Combatting vaccine disparity in underserved communities

As the initial growing pains of developing a national vaccine rollout fade in the United States, Black and Hispanic communities have increasingly become the focus of vaccine misinformation. While frontline workers have been waging a coordinated effort online against misinformation campaigns, prominent anti-vaccination advocates continue to produce false and misleading media that liken the vaccine to historical governmental experimentation. The reason that anti-vaccination often "works" is that many people have a rational mistrust towards doctors and public health efforts. Meanwhile, vaccine hesitancy has also been high among rural White (i.e. often Republican) voters, who are often hard to reach and who do not have a great deal of interest in being "told" what to do or think, no matter how accurate or well-meaning those messages may be. In sum, vaccine hesitancy cuts across many demographic lines, and for varying reasons. 

Fortunately, those working to combat misinformation are about to get a boost from the federal government. Announced on Monday, the US Department of Health and Human Services (HHS) has launched a $250 million effort to encourage covid-19 safety and vaccination in underserved communities. Called Advancing Health Literacy to Enhance Equitable Community Response to COVID-19, this initiative seeks to fund approximately 30 urban and 43 rural community projects for two years. The projects will be asked to create impact statements for their local population, and create and enact health literacy plans, "to increase the availability, acceptability and use of COVID-19 public health information and services by racial and ethnic minority populations and others considered vulnerable." Grants will range between $3 million and $4 million. Applications for project funding are due April 20. While these efforts will certainly help, hesitancy within these groups has been found to be decreasing, with access to supplies becoming the limiting factor. However, with President Biden announcing yesterday that all adults should have access to a coronavirus vaccine by May 1st, hesitancy may again be what keeps us from reaching herd immunity. Various. 12 March 2021.

CDC and Medicare and Medicaid Federal agencies relax nursing home visit guidelines

The covid-19 pandemic has caused historically high numbers of deaths among adults of all ages. The number of elderly people in the US who have died in the last year well exceeds anything we've seen in the modern era. But nursing homes in particular have been the setting for what were at times apocalyptic scenes. While fewer than 1 percent of all US residents live in long-term care facilities, around 34 percent of all covid-19 deaths occurred among this population. Therefore, policies that limited or banned visitors made sense at times.

That said, denying visits between families and loved ones and long-term care facility residents who may not have long to live is about as depressing a policy as one could imagine. That's why the new "Revised Visitation Recommendations" for nursing homes and other long-term care facilities, published Wednesday, is so welcome.

The document is a collaboration between the US Centers for Disease Control and Prevention and the Centers for Medicare and Medicaid Services. Now that over 3 million coronavirus vaccine doses have been administered in the relevant facilities, the easing of strict policies makes sense. Per the policy, "responsible indoor visitation" should be permitted "at all times and for all residents," regardless of vaccination status of either the resident or the visitor. Thus, the default position is "yes, visits are allowed," unless particular problems are noted; the named exceptions to the policy are as follows:

  1. For unvaccinated residents, if the positivity rate for SARS-CoV-2 tests within the county where the facility is located is greater than 10 percent and less than 70 percent of residents in that facility have yet to have been fully vaccinated.
  2. Residents with test-confirmed SARS-CoV-2 infection (regardless of vaccination status) until they have met the usual criteria for ceasing of precautions for infected persons.
  3. Residents in quarantine (regardless of vaccination status) until the usual quarantine period/criteria have been met.

In fact, these rules are even more aggressive than they initially appear. That's because the caveats listed above apply to "regular" nursing home residents only. The guidance goes even further for residents who are gravely ill and at risk of imminent death or a change in their overall health. For those residents, even the above restrictions should not apply.

These new policies reflect the reality that herd immunity in nursing homes, at least, may be in sight. If so, nursing homes have gone from becoming the most dangerous epicenter of this crisis, to among the safest locales. That's what vaccine rollouts can achieve. 11 March 2021.

Vaccinated Americans get CDC approval to take another step toward normalcy

With mounting evidence that the new covid-19 vaccines are effective and reduce infection of SARS-CoV-2 to at least some extent, the US Centers for Disease Control and Prevention (CDC) took a bold step towards a semblance of normalcy. Yesterday, the agency released new recommendations geared towards those who are fully vaccinated—in other words, those who are two weeks out from a full complement of vaccine doses (two shots in the case of Moderna and Pfizer, or one dose for Johnson & Johnson). The announcement came after some delays last week, and was met with mostly positive reviews from public health experts, though some felt that the new policies do not go far enough in loosening recommended behavioral changes, especially with regards to travel.

In broad strokes, the new guidelines state that vaccinated individuals can gather indoors without masks. At a more granular level, the CDC also specifically stated that vaccinated grandparents should be able to visit unvaccinated grandchildren in most cases, and that vaccinated persons could spend time with individuals from a single household who might not be vaccinated, provided they are at low risk for serious disease if they were to become infected.

The guidelines continue to recommend that all persons continue to wear a well-fitting mask when outside their home and practice social distancing in public, regardless of vaccine status. As before, the agency guidelines remain that any person experiencing symptoms consistent with covid-19 should quarantine and seek further testing, however vaccinated individuals who are exposed to someone diagnosed with covid-19 do not need to isolate unless they become symptomatic.

As mentioned, travel guidelines were not updated, though future iterations are expected soon, as more Americans get inoculated. At the time of the announcement, around 9 percent of the US population has been fully vaccinated, though over 60 percent of the older population has received protection via vaccines, meaning that mortality rates are expected to plummet in the months ahead, provided that variants neither render the vaccinated population less protected nor cause an increase in severe and critical disease among younger persons. 9 March 2021.

FDA rejects ivermectin, despite growing interest in some corners of the internet

Throughout the pandemic, various treatments and preventives have floated into the public consciousness as possible covid-19 treatments based on their efficacy against other, unrelated conditions or based on studies done on cells in laboratories. One drug that has gained popular footing is called ivermectin, an anti-parasitic drug. A recent JAMA article (covered in Brief19)provides background on this growing interest, as a result of the drug's efficacy against the virus in animal and in vitro models.

The US Food and Drug Administration (FDA) has now updated its information page on ivermectin, stating that the drug is only approved to treat two conditions caused by parasitic worms in humans, as well as multiple parasitic infections in animals. Further, the agency specifies that ivermectin is not considered a true antiviral therapy. The biggest point that the FDA emphasizes is that formulations for animals are different than those for humans, and individuals should under no circumstances take medication compounded for a different species. Various. 10 March 2021.

Senate stimulus slimmer in some ways, fatter in others

After a grueling stint in the Senate, including Senator Ron Johnson (R) forcing floor staff to read aloud every word of the 628 page proposed stimulus package, and Senator Joe Manchin (D) wavering on the degree of federal support for unemployment, the upper chamber of US Congress voted to pass its version of the next coronavirus stimulus package. The vote went strictly along party lines. While the House bill mirrored President Biden's proposal, the Senate version has some key omissions that show ongoing divisions within the Democratic Party.

The Senate was able to pass the legislation via a simple majority (avoiding filibuster rules) using a technique called "reconciliation", wherein Congress can pass one fiduciary bill per fiscal year; under the relevant Senate rules, there is a fifty-hour time limit for debate, and no extensions are allowed. The chamber then begins a "vote-a-rama" that allows any Senator to propose any amendment without debate, with no limitations on the number of additions proposed; this process continues until an unanimous vote to cease is reached. In addition to new proposals, any Senator may object to inclusions deemed to not affect the level of spending or revenues, or which results in an incidental change under what is known as the "Byrd Rule." These are considered and adjudicated by the Senate Parliamentarian, a non-political non-partisan appointee. Senators who object to the Parliamentarian's decision need sixty votes to overcome an item's removal.

For the stimulus bill, this mattered in several instances. First, one proposed inclusion in the package was an increase on the minimum wage to $15 an hour by 2025; this fell victim to the Byrd Rule and the Parliamentarian. So did a section regarding a rail system in Silicon Valley, as did a transportation-related fund for a new bridge between New York and Canada.

But even on issues more directly related to the effects of the pandemic, keeping moderate Democrats onboard meant tightening the eligibility for direct stimulus checks. Federal unemployment aid was reduced from $400 to $300 to appease Senator Manchin, for example. But the Senate did not only take items away. They also voted to exempt student loan forgiveness from income tax consideration through 2025. Additionally, up to $10,200 in unemployment assistance will likewise be exempt on 2020 income tax for households making less than $150,000, and cover 100 percent of COBRA premiums through September. Now the package heads to the White House for the President's signature into law. Various.8 March 2021.

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