

About a quarter of adults hold the view that they won’t be vaccinated when eligible. That’s equivalent to about 64 million Americans.

Who are they? As prior polls have shown, they’re disproportionately political conservatives. At the outset of the pandemic, there was concern that vaccine skepticism would heavily be centered in non-White populations. At the moment, though, the rate of skepticism among those who say they voted for Donald Trump in 2020 and among Republicans is substantially higher than skepticism overall.

That shows up in another way in the Economist poll. Respondents were asked whose medical advice they trusted. Among those who say they don’t plan to get the vaccine, half say they trust Trump’s advice a lot or somewhat — far more than the advice of the Centers for Disease Control and Prevention or the country’s top infectious-disease expert Anthony S. Fauci.

If we look only at Republican skeptics, the difference is much larger: Half of Republican skeptics say they have a lot of trust in Trump’s medical advice.

The irony, of course, is that Trump sees the vaccine as his positive legacy on the pandemic. He’s eager to seize credit for vaccine development and has — sporadically — advocated for Americans to get the vaccine. (He got it himself while still president, without advertising that fact.) It’s his supporters, though, who are most hostile to the idea.

Trump bears most of the responsibility for that, too. Over the course of 2020, worried about reelection, he undercut containment efforts and downplayed the danger of the virus. He undermined experts such as Fauci largely out of concern that continuing to limit economic activity would erode his main argument for his reelection. Over and over, he insisted that the virus was going away without the vaccine, that it was not terribly dangerous and that America should just go about its business as usual — and his supporters heard that message.

They’re still listening to it, as the Economist poll shows. One result may be that the United States doesn’t reach herd immunity through vaccinations and, instead, some large chunk of those tens of millions of skeptics end up being exposed to the virus. Some of them will die. Some may risk repeat infections from new variants against which a vaccine offers better protection. Some of those unable to get vaccinated may also become sick from the virus because we haven’t achieved herd immunity, suffering long-term complications from covid-19.

Trump wants his legacy to be the rollout of the vaccine. His legacy will also probably include fostering skepticism about the vaccine that limits its utility in containing the pandemic.

CDC director walks tightrope on pandemic messaging

https://thehill.com/policy/healthcare/546269-cdc-director-walks-tightrope-on-pandemic-messaging

Images: Tightrope walk across the Grand Canyon

Centers for Disease Control and Prevention (CDC) Director Rochelle Walensky finds herself in a delicate position as she seeks to balance the optimism of increasing vaccinations with the reality that the U.S. is still very much in the grip of a deadly pandemic.

Walensky started the CDC job with a reputation as a savvy communicator, tasked with salvaging the reputation of an agency that took a beating under the Trump administration.

“When I first started at CDC about two months ago, I made a promise to you: I would tell you the truth, even if it was not the news we wanted to hear,” Walensky told reporters recently.

Walensky’s expertise is in HIV research, like her predecessor Robert Redfield, and before being appointed to lead the CDC, she was head of infectious diseases at Massachusetts General Hospital.

While former colleagues say Walensky is the perfect fit for the CDC post, her skills are now being put to the test as she faces criticism for being both too negative and too hopeful.

“She is quite a compelling and clear communicator, but it’s a challenging set of messages to try and get out there,” said Chris Beyrer, a professor of epidemiology at Johns Hopkins Bloomberg School of Public Health.

Public health messaging during a global pandemic is complicated enough, but experts say this particular moment is especially difficult.

After weeks of decline and then stagnation, the rate of coronavirus infections has once again started to climb across much of the country. Cases are up about 12 percent nationally compared with the previous week, averaging around 62,000 cases per day, according to the CDC.

At the same time, nearly 100 million Americans have received at least one dose of a coronavirus vaccine. Many states are expanding vaccine eligibility, in some instances to all adults, and federal health officials say there will be enough supply for everyone to be vaccinated by the end of May.

Walensky tried to emphasize both aspects this week when she issued an emotional appeal to the public.

“We have so much to look forward to, so much promise and potential of where we are, and so much reason for hope. But right now I’m scared,” Walensky said, adding that she had a “sense of impending doom” if people continued to ignore public health precautions.

Yet almost in the next breath, she talked about a “tremendously encouraging” new study showing that vaccinated people were 90 percent protected from infection, meaning they pose an extremely low risk of spreading the virus.

While that may come across as mixed messaging, experts say it accurately reflects not only where things stand right now but also how the country has been reacting to the virus for the past year.

“Whiplash is a true reflection of how we’re all experiencing the epidemic and the response to it. So I’d rather she be honest about that and others be honest about that than give people something that they want … to make them feel better,” said Judith Auerbach, a professor in the University of California San Francisco School of Medicine.

Auerbach, who previously worked with Walensky on HIV research, praised the director’s openness, which she said had been missing from agency leadership during the Trump administration.

“She’s being really honest about her own emotions. That’s hard for a fed to do and get away with,” Auerbach said. “The science that says we all still need to be, in fact, quite scared because we’re in this race between the vaccines … versus the emergence of these variants, and she felt it at a visceral level, and she conveyed that in a way that I thought was quite telling.”

Glen Nowak, director of the Center for Health and Risk Communication at the University of Georgia and a former CDC media relations director, said Walensky’s candor helps establish credibility.

“She has embraced the fact that credibility comes from being transparent and honest and genuine about your fears and your concerns,” Nowak said.

The CDC declined to make Walensky available for an interview, but in a statement to The Hill, an agency spokesman said every communication reflects the latest science and epidemiology.

“At times, moments must balance hope that we will move out of the pandemic with the reality that we are not out of it yet,” the spokesman said.

“We acknowledge the challenge of conveying such hope and promise that vaccines offer with the reality that cases and deaths are rising. While we are sending the critical message that people cannot and should not let up on their prevention measures, we do remain very optimistic about what the future of a fully vaccinated public will offer,” the spokesman added.

On Friday, Walensky again came under criticism for her messaging. In updated guidance, the CDC said it is safe for people who have been fully vaccinated to travel.

But Walensky struck a cautionary tone by saying the CDC still recommends anyone, vaccinated or not, avoid nonessential travel because infection numbers are so high.

“We know that right now we have a surging number of cases,” Walensky said during a White House briefing. “I would advocate against general travel overall. Our guidance is silent on recommending or not recommending fully vaccinated people travel. Our guidance speaks to the safety of doing so.”

Nowak said part of what makes public health messaging so difficult is the fact that science doesn’t always deal in absolutes and that the public overall doesn’t do well with nuance.

“Often people don’t want to listen to the nuance; they want advice and guidance to be stable. They get frustrated with the changes or when it seems to be contradictory. They also get frustrated if it doesn’t match their everyday living experiences,” Nowak said.

With the travel guidance, Walensky attempted to spell out the balance she was trying to strike and asked the public for patience and understanding.

“I want to acknowledge today that providing guidance in the midst of a changing pandemic and its changing science is complex,” Walensky said.

“The science shows us that getting fully vaccinated allows you to do more things safely, and it’s important for us to provide that guidance, even in the context of rising cases. At the same time, we must balance the science with the fact that most Americans are not yet fully vaccinated, which is likely contributing to our rising cases,” she said.

Jen Kates, director for global health and HIV policy at the Kaiser Family Foundation, who has known Walensky for decades, said she thinks the CDC director is aware that she can’t escape criticism, especially when so many people have pandemic fatigue.

If the CDC is too strict and refuses to endorse relatively normal behavior, especially after people get vaccinated, it could risk others refusing to get the shot, Kates said.

But if the agency paints too rosy a picture, more people could act like the pandemic is over and risk further spread of the virus.

“It behooves public officials to always be cognizant that their words are being listened to and can be taken out of context or may be hard for people to grasp,” Kates said. “So I think Dr. Walensky is a great communicator, but that doesn’t mean that this is always easy to do and the balance is always straightforward.”

How Vaccine Refusal Could Prolong the Pandemic

Stephanie Nana, an evangelical Christian in Edmond, Okla., refused to get a Covid-19 vaccine because she believed it contained “aborted cell tissue.”

Nathan French, who leads a nondenominational ministry in Tacoma, Wash., said he received a divine message that God was the ultimate healer and deliverer: “The vaccine is not the savior.”

Lauri Armstrong, a Bible-believing nutritionist outside of Dallas, said she did not need the vaccine because God designed the body to heal itself, if given the right nutrients. More than that, she said, “It would be God’s will if I am here or if I am not here.”

The deeply held spiritual convictions or counterfactual arguments may vary. But across white evangelical America, reasons not to get vaccinated have spread as quickly as the virus that public health officials are hoping to overcome through herd immunity.

The opposition is rooted in a mix of religious faith and a longstanding wariness of mainstream science, and it is fueled by broader cultural distrust of institutions and gravitation to online conspiracy theories. The sheer size of the community poses a major problem for the country’s ability to recover from a pandemic that has resulted in the deaths of half a million Americans. And evangelical ideas and instincts have a way of spreading, even internationally.

There are about 41 million white evangelical adults in the U.S. About 45 percent said in late February that they would not get vaccinated against Covid-19, making them among the least likely demographic groups to do so, according to the Pew Research Center.

“If we can’t get a significant number of white evangelicals to come around on this, the pandemic is going to last much longer than it needs to,” said Jamie Aten, founder and executive director of the Humanitarian Disaster Institute at Wheaton College, an evangelical institution in Illinois.

As vaccines become more widely available, and as worrisome virus variants develop, the problem takes on new urgency. Significant numbers of Americans generally are resistant to getting vaccinated, but white evangelicals present unique challenges because of their complex web of moral, medical, and political objections. The challenge is further complicated by longstanding distrust between evangelicals and the scientific community.

“Would I say that all public health agencies have the information that they need to address their questions and concerns? Probably not,” said Dr. Julie Morita, the executive vice president of the Robert Wood Johnson Foundation and a former Chicago public health commissioner.

No clear data is available about vaccine hesitancy among evangelicals of other racial groups. But religious reasoning often spreads beyond white churches.

Many high-profile conservative pastors and institutional leaders have endorsed the vaccines. Franklin Graham told his 9.6 million Facebook followers that Jesus would advocate for vaccination. Pastor Robert Jeffress commended it from an anti-abortion perspective on Fox News. (“We talk about life inside the womb being a gift from God. Well, life outside the womb is a gift from God, too.”) The president of the Southern Baptist Convention, J.D. Greear, tweeted a photo of himself receiving a shot.

But other influential voices in the sprawling, trans-denominational movement, especially those who have gained their stature through media fame, have sown fears. Gene Bailey, the host of a prophecy-focused talk show on the Victory Channel, warned his audience in March that the government and “globalist entities” will “use bayonets and prisons to force a needle into your arm.” In a now-deleted TikTok post from an evangelical influencer’s account that has more than 900,000 followers, she dramatized being killed by authorities for refusing the vaccine.

Dr. Simone Gold, a prominent Covid-19 skeptic who was charged with violent entry and disorderly conduct in the Jan. 6 Capitol siege, told an evangelical congregation in Florida that they were in danger of being “coerced into taking an experimental biological agent.”

The evangelical radio host Eric Metaxas wrote “Don’t get the vaccine” in a tweet on March 28 that has since been deleted. “Pass it on,” he wrote.

Some evangelicals believe that any Covid restrictions — including mask mandates and restrictions on in-person church worship — constitute oppression.

And some have been energized by what they see as a battle between faith and fear, and freedom and persecution.

Fear is the motivating power behind all of this, and fear is the opposite of who God is,” said Teresa Beukers, who travels throughout California in a motor home. “I violently oppose fear.”

Ms. Beukers foresees severe political and social consequences for resisting the vaccine, but she is determined to do so. She quit a job at Trader Joe’s when the company insisted that she wear a mask at work. Her son, she said, was kicked off his community college football team for refusing Covid testing protocols.

“Go ahead and throw us in the lions’ den, go ahead and throw us in the furnace,” she said, referring to two biblical stories in which God’s people miraculously survive persecution after refusing to submit to temporal powers.

Jesus, she added, broke ritual purity laws by interacting with lepers. “We can compare that to people who are unvaccinated,” she said. “If they get pushed out, they’ll need to live in their own colonies.”

One widespread concern among evangelicals is the vaccines’ ties to abortion. In reality, the connection is remote: Some of the vaccines were developed and tested using cells derived from the fetal tissue of elective abortions that took place decades ago.

The vaccines do not include fetal tissue, and no additional abortions are required to manufacture them. Still, the kernel of a connection has metastasized online into false rumors about human remains or fetal DNA being an ingredient in the vaccines.

Some evangelicals see the vaccine as a redemptive outcome for the original aborted fetus.

Some Catholic bishops have expressed concerns about the abortion link, too. But the Vatican has concluded the vaccines are “morally acceptable,” and has emphasized the immediate danger posed by the virus. Just 22 percent of Catholics in America say they will not get the vaccine, less than half the share of white evangelicals who say that.

White evangelicals who do not plan to get vaccinated sometimes say they see no need, because they do not feel at risk. Rates of Covid-19 death have been about twice as high for Black, Hispanic, and Native Americans as for white Americans.

White pastors have largely remained quiet. That’s in part because the wariness among white conservative Christians is not just medical, but also political. If white pastors encourage vaccination directly, said Dr. Aten, “there are people in the pews where you’ve just attacked their political party, and maybe their whole worldview.”

Dr. Morita, of the Robert Wood Johnson Foundation, said the method to reach white evangelicals is similar to building vaccine confidence in other groups: Listen to their concerns and questions, and then provide information that they can understand from people they trust.

But a public education campaign alone may not be enough.

There has been a “sea change” over the past century in how evangelical Christians see science, a change rooted largely in the debates over evolution and the secularization of the academy, said Elaine Ecklund, professor of sociology and director of the Religion and Public Life Program at Rice University.

There are two parts to the problem, she said: The scientific community has not been as friendly toward evangelicals, and the religious community has not encouraged followers to pursue careers in science.

Distrust of scientists has become part of cultural identity, of what it means to be white and evangelical in America, she said.

For slightly different reasons, the distrust is sometimes shared by Asian, Hispanic and Black Christians, who are skeptical that hospitals and medical professionals will be sensitive to their concerns, Dr. Ecklund said.

“We are seeing some of the implications of the inequalities in science,” she said. “This is an enormous warning of the fact that we do not have a more diverse scientific work force, religiously and racially.”

Among evangelicals, Pentecostal and charismatic Christians may be particularly wary of the vaccine, in part because their tradition historically emphasizes divine health and miraculous healing in ways that can rival traditional medicine, said Erica Ramirez, a scholar of Pentecostalism and director of applied research at Auburn Seminary. Charismatic churches also attract significant shares of Black and Hispanic Christians.

Dr. Ramirez compares modern Pentecostalism to Gwyneth Paltrow’s Goop, with the brand’s emphasis on “wellness” and “energy” that infuriates some scientists: “It’s extra-medical,” she said. “It’s not anti-medical, but it decenters medicine.”

The Centers for Disease Control and Prevention and Dr. Anthony Fauci are not going to be able to persuade evangelicals, according to Curtis Chang, a consulting professor at Duke Divinity School who is leading an outreach project to educate evangelicals about the vaccine.

The project includes a series of short, shareable videos for pastors, answering questions like “How can Christians spot fake news on the vaccine?” and “Is the vaccine the Mark of the Beast?” The latter refers to an apocalyptic theory that the AntiChrist will force his sign onto everyone at the end of the world.

These are questions that secular public health entities are not equipped to answer, he said. “The even deeper problem is, the white evangelicals aren’t even on their screen.”

Mr. Chang said he recently spoke with a colleague in Uganda whose hospital had received 5,000 vaccine doses, but had only been able to administer about 400, because of the hesitancy of the heavily evangelical population.

“How American evangelicals think, write, feel about issues quickly replicates throughout the entire world,” he said.

At this critical moment, even pastors struggle to know how to reach their flocks. Joel Rainey, who leads Covenant Church in Shepherdstown, W.Va., said several colleagues were forced out of their churches after promoting health and vaccination guidelines.

Politics has increasingly been shaping faith among white evangelicals, rather than the other way around, he said. Pastors’ influence on their churches is decreasing. “They get their people for one hour, and Sean Hannity gets them for the next 20,” he said.

Mr. Rainey helped his own Southern Baptist congregation get ahead of false information by publicly interviewing medical experts — a retired colonel specializing in infectious disease, a church member who is a Walter Reed logistics management analyst, and a church elder who is a nurse for the Department of Veterans Affairs.

On the worship stage, in front of the praise band’s drum set, he asked them “all of the questions that a follower of Jesus might have,” he said later.

“It is necessary for pastors to instruct their people that we don’t always have to be adversaries with the culture around us,” he said. “We believe Jesus died for those people, so why in the world would we see them as adversaries?”