With not just one, but three Covid-19 vaccines under consideration and expected to roll out before the end of the year, patients and healthcare providers are preparing for what may be an historic, record-breaking vaccination drive. This short FAQ covers key “W’s” such as what, when, who, and “will the vaccine make me feel sick?”
What Covid-19 vaccines will be available first?
At present three candidates have applied for emergency use authorization (EUA). The manufacturers are Pfizer, Moderna, and AstraZeneca. Pfizer and Moderna have produced the first vaccines for humans based on messenger RNA technology; the AstraZeneca vaccine makes use of a harmless cold-causing virus. For a full graphic explanation of all three vaccines see this Washington Post article.
When will they start to administer the first Covid vaccine in the US?
Pfizer’s EUA will be evaluated by the FDA on December 10 and Moncef Slaoui, the chief science adviser for Operation Warp Speed, says that if approved, administration of the Pfizer Covid-19 vaccine could begin as soon as 24 hours later, on the 11th or 12th. The Moderna vaccine is likely to be approved shortly thereafter, and is expected to be in use by mid-December. Most experts predict that the vaccines will be available to the general public by April.
Do all three Covid-19 vaccine candidates require booster shots?
Each of the three vaccine candidates is administered in two shots, with the second shot to be administered three weeks to a month later, depending on which vaccine is used. Johnson & Johnson’s one-shot vaccine is still in limbo, and they are now working on a two-shot version of the vaccine, so it is almost certain that the first vaccines will all require two shots.
Who will receive the first Covid-19 vaccinations?
To date, there has been no official ruling to designate the initial vaccine recipients. Dr. Slaoui has announced that after the EUA is approved, the CDC and an advisory panel will then issue recommendations regarding the first groups to be vaccinated. However, there is little doubt about the issue, as most experts have recommended that frontline healthcare workers be… at the front of the line for the Covid-19 vaccine, along with first responders and essential workers.
What sorts of side effects have been seen, and what should I expect?
As with most vaccines, your Covid-19 vaccine shot is designed to activate your immune response, and reactogenicity may cause discomfort for a few days. Don’t be surprised if you feel fatigued, mildly feverish, or have headaches or muscle and joint aches. The likelihood of side-effects is not unusual, but if—as hoped—an unprecedented number of Americans receive the Covid-19 vaccines, sheer numbers will make side-effects seem more common. As Science magazine notes, “Fewer than 2% of recipients of the Pfizer and Moderna vaccines developed severe fevers of 39°C to 40°C. But if the companies win regulatory approvals, they’re aiming to supply vaccines to 35 million people globally by the end of December. If 2% experienced severe fever, that would be 700,000 people.”
However, weighed against the dangers of spreading or falling ill from a virus that has taken over 250,000 American lives in less than a year, a brief fever from a Covid-19 vaccine could be viewed as a harbinger of returning normalcy.
Registered nurse Pascaline Muhindura has spent the past eight months treating COVID patients at Research Medical Center in Kansas City, Missouri.
But when she returns home to her small town of Spring Hill, Kansas, she’s often stunned by what she sees, like on a recent stop for carryout food.
“No one in the entire restaurant was wearing a mask,” Muhindura said. “And there’s no social distancing. I had to get out, because I almost had a panic attack. I was like, ‘What is going on with people? Why are we still doing this?’”
Many rural communities across the U.S. have resisted masks and calls for social distancing during the coronavirus pandemic, but now rural counties are experiencing record-high infection and death rates.
Critically ill rural patients are often sent to city hospitals for high-level treatment and, as their numbers grow, some urban hospitals are buckling under the added strain.
Kansas City has a mask mandate, but in many smaller communities nearby, masks aren’t required — or masking orders are routinely ignored. In the past few months, rural counties in both Kansas and Missouri have seen some of the highest rates of COVID-19 in the country.
At the same time, according to an analysis by KHN, about 3 in 4 counties in Kansas and Missouri don’t have a single intensive care unit bed, so when people from these places get critically ill, they’re sent to city hospitals.
A recent patient count at St. Luke’s Health System in Kansas City showed a quarter of COVID patients had come from outside the metro area.
Two-thirds of the patients coming from rural areas need intensive care and stay in the hospital for an average of two weeks, said Dr. Marc Larsen, who leads COVID-19 treatment at St. Luke’s.
“Not only are we seeing an uptick in those patients in our hospital from the rural community, they are sicker when we get them because [doctors in smaller communities] are able to handle the less sick patients,” said Larsen. “We get the sickest of the sick.”
Dr. Rex Archer, head of Kansas City’s health department, warns that capacity at the city’s 33 hospitals is being put at risk by the influx of rural patients.
“We’ve had this huge swing that’s occurred because they’re not wearing masks, and yes, that’s putting pressure on our hospitals, which is unfair to our residents that might be denied an ICU bed,” Archer said.
Hospital leaders have continued to plead with Missouri Republican Gov. Mike Parson, and with Kansas’ conservative legislature, to implement stringent, statewide mask requirements but without success.
Parson won the Missouri gubernatorial election on Nov. 3 by nearly 17 percentage points. Two days later at a COVID briefing, he accused critics of “making the mask a political issue.” He said county leaders should decide whether to close businesses or mandate masks.
“We’re going to encourage them to take some sort of action,” Parson said Thursday. “The holidays are coming and I, as governor of the state of Missouri, am not going to mandate who goes in your front door.”
In an email, Dave Dillon, a spokesperson for the Missouri Hospital Association, agreed that rural patients might be contributing to hospital crowding in cities but argued that the strain on hospitals is a statewide problem.
The reasons for the rural COVID crisis involve far more than the refusal to mandate or wear masks, according to health care experts.
Both Kansas and Missouri have seen rural hospitals close year after year, and public health spending in both states, as in many largely rural states, is far below national averages.
Rural populations also tend to be older and to suffer from higher rates of chronic health conditions, including heart disease, obesity and diabetes. Those conditions can make them more susceptible to severe illness when they contract COVID-19.
Rural areas have been grappling with health problems for a long time, but the coronavirus has been a sort of tipping point, and those rural health issues are now spilling over into cities, explained Shannon Monnat, a rural health researcher at Syracuse University.
“It’s not just the rural health care infrastructure that becomes overwhelmed when there aren’t enough hospital beds, it’s also the surrounding neighborhoods, the suburbs, the urban hospital infrastructure starts to become overwhelmed as well,” Monnat said.
Unlike many parts of the U.S., where COVID trend lines have risen and fallen over the course of the year, Kansas, Missouri and several other Midwestern states never significantly bent their statewide curve.
Individual cities, such as Kansas City and St. Louis, have managed to slow cases, but the continual emergence of rural hot spots across Missouri has driven a slow and steady increase in overall new case numbers — and put an unrelenting strain on the states’ hospital systems.
The months of slow but continuous growth in cases created a high baseline of cases as autumn began, which then set the stage for the sudden escalation of numbers in the recent surge.
“It’s sort of the nature of epidemics that things often look like they’re relatively under control, and then very quickly ramp up to seem that they are out of hand,” said Justin Lessler, an epidemiologist at Johns Hopkins Bloomberg School of Public Health.
Now, a recent local case spike in the Kansas City metro area is adding to the statewide surge in Missouri, with an average of 190 COVID patients per day being admitted to the metro region’s hospitals. The number of people hospitalized throughout Missouri increased by more than 50% in the past two weeks.
Some Kansas City hospitals have had to divert patients for periods of time, and some are now delaying elective procedures, according to the University of Kansas Health system’s chief medical officer, Dr. Steven Stites.
But bed space isn’t the only hospital resource that’s running out. Half of the hospitals in the Kansas City area are now reporting “critical” staffing shortages. Pascaline Muhindura, the nurse who works in Kansas City, said that hospital workers are struggling with anxiety and depression.
“The hospitals are not fine, because people taking care of patients are on the brink,” Muhindura said. “We are tired.”
Published courtesy of Kaiser Health News. This story is from a reporting partnership that includes KCUR, NPR, and KHN.KHN (Kaiser Health News) is a nonprofit news service covering health issues. It is an editorially independent program of KFF (Kaiser Family Foundation), which is not affiliated with Kaiser Permanente.
Even before hard data was available, many pregnant women were taking extra precautions against COVID-19, and a new CDC report indicates that they may indeed face additional risks from infection. “Although the absolute risks for severe COVID-19–associated outcomes among women were low,” the report states, “Pregnant women were at significantly higher risk for severe outcomes compared with nonpregnant women.” Another recent report found that pregnant women with Covid were also more likely to have pre-term births.
In a January-October 2020 study of symptomatic cases among over 400,000 women between the ages of 15-44, the CDC study found that pregnant women were up to four times more likely to require ventilation and two times more likely to die. The results varied depending on ethnicity. Pregnant Latina women faced a higher risk for infection and death compared with nonpregnant Latina women, and regardless of pregnancy status, non-Hispanic Black women experienced a disproportionate number of deaths. To view data on ICU admissions and invasive treatments (ventilation and ECMO life support) broken down by age, pregnancy status, race/ethnicity, see this table.
Based on these reports, the CDC advises pregnant women to
Limit unnecessary interactions with persons who might have been exposed to or are infected with SARS-CoV-2, including those within their household, as much as possible.
When going out or interacting with others, wear a mask, social distance, avoid persons who are not wearing a mask, and frequently wash their hands.
Take measures to ensure their general health, including staying up to date with annual influenza vaccination and prenatal care.
Dr Denise Jamieson, chair of the gynecology and obstetrics department at Emory University School of Medicine, also commented, “Pregnant women need to be included in the different phases of vaccine trials, so that when a vaccine is available we understand the safety and efficacy of vaccines in pregnancy.”
The data on COVID-19 and pregnant women appeared close on the heels of an American Academy of Pediatrics report stating that infections among children are on the rise. The 61,000 new cases in children during the last week of October “is larger than any previous week in the pandemic,” according to the AAP. However, most cases in children still tend to involve milder symptoms. CDC studies have found that just 54%-56% of children experience fever and cough, compared to 71%-80% of adults, and only 13% suffer from shortness of breath, compared to 43% of adults. Pediatric cases requiring hospitalization, though, are as likely to require ICU care as adult cases, with one in three leading to the ICU.
As Covid-19 cases spike all over the country, many healthcare systems are in desperate straits. States that proudly saw thousands of their nurses fly out this spring to “frontline” hotspots like New York City, Seattle, New Orleans, and Boston are now starved for resources themselves. With the latest stage of the pandemic coursing through 48 states, the frontlines are often in smaller cities and rural states that tend to lack the amenities common at metropolitian hospitals. Local and state health care systems are struggling to treat patients amid dire shortages of staff, beds, and equipment.
Under the strain of the present surge, healthcare systems are assigning non-Covid patients to beds in convention centers, hospitals are canceling elective surgeries, ICU nurses are working 60-hour weeks, and nurses who sped to New York in April are now working overtime to treat Covid patients in their hometowns. Areas that are especially overwhelmed, such as El Paso, store their dead in mobile cooling units staffed by jail inmates, and airlift non-Covid patients to hospitals in cities that for the present have escaped the new surge. In addition to seeking aid from National Guard medics, the American Hospital Association’s vice president of quality and patient safety, Nancy Fosterome, told Stat News that some hospitals are even turning to local dentists, Red Cross volunteers, and people with basic health experience to help with tasks that require less training.
In North Dakota, the weight of the Covid caseload—currently the worst in the country and, per capita, one of the worst in the world—has effectively broken the state’s contact tracing system. Kailee Lingang, a University of North Dakota nursing student now helping with contact tracing in the state, told the Washington Post that “Test and trace went by the wayside. Even if we had enough staff to call up everyone’s workplace and contact, there are so many new infections that it wouldn’t be as effective. At this point, the government has given up on following the virus’s path through the state. All we can do is notify people, as quickly as we can, that they have the virus.”
In Indiana, the state and local healthcare systems are sputtering in the wake of a 60% increase in hospitalizations. One doctor in the state, Timothy Mullinder, told MedPage Today that patients “who need to go to the ICU have been stuck in the ER for 24 hours because there are no beds available. Post-operative patients are stuck in the PACU recovery area well over 24 hours because there are no beds available.”
With the entire state out of staffed hospital beds, Iowa’s healthcare system is also overwhelmed. Whitney Neville, an Iowa nurse, told the Atlantic on November 13, “Last Monday we had 25 patients waiting in the emergency department. They had been admitted but there was no one to take care of them.” The strain on the system, combined with the state’s relaxed social distancing policies, prompted one infectious disease doctor to speak in near-apocalyptic tones: “The wave hasn’t even crashed down on us yet. It keeps rising and rising, and we’re all running on fear. The health-care system in Iowa is going to collapse, no question.” The problem, however, extends well beyond North Dakota, Texas, and Iowa. A November 17 Atlantic article found that 22% of all US hospitals are facing staffing shortages, and added, “More than 35 percent of hospitals in Arkansas, Missouri, North Dakota, New Mexico, Oklahoma, South Carolina, Virginia, and Wisconsin are anticipating a staffing shortage this week.”
At the center of the system, nurses and other healthcare workers are working as many shifts as they can, while doing their best to attend to waves of incoming patients. The latest surge, however, has driven a growing number of nurses to express their frustration with incoherent policies and public intransigence on the matter of masking, social distancing, and incredulity over the very existence of the virus. Michelle Cavanaugh, a nurse at the Nebraska Medicine Medical Center, spoke for many when she told a Utah reporter, “We’re seeing the worst of the worst and these patients are dying, and you go home at the end of the night and you drive by bars and you drive by restaurants and they’re packed full and people aren’t wearing masks. I wish that I could get people to see COVID through my eyes.”
“Micro-clusters” of Covid cases are now the focus in New York City’s battle against the pandemic. After a devastating spring in which COVID-19 took over 20,000 lives across its five boroughs, city public health officials and legislators have taken the fight against the virus to the streets. The health department now monitors micro-clusters as they pop up in city neighborhoods. As zip code areas are too imprecise in a metropolis of nearly 8.4 million people, officials track micro-clusters block by block and shut down hotspots to choke off the virus before it has a chance to set the city on fire again. Using a “focus zone” system, the city enforces aggressive lock-down restrictions on gatherings and businesses in hotspot red zones, and when a red zone is densely populated, more moderate restrictions are imposed in adjacent orange or yellow “buffer zone” areas to isolate the hotspots and prevent the virus from spreading to nearby neighborhoods.
Governor Cuomo’s micro-cluster tracking strategy allows for flexible, rapid responses to sudden outbreaks. As Thomas Tsai, a health policy expert at Harvard’s T.H. Chan School of Public Health, explained to Stat News: “Social distancing policy is not an on/off switch — this is a dial that needs to be calibrated to the temperature.” In the same article, Ana Bento, a disease ecologist at Indiana University elaborated, “The idea is to… from what we know, create more efficient and evidence-based types of lockdowns. In different cities and in different states, these lockdowns may look very different from each other.”
In a city of nearly 8.4 million people—fertile ground for any epidemic—wresting control away from the virus entails a mammoth, intensive, and a constantly vigilant Test & Trace Corps comprised of doctors, public health professionals and community advocates. New York City currently has over 200 free COVID testing centers at hospitals, health centers, and pop-up locations located across all five boroughs. The state testing program has achieved considerable penetration, administering over 700 daily tests per every 100,000 residents. During August and September, 45-50,000 residents were tested every day, and since cases started to surge in late October, as many as 58,000 people have been tested in a single day (NYC testing figures).
Positive cases and micro-clusters are monitored and aided by a team of over 4,000 contact tracers. Every day, the Test and Trace Corps sends about 500 COVID-positive New Yorkers a “Take Care” package with PPE and other equipment for a 10-14 day quarantine: a medical-grade mask, sanitizing wipes, hand sanitizer, thermometer, two at-home testing kits for contacts, and a pulse oximeter to monitor their oxygen levels. If they are unable to isolate themselves at home, those testing positive are provided with temporary quarters in a local hotel. At present, the Corps has a 98% compliance rate (i.e., in 98 out of every 100 positive cases the patients are complying with quarantine guidelines and staying indoors alone).
How has the city been faring in its block-by-block micro-cluster battle? With April’s images of refrigerated morgue trucks still fresh in their minds, many New York residents continue to accept the restrictions of social distancing, but exceptions are inevitable in a city containing a multitude of diverse neighborhoods and cultures. Like their counterparts all over the US, NYC officials are contending with “COVID Fatigue,” complacency, and expressions of heated resentment by residents and businesses in locked down neighborhoods. Overall, the zone-based lockdown program seems to be working, but the system may be sorely tested by the current surge and the approach of winter. “We’re all heartened at the fact that this is working,” Jackie Bray, deputy executive director of NYC Test & Trace Corps, told the Washington Post, but “We’re clear-eyed [about] how hard this is going to be to sustain through the fall and the winter.”
But is the system working? New York City cases more than doubled between November 2 and November 22. Governor Cuomo and Mayor de Blasio once again closed public schools on November 18, indoor dining is no longer permitted in the city (many argued that dining inside restaurants should have ceased earlier), and an emergency hospital has been reopened on Staten Island to reduce the pressure on other area hospitals.
A growing number of letters, editorials, and petitions are urging the incoming Biden administration to include nurses in their Covid-19 task force. When the new team assembles to battle the pandemic in 2021, the Emergency Nurses Association, the American Association of Nurse Anesthetists, and representatives from Rutgers and NYU’s Rory Meyers School of Nursing, among others have declared that nurses must have a place at the table.
In a widely published opinion piece for CNN, Caroline Dorsen, PhD, FNP-BC, associate professor and associate dean of advanced practice and clinical partnerships at Rutgers School of Nursing and Lauren Ghazal, a PhD candidate at NYU Rory Meyers College of Nursing stated that nurses are “public health experts who will add a unique and important perspective to this critical work.” They added, “Nurses are vital to meeting the task force’s goals, including making rapid testing widely available, building a workforce of contact tracers, prioritizing getting vaccines to at-risk populations (including people of color that have been disproportionately affected by Covid-19), developing clear and detailed prevention and treatment guidelines, providing necessary resources for schools and businesses to reopen safely, protecting workers and the public and, of course, caring for the sick and dying with skill, kindness and dignity.”
Emergency Nurses Association (ENA) president Mike Hastings, MSN, RN, CEN, wrote an open letter to Biden, pressing for the inclusion of nurses on the task force: “As the surge in cases and hospitalizations are expected to continue in the months ahead, the nursing perspective will be critical as your team prepares to address the crisis. Once a vaccine is approved, nurses will play a critical role in its administration to the public. Accordingly, we respectfully request that you consider placing nurses with experience and expertise in pandemics, the frontline treatment of patients and infectious diseases on the COVID-19 task force.”
Using the hashtag #NurseOnTaskForce, a Change.org petition calling for the inclusion of nurses on the task force stated that “input from nurses is crucial to insure that the recommendations regarding COVID apply to all health care workers.” The petition had acquired over 5,000 signatures by November 17.
While there is some debate over including nurses as task force members, the Biden team’s actual plan for handling the pandemic (click here to see a summary of the plan) has been met with enthusiastic approval by National Nurses United. NNU president Zenei Cortez said, “Not only does the plan address the current crisis, it would begin to rebuild the infrastructure needed to be able to respond to infectious disease outbreaks, that are likely to happen more often due to the climate crisis, globalization, and rapid urbanization in the future.”