The Vaccine Project Newsletter: Masks On, Masks Off?

This edition of the Vaccine Project Newsletter is 3,480 words long and will take you 10 minutes to read.

Source: Getty Images
Source: Getty Images

Raise your fully vaccinated arm if you were surprised by the Centers for Disease Control and Prevention’s advice to shed the mask both indoors and outdoors, with a few notable exceptions. The decision to liberate the fully vaccinated is raising as many practical questions as it answers – and raising some hackles as well. It remains a good idea to check your local listings, as a number of jurisdictions are keeping their “masks on” rules in place for now. The CDC has also said that masking and distancing need to continue in schools.

One of the CDC’s bullet points that got lost in all the buzz is that “fully vaccinated people should continue to follow any applicable federal, state, local, tribal or territorial laws, rules and regulations.” Others are following their own counsel: Many home care providers, for example, are choosing to keep masks on, Diane Eastabrook reports in McKnight’s Home Care Daily. Campaign’s Betsy Kim interviewed 25 leading retailers to find out what they’re telling customers. Many are gladly offering masks to shoppers who don’t have them.

Will the CDC’s announcement inspire the unvaccinated, of which there are tens of millions, to roll up their sleeves? Or simply encourage them to take off their masks? CDC Director Rochelle Walensky appeared on four Sunday news programs to defend the decision and said that unvaccinated people who take their masks off are putting themselves at risk. They’re putting others at risk, too.

One observer called it the “right decision wrongly handled,” while another said the CDC has “lurched from overcaution to abandoning all caution.” National Nurses United, the country’s largest nurses’ union, condemned the decision and said it “threatened the lives of patients, nurses and other frontline workers across the country.” Eastabrook has further details on the nurses’ outrage,

Leana Wen, an emergency physician and guest columnist for the Washington Post, calls the decision “a mess” and says the White House needs to clarify “that while vaccinated people are generally not at risk, the unvaccinated are still at high risk. Therefore, if there is no reliable way to verify vaccination status, indoor mask mandates must still remain in place.” Wen also says the administration should provide criteria for lifting mask mandates – “for example, when 70% of a community is fully vaccinated.”

California has simply decided to postpone the mask drawdown until June 15 to give businesses time to prepare and people time to get vaccinated.

George Benson sang it:  Searching but not finding understanding anywhere/We’re lost in a masquerade. 

But you know what? We’ll find our way.

This edition of the Vaccine Project Newsletter is 3,480 words long and will take you 10 minutes to read.

Opening shot

It may be fair to say that 12- to 15-year-olds have not received this much national love since Doogie Howser finished medical school at the ripe old age of 14.

The approval of Pfizer’s COVID-19 vaccine for the 12-to-15 age group (some 17 million sixth through ninth graders) was not just a reasonable way to extend the reach of the nation’s vaccination campaign. In making its recommendation, the CDC’s Advisory Committee on Immunization Practices (ACIP) noted that “COVID-19 in adolescents is a major public health problem.” 

From March 1, 2020 through April 30, 2021, some 1.5 million cases of COVID-19 in youngsters ages 11 to 17 were reported to the CDC. Adolescents represent a growing proportion of new cases “and have been shown to contribute to household transmission,” the ACIP added.

As of May 1, the COVID-19 hospitalization rate for youngsters ages 12 to 17 was more than twice the rate of hospitalization for H1N1 flu in the same age group during the pandemic of 2009. In addition, adolescents 12 to 17 account for more than one in five cases of multisystem inflammatory syndrome in children (MIS-C), an uncommon but severe condition affecting multiple organ systems (heart, lungs, kidneys, brain, GI tract) and typically developing several weeks after acute SARS-CoV-2 infection.

The American Academy of Pediatrics quickly announced its support for COVID-19 vaccination of all children and adolescents 12 and older who do not have a contraindication. The AAP and CDC now support giving children and adolescents other routinely recommended immunizations at the same time they get their COVD-19 vaccination. That should help kids who have fallen behind schedule on their regular shots. 

FYI, a reboot of Doogie Howser, MD is in the works at Disney+ as “Doogie Kamealoha, MD,” starring Peyton Elizabeth Lee as a 16-year-old girl practicing medicine in Hawaii.

The communications effort

Now more than ever, it’s what you say, and how clearly you say it, that counts.

· The CDC says its latest recommendations for the fully vaccinated were heavily influenced by the latest real-world study, showing that mRNA vaccines were 94% effective in preventing symptomatic COVID-19 in healthcare workers, a high-risk population. The 94% figure was for the fully vaccinated (seven or more days after dose two). Effectiveness was 82% for the partially vaccinated (from 14 days after dose one to six days after dose two). CDC director Walensky said the study, covering more than 1,800 healthcare workers across 33 sites in 25 states, offers “the most compelling information to date” that vaccines work.

· Walensky also points to “a growing body of evidence that fully vaccinated people are less likely to have asymptomatic infection and potentially less likely to transmit SARS-CoV-2 to others.”

· YouTube and the National Health Service are teaming up in an effort to persuade 18- to 34-year-olds in the U.K. to be vaccinated, Ben Bold reports in Campaign. The theme is “Let’s not go back,” emphasizing the importance of avoiding another national surge in COVID-19 cases. Vaccine hesitancy is reported to be 13% among people ages 16 to 29, nearly double the national average. Developed by Google’s Creative Lab and produced by Gramafilm, the campaign includes 13 video ads plus digital banners, national press and paid social. BTW, YouTube is used by 98% of the 18-to-34 age group every month.

· The Ad Council and numerous collaborators have just opened a new effort to reach young adults 18 to 29, 55% of whom are unsure or disagree that COVID-19 vaccine benefits outweigh the risks.

· The Veterans Administration has produced a video titled “Fighting for Our Lives: VA Minority Clinicians Talk COVID-19 Vaccine.“ The 15-minute program features a Black pharmacist, a psychologist from the Navajo Nation, a Hispanic nurse, an Asian Pacific islander pathologist and a Black physician, all sharing personal and professional experiences. The video emphasizes that the choice to get vaccinated is a personal one and that trusted neighborhood health professionals can help individuals make the best decision for themselves and their families.

· 74-year-old Vietnam veteran John Ziegler is one of several Milwaukee residents featured in Healthy MKE, a local coalition’s campaign to reach people who are disproportionately affected by COVID-19 and are undecided about vaccination. Ziegler and other participants show us their vaccination Band-Aids as signs of hope, love and strength.

· “Emphasizing hesitancy misses the point,” says a commentary in The New England Journal of Medicine by clinicians in New York City and St. Louis. They describe a spectrum of hesitancy from vaccine ready to neutral to resistant and compare it to Prochaska’s classic “stages of change” model for behavioral decision-making. The “vaccine ready” group can be subdivided into people avidly seeking vaccination and those who are receptive and “prepared to accept vaccination if it involves minimal effort.” Local doctors, nurses and community leaders are well positioned to provide ready access to vaccines in a familiar setting along with empathetic, persuasive messages (“motivational guidance”) that can help move the reluctant through the stages of change to a positive health behavior.

· Curative, a company based in Menlo Park, CA, has pivoted from running mass testing and vaccination sites at Dodgers Stadium to working with local leaders and organizations to provide pop-up kiosks, mobile vaccination vans and other efforts in hard-to-reach rural and urban communities. In Arizona, outreach to the Islamic community included timing vaccinations in ways that respected religious norms and cultural nuances, protecting the Islamic Center’s Holy Carpet, ensuring no food in the area past the entrance and coordinating with trained interpreters.

· The new federal requirement that nursing homes report COVID-19 vaccination data for residents and staff comes with a requirement that they provide vaccine education as well, Danielle Brown notes in McKnight’s Long-Term Care News. The mantra is “educate, vaccinate and be ready to prove it.” Enforcement begins the week of June 13, at which point surveyors may ask for samples of educational materials or a roster of attendees at educational sessions. Unvaccinated residents and staff may be asked how they were educated and whether they were offered the vaccine. Data will be posted on a publicly accessible federal website.

· LLYC, a global communication and public affairs company, analyzed pro- and anti-vaccine activity in the English- and Spanish-speaking digital worlds from November through April. During that time, the digital conversation in the U.S. grew 48%, with more than 2 million conversations across a variety of social media platforms. The main misconception being spread about COVID-19 vaccine is that it alters one’s DNA. Another key finding: “While most U.S. Hispanics showed fear and doubt regarding the vaccine (generally because they have received misleading information) up until March 2021, this trend reversed in April.” Now, much of the Hispanic community is pro-vaccination, although opponents have become more vocal online.

· The Kaiser Family Foundation reports that one in three unvaccinated Latinos want to get a shot as soon as possible, twice the number of unvaccinated white (16%) or Black (17%) adults. The survey findings, Kaiser says, “hint at fixable, though difficult, vaccine access problems for the population.” Latinos are more worried than others about missing work because of vaccine side effects and concerned about possible out-of-pocket costs. More than a third fear immigration consequences for themselves or a family member.

· The National Black Nurses Association and National Hispanic Nurses Association hosted a 90-minute online town hall for colleagues and families during National Nurses Week this month. “Your Questions Get Answered on COVID-19 Vaccines” was a joint effort with the Ad Council and COVID Collaborative along with media partner El Rey Network. Both the NBNA and NAHN have been providing educational webinars and sharing COVID-19 resources with their members throughout the pandemic.The Ad Council and numerous collaborators have just opened a new effort to reach young adults 18 to 29, 55% of whom are unsure or disagree that COVID-19 vaccine benefits outweigh the risks.

The Takeaway: We’ve learned that “hesitancy” is a complex and loaded term, and that unpacking its elements is essential to understanding what’s in human hearts and minds.

Source: Getty Images

The rollout

Checking the dashboard: 47.6% of U.S. adults are fully vaccinated and 60% have had at least one shot (goal of 70% by July 4). Figuratively speaking, on a cross-country trip from New York to San Francisco, we’re somewhere around Maxwell, Nebraska (population 410).

· From May 24 through July 4, Uber and Lyft will offer free rides to and from COVID-19 vaccination sites. The initiative, with White House support, builds on previous efforts by both ride-share companies to further the vaccination effort.

· In McKnight’s Home Care Daily, Diane Eastabrook details a number of programs under way to prioritize and immunize the homebound in New York, Dallas and Los Angeles.

· Where to vaccinate a young teenager? Just about anywhere will do, as local vaccinators prepare to make use of schools, camps, doctors’ offices, hospitals, even beaches. In Bergen County, New Jersey, 12- to 21-year-olds will get a $25 Amazon gift card for each vaccine dose received.

· Maine offers Your Shot to Get Outdoors. Get your COVID-19 vaccination and receive a state hunting or fishing license, or a season pass to the Maine Wildlife Park or day pass to Maine State Park. But wait, there’s more! Other choices include a $20 L.L. Bean gift card, tickets to a Portland Sea Dogs baseball game or a pass to the Oxford Plains Speedway.

· The Pew Trusts take a look at how community health centers are stepping up to energize the vaccination effort at a time when mass vaccination centers have stepped down. A center in northern Virginia is going beyond its patient list and partnering with 100 social welfare organizations that have referred more than 19,000 low-income patients for their COVID-19 shots. Churches and temples have been among the most effective collaborators. One group they are trying to reach: young adults in medically underserved neighborhoods who aren’t being treated at the health center and may be ambivalent about getting vaccinated.

· The “Ohio Vax-a-Million” lottery will give away $1 million to each of five lucky and vaccinated (at least one dose) state residents, with weekly drawings every Wednesday from May 26 through June 23. That’s for adults; for younger Buckeyes ages 12 to 17, the weekly prize will be a full-ride four-year scholarship to a state college or university. The money is coming from federal coronavirus relief funds. Odds of winning the $1 million prize are roughly 1 in 4.9 million, according to the Cincinnati Enquirer. By way of comparison, odds of winning Powerball are about 1 in 11.7 million.

· Adults who get their first or second COVID-19 shot at Kroger or Walmart in Kentucky will receive a coupon for a state lottery ticket. About 225,000 coupons are available through May 21 for the Kentucky Cash Ball; the top prize is $225,000.

· First Lady Jill Biden and actress Jennifer Garner visited a vaccination clinic at a West Virginia high school last Thursday. The Hill said it was Biden’s “first maskless public remarks at an in-person event since the beginning of the pandemic.” Garner, who grew up in West Virginia, said she was thrilled that two of her three school-age children had vaccination appointments scheduled.

· Mary Washington Hospital in Fredericksburg, VA, used a restaurant booking app to streamline its vaccination effort. Lots of tables for one.

· Bran Castle, Dracula’s abode in Transylvania, is hosting “weekend vaccination marathons” in May. Get your vaccination in the Medieval Customs buildings, receive a vaccination “diploma” and enjoy free access to the Medieval Torture Instruments Exhibition. For Romania, this is one way of dealing with a vaccine hesitancy rate among the highest in Europe. Visitors to the Castle are assured they’ll be stuck only once that day.

The Takeaway: At one in 5 million, the chance of winning the lottery is no match for the 94% chance of being protected by the vaccine.

Source: Getty Images

The challenges

There are a few stones in this road.

· People who say they are not going to get a COVID-19 vaccination cite possible side effects not supported by evidence, a Harris poll reveals, including alteration of DNA (mentioned by 26%), infertility (24%), birth defects (24%), cancer (22%) and death (45%).

· More than 70% of U.S. adults believe that public health agencies are extremely or very important to the health of the nation, but only 54% rate the CDC’s recent performance as excellent or good, and even fewer have a favorable impression of the FDA (48%) and National Institutes of Health (47%). The findings come from a survey conducted by The Robert Wood Johnson Foundation and Harvard’s T.H. Chan School of Public Health. Democrats (74%) were much more likely than Republicans (32%) to give the CDC a favorable rating. When it comes to earning trust, however, it’s nurses, doctors, and “healthcare workers you know” at the top of the list.

· As a number of studies have reported, cancer patients may not mount a robust antibody response to COVID-19 vaccination and can’t abandon mask and distancing precautions even when fully vaccinated. STAT explores the practical challenges faced by cancer patients, organ transplant recipients and others with compromised immune systems.

· Twenty-eight cases of blood clots and low platelet counts—thrombosis with thrombocytopenia, or TTS—have been reported in people who received the J&J COVID-19 vaccine, the ACIP notes. CDC officials are describing TTS as a “rare, clinically serious and potentially life-threatening condition” with a “plausible causal association” with the vaccine. Most cases have occurred in women 30 to 49 years of age, but six of the 28 reported cases occurred in men. Three patients have died. As of May 7, more than 8.7 million doses of the J&J vaccine had been administered in the U.S.

· Although more than 300 colleges are requiring COVID-19 vaccination for students returning to campus this fall, others are hoping that incentives short of a mandate will work. That includes colleges in states that have imposed bans on COVID-19 vaccine mandates (Florida) or are considering them. The Chronicle of Higher Education reports on a number of incentives, most of which involve easing restrictions on campus activities if certain vaccination thresholds, typically 80%, are reached.

· COVID-19 vaccination of older adults (65+) is mostly a success story, though some areas are doing better than others. New Hampshire established early partnerships with local pharmacies, first responders and the National Guard and set up a centralized state website for vaccination sign-ups. Result: 99.9% of folks 65 and up received at least one dose of vaccine, according to CDC data. The national average was 79.1% and the low was 68.9%, in Alabama. For all the success, 11 million seniors remained unvaccinated as of April 10, with lower rates in counties where a high percentage of older adults lack Internet access, are poor or live alone. A Kaiser Family Foundation county-by-county analysis of the CDC data shows that issues of vaccine equity persist in the older population.

· Across all ages, vaccination rates (first dose) were notably lower in rural counties (38.9%) than urban ones (45.7%) from December through early April, the CDC reports, noting that vaccine hesitancy in rural areas is a “major barrier” that needs to be addressed.

The Takeaway: The pandemic will continue to pose medical, social and political challenges. Our responses will need to check all those boxes.

Source: Getty Images

The vaccine dashboard

As vaccine development proceeds along numerous fronts, vaccine deployment is taking center stage globally.

· Sanofi and GSK shared encouraging results from the Phase 2 trial of their COVID-19 vaccine candidate, a protein-based, adjuvanted recombinant vaccine. Patients across all age groups (18 to 95) demonstrated strong antibody responses following the second dose, with 95% to 100% seroconversion and no safety concerns. Next step: a pivotal Phase 3 trial with global enrollment of more than 35,000 adult participants. Next step after that, if all goes well: regulatory approval in Q4. Sanofi and GSK will also explore the ability of a lower dose to generate a strong booster response to any type of previous COVID-19 vaccine.

· Adults in the U.S. have not exactly lit up the night with high immunization rates for routinely recommended vaccines. Take flu, for example: Less than 50% of adults get their annual shot (48.4% in the 2019-2020 season). A newly released CDC surveillance report on adult immunization, focusing on 2018, also finds low rates for shingles vaccine (24% of those 50 and older and 34.5% of those 60 and older) and Tdap, covering tetanus, diphtheria and whooping cough (31% of all adults). Maybe COVID-19 vaccination will provide a rising tide that lifts those boats.

· The U.S. is preparing to send 20 million additional doses of vaccine to other countries by the end of June. The 20 million Pfizer, Moderna or J&J doses will be in addition to 60 million doses of previously promised AstraZeneca vaccine, not yet approved in the U.S. but sitting in our stockpile. President Biden has promised that the U.S. will serve as “an arsenal of vaccines” for the world.

· The World Health Organization keeps warning that the pandemic isn’t over despite a growing mindset to that effect in countries with high rates of vaccination. “It will not be over anywhere until it’s over everywhere,” said WHO Director General Tedros Adhanom Ghebreyesus, not for the first time and certainly not for the last.

· PhRMA and other global players have in fact agreed to a five-point plan to assure vaccine equity on the planet, with emphasis on maximizing production, stepping up dose sharing and reducing trade barriers..

· Wealthy nations that were applauded as early successes in controlling the spread of the pandemic are now lagging in vaccinations, the AP reports, with coverage rates in the single digits in Japan, South Korea and New Zealand. Japan has fully vaccinated just 1% of its population with the Tokyo Olympics less than 10 weeks away.

The Takeaway: What Tedros said.

… and some songs, from members of The Rock & Roll Hall of Fame’s 2021 class of inductees.

· Empire State of Mind, JAY-Z

· We Got the Beat, The Go-Go’s

· Better Be Good to Me, Tina Turner

· (You Make Me Feel Like) A Natural Woman, Carole King

· Hello, It’s Me, Todd Rundgren

· The Pretender, Foo Fighters

Keep on rockin’ and we’ll see you here tomorrow with a brand new edition of Haymarket’s Coronavirus Briefing. Be well, and be well vaccinated.

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