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C.D.C. Panel Endorses Pfizer Boosters for Some, but Not Health Workers

ImageA dose of the Pfizer-BioNTech vaccine was prepared at a clinic in Reading, Pa., earlier this month. 
Credit…Matt Rourke/Associated Press

A day after federal regulators authorized Pfizer-BioNTech coronavirus booster shots for Americans at risk of severe Covid-19, scientific advisers to the Centers for Disease Control and Prevention on Thursday recommended the booster shots for a wide swath of the country, including tens of millions of older Americans and those with certain medical conditions. But the panel excluded those at risk because of their jobs.

The Food and Drug Administration on Wednesday authorized boosters for older and high-risk recipients of the Pfizer vaccine at least six months after their second injection, as well as for people whose jobs leave them exposed to the virus, including health workers, teachers and grocery workers.

The C.D.C.’s science advisers unanimously supported the booster for adults older than 65 and for residents of long-term care facilities. And 13 of the committee’s 15 members also endorsed the shots for people aged 50 to 64 years with medical conditions that leave them at risk for severe Covid-19.

Some members urged the committee to include some flexibility for individuals under 50 to obtain boosters, based on their individual benefit and risk. But others pointed — with considerable frustration — to a lack of data supporting the need in the other groups.

After a protracted discussion, a majority of the panel recommended the boosters for adults aged 18 to 49 years with underlying medical conditions, based on their individual benefit and risk.

They disagreed most on whether some people in some occupations or settings are at heightened risk. By a close vote of nine to six, they voted to exclude people at risk because of their occupations. This measure would have applied to health care workers, teachers and other workers who do not meet the other criteria.

The Pfizer-BioNTech vaccine is approved for anyone over age 16, but the F.D.A.’s authorization for the booster includes only those over age 18.

The next step is for Dr. Rochelle Walensky, the director of the C.D.C., to make a formal recommendation. If she follows the guidance of the agency’s advisory committee, as is typically the case, the C.D.C. guidance may conflict with that of the F.D.A.

The number of Americans who will qualify includes only those who already received two doses of the Pfizer-BioNTech vaccine. The panel was not asked to judge whether people who received the Moderna and Johnson & Johnson vaccines should receive booster shots, which have not been authorized by the F.D.A.

Several experts nevertheless supported a mix-and-match strategy, and signaled that they would revisit the issue as new data emerge.

State health departments generally follow the recommendations of the C.D.C.’s Advisory Committee on Immunization Practices.

And anyone who wants a booster may simply be able to walk into a pharmacy and ask for one — many Americans already did so before the F.D.A.’s authorization, typically by finding a cooperative pharmacist or pretending to be unvaccinated.

The C.D.C. panel’s guidance followed weeks of internal disagreement and public debate among American health officials and advisers. In mid-August, President Biden announced plans for a booster rollout, but regulators significantly slowed the proposed timeline.

And public health experts criticized what they said were confusing public messages from the Biden administration, all the more notable because the F.D.A. does not have a permanent leader. Its acting commissioner, Janet Woodcock, said on Wednesday that the authorization would allow for booster doses “in certain populations such as health care workers, teachers and day care staff, grocery workers and those in homeless shelters or prisons, among others.”

But some members of the C.D.C. panel said there was little evidence to suggest that vaccinated teachers, and even health care workers, are at risk of repeated exposure to the virus.

During a two-day meeting culminating on Thursday, the C.D.C.’s advisory panel wrestled with the public’s expectations for Covid vaccines, the safety of third doses and how a booster program would affect nursing home residents.

The advisers also grappled with the lack of clarity on the goal of the vaccines: Is it to prevent all infections, or only to forestall severe illness and hospitalization? Many suggested it should be the latter, and that thwarting all infections was a foolhardy goal.

Several members of the committee pointedly questioned why federal health agencies were focusing on booster shots for Pfizer recipients to begin with, given the higher risks facing the unvaccinated.

“We may move the needle a little bit by giving a booster dose to people,” said Dr. Helen Talbot, an associate professor of medicine at Vanderbilt University. But, she added, “the hospitals are full because people are not vaccinated.”

Pfizer scientists had argued to the committee that waning antibody levels in people who had received the shot indicated that their immunity was dropping.

And on Thursday, C.D.C. scientists presented models indicating that, if booster doses were to slightly increase people’s protection against hospitalization, the additional shots could prevent more than 2,000 hospitalizations for every million doses given.

But it is not at all clear how long any additional protection from a booster would last.

Some committee members doubted the wisdom of looking only at antibody levels to gauge immunity. The antibodies needed to prevent infection may naturally wane a few weeks to months after the injection, but the immune cells that prevent illness from progressing — but are harder to measure — remain stable many months after the second dose, according to data presented by one C.D.C. scientist.

Boosters can reduce infections in nursing home residents, who are among those at highest risk. Even so, cases in nursing homes will persist when community transmission is high, according to a modeling study presented at the meeting.

Scientists who presented data to the advisers noted that while a third dose would undoubtedly amp up antibody levels, it’s unclear how long those elevated levels would last, whether they translate to meaningful extra protection against severe disease, and whether they can significantly decrease transmission of the virus.

They also noted the paucity of safety data, especially among younger people.

Credit…Dado Ruvic/Reuters

A committee of scientific advisers to the Centers for Disease Control and Prevention voted on Thursday to recommend booster doses of the Pfizer-BioNTech coronavirus vaccine to many Americans who were fully inoculated with the same vaccine. The panel advised that those booster shots go to older Americans and people with certain medical conditions, but excluded those at risk because of their jobs.

But the panel was not asked to judge whether people who received the Moderna and Johnson & Johnson vaccines should receive Pfizer boosters. The Food and Drug Administration is reviewing data for a Moderna booster, but has not received an application from Johnson & Johnson for a booster of its vaccine.

Several experts nevertheless supported a mix-and-match strategy, and signaled that they would revisit the issue as new data emerge.

The advisers wrestled with the practicalities of endorsing a booster shot of Pfizer’s vaccine, but not the other two. Recipients of those vaccines may rightly feel resentful of being asked to wait if the evidence suggests they need boosters, they noted.

“I just don’t understand how, later this afternoon, we can say to people 65 and older, ‘You’re at risk for severe disease and death, but only half of you can protect yourselves right now,’” said Dr. Sarah Long, a pediatrician and infectious diseases expert at Drexel University College of Medicine in Pennsylvania.

“It might be the right thing to do,” she said. “It just doesn’t sound like a good public health policy.”

Some experts seemed to suggest on Wednesday that it might be better to hold off on recommending any booster shots until recipients of all three vaccines could qualify for them.

Moderna’s authorization may arrive in a few days, or weeks. The company has applied for authorization of a booster carrying half the dosage given in the first two shots, which has delayed the F.D.A.’s deliberations.

Federal regulators have indicated that there was insufficient evidence for mixing first shots of the Moderna vaccine with a Pfizer booster, or vice versa.

Credit…Saul Martinez for The New York Times

A committee of scientific advisers to the Centers for Disease Control and Prevention voted on Thursday to recommend booster doses of the Pfizer-BioNTech coronavirus vaccine to many Americans, including older people and those with certain underlying medical conditions, but excluded those at risk because of their jobs. The panel debated a number of thorny questions before reaching a decision that will shape the federal government’s guidance.

But who exactly are those experts on the agency’s Advisory Committee on Immunization Practices?

According to the agency, the committee includes 15 voting members who are responsible for making recommendations on all kinds of vaccines. Their recommendations are very likely to influence who gets the booster shots in practice. Members are selected by the Secretary of Health and Human Services after a lengthy nomination process.

Fourteen members are medical practitioners and scientists with expertise in fields like vaccinology, immunology, pediatrics and public health. The 15th is a consumer representative who provides perspectives on the social and community aspects of vaccination.

Dr. Grace M. Lee is the chair of the committee. She is associate chief medical officer at the Stanford Children’s Health system, and a professor of pediatrics at the Stanford University School of Medicine.

Here are the other voting members:

  • Dr. Kevin A. Ault is a professor of obstetrics and gynecology at the University of Kansas School of Medicine and a practicing obstetrician-gynecologist.

  • Lynn Bahta, a registered nurse and public health expert, is the immunization program consultant for the Minnesota Department of Health.

  • Dr. Beth P. Bell is a clinical professor in the Department of Global Health at the University of Washington School of Public Health, where she leads efforts to improve work in the areas of pandemic preparedness and global health security.

  • Dr. Oliver Brooks is the chief medical officer at Watts Healthcare Corp. in Los Angeles, and served as co-chair of the California working group that oversaw Covid-19 vaccine allocation in the state.

  • Dr. Wilbur H. Chen is a professor of medicine at the University of Maryland School of Medicine and director of the university’s travel medicine practice.

  • Dr. Sybil Cineas is an internal medicine and pediatric expert and the associate program director for the Brown Combined Internal Medicine-Pediatrics Residency Program in Providence, R.I.

  • Dr. Matthew Daley is a practicing pediatrician and a vaccine safety investigator at the Institute for Health Research, Kaiser Permanente Colorado, in Aurora, Colo. He is also an associate professor at the University of Colorado School of Medicine.

  • Dr. Camille N. Kotton is an infectious disease clinician at Massachusetts General Hospital and an associate professor at Harvard Medical School.

  • Dr. James Loehr is a practicing family physician in Rochester and Ithaca, N.Y.

  • Dr. Sarah S. Long is a professor of pediatrics at Drexel University College of Medicine, and a practicing physician in Philadelphia specializing in infectious diseases in children.

  • Veronica V. McNally is the chief executive officer of the Franny Strong Foundation in East Lansing, Mich., which promotes vaccinations and education about vaccines. The foundation is named for her daughter, who died of whooping cough.

  • Dr. Katherine A. Poehling is a professor of pediatrics and of epidemiology and prevention at the Wake Forest School of Medicine.

  • Dr. Pablo J. Sanchez is a professor of pediatrics with expertise in neonatal and perinatal infections at The Ohio State University — Nationwide Children’s Hospital in Columbus, Ohio.

  • Dr. Helen Keipp Talbot is an internist and infectious disease specialist at Vanderbilt University.

Credit…Themba Hadebe/Associated Press

African public health experts on Thursday hailed President Biden’s plan to expand global coronavirus vaccine donations, but warned that his ambitious goals would not be met without timelier deliveries and greater transparency about when and how many doses were coming.

Africa, the continent with the lowest Covid-19 vaccination rate, has suffered not only from a shortage of vaccine doses but also from delayed and inconsistent deliveries. Although supplies have been increasing — four million doses arrived over the past week from Covax, the global vaccine-sharing facility — African countries have still received only one-third of the doses they were promised for this year, experts said at a virtual briefing held by the World Health Organization.

“The first thing to say is, we appreciate all the donations that were pledged by the rich countries and those who have doses to offer,” said Githinji Gitahi, chief executive of Amref Health Africa, a charity. “But we call for a commitment to deliver on those, and deliver in a timely manner.”

Anger over the rich-poor divide in vaccine access was a consistent theme among the leaders of African countries speaking at the United Nations General Assembly on Thursday.

“Unfortunately, the global rollout of the vaccine has not been impervious to the scourge of inequality,” said President Hage G. Geingob of Namibia. He called the situation “vaccine apartheid.”

President João Lourenço of Angola said it was “shocking to see the disparity between some nations and others with respect to availability of vaccines.”

At a summit on Wednesday, Mr. Biden pledged to donate an additional 500 million doses of the Pfizer-BioNTech vaccine, nearly doubling the United States’ total committed donations to 1.1 billion doses, more than any other country. But only 300 million of the doses are expected to be shipped this year, leaving poorer nations with the prospect of a longer wait.

Mr. Biden embraced the target of vaccinating 70 percent of the world’s people by the end of 2022. But that would require raising the pace of vaccinations in Africa sevenfold, to about 150 million doses a month, said Benido Impouma, a program director with the World Health Organization’s Africa program.

“It is in every country’s interest that this happen quickly,” Dr. Impouma said of speeding up the continent’s vaccination campaign. “The longer the delay in rolling out the vaccine, the greater the risk of other challenges emerging,” he added, including the rise of more troubling coronavirus variants.

To date, he and others said, vaccine deliveries to Africa have been not only slow and scant, but also unpredictable. Many shipments have arrived with little notice, hampering health systems’ ability to administer them, and with doses soon to expire.

Richard Mihigo, coordinator of the W.H.O. immunizations program in Africa, said that the agency had analyzed the vaccine shipments and found that the average shelf life of doses that reached Africa was two to three months. That wasn’t long enough for health systems to get the doses to people who needed them, many of whom lived far from health facilities, he said.

“Most of time the news about donations comes on short notice, within a couple of days,” Dr. Mihigo said. “Countries do not have time to prepare. To change this paradigm, we need a bit more predictability on doses, how many doses, when they are coming.”

The surfeit of soon-to-expire doses has also contributed to vaccine hesitancy in parts of Africa, said Jean-Jacques Muyembe, director general of the National Institute for Biomedical Research in the Democratic Republic of Congo.

“People consider that a short shelf life, such as three months, is a synonym for bad quality,” he said.

Rick Gladstone contributed reporting.

Credit…Loren Holmes/Anchorage Daily News, via Associated Press

Alaska, once a leader in vaccinating its citizens, is now in the throes of its worst coronavirus surge of the pandemic, as the Delta variant rips through the state, swamping hospitals with patients.

As of Tuesday, the state was averaging 117 new cases a day for every 100,000 people, more than any other in the nation, according to recent data trends collected by The New York Times. That figure has shot up by 42 percent in the last two weeks, and by more than twentyfold since early July.

On Wednesday, the state said it had activated “crisis standards of care,” giving hospitals legal protections for triage decisions that force them to give some patients substandard care. The state also announced an $87 million contract to bring in hundreds of temporary health care workers.

Gov. Mike Dunleavy, a Republican, said that while hospitals were strained, he did not see a need to implement restrictions aimed at curbing transmission. Still, he encouraged people who had not yet received a vaccination to seriously consider it.

“We have the tools available to us for individuals to be able to take care of themselves,” Mr. Dunleavy said. While the state led the nation in vaccinations early in the year, it has been lagging in recent months, with under half of its population fully vaccinated, compared with 55 percent nationally, according to federal data.

Jared Kosin, the head of the Alaska State Hospital and Nursing Home Association, called the surge “crippling” in an interview on Tuesday. He added that hospitals were full, and health care workers were emotionally depleted. Patients recently were kept waiting for care in their cars outside overwhelmed emergency rooms.

There is growing anxiety in outlying communities that depend on transferring seriously ill patients to hospitals in Anchorage, Mr. Kosin said. Transfers are getting harder to arrange and are often delayed, he said.

“We are all wondering where this goes, and whether that transfer will be available, even tomorrow,” Mr. Kosin said.

Critically ill people in rural areas, where many Alaska Natives reside, often have to be taken by plane to a hospital that can provide the treatment they need, said Dr. Philippe Amstislavski, an associate professor of public health at the University of Alaska Anchorage.

“Unlike in the lower 48, you don’t have that ability to move people quickly, because of the distances and remoteness,” said Dr. Amstislavski, who was formerly the public health manager for the Interior Region of Alaska, focusing on rural and predominantly Alaska Native communities.

Mr. Kosin said that if hospitalizations rise much further, hospitals and clinics around the state could be forced to apply crisis standards of care and more extreme triage decisions. “That is the worst-case scenario we could be heading to,” he said.

Alaska Natives, who have historically suffered from health disparities in the state, are disproportionately struggling during the latest virus wave, Dr. Amstislavski said.

Dr. Anne Zink, Alaska’s chief medical officer, said several factors may be contributing to the surge, including summer tourists bringing in and spreading the virus.

“We’re hoping that as the snow falls and we have less people visiting, those numbers will settle down,” Dr. Zink said in an interview Tuesday night.

On the other hand, she noted that cooling weather drives residents indoors, where the virus spreads more readily.

The state’s Canadian neighbors to the east, Yukon and British Columbia, have not suffered such severe outbreaks, Dr. Amstislavski said, possibly because of that country’s stricter travel restrictions and less strained health care system.

Credit…Alexandre Meneghini/Reuters

Using its own vaccines, Cuba expects to reach “full immunization” against Covid-19 by the end of the year, the president of the island nation whose 11 million citizens have long been isolated by the American embargo, told the United Nations General Assembly on Thursday.

President Miguel Díaz-Canel Bermúdez devoted much of his recorded address to fulminating against the United States for what he called its policies of economic coercion and deprivation, which he said were meant “to erase the Cuban revolution from the political map to the world.”

But he also extolled Cuba’s medical and scientific communities for what he described as their heroic achievements in creating vaccines to combat the pandemic. More than one-third of the Cuban population has been fully vaccinated with them, he said.

“We expect to achieve full immunization by the end of 2021, which will make it possible for us to advance in the struggle against the new outbreak of the pandemic,” Mr. Diaz-Canel said.

Cuba has been especially hard hit recently by the Delta variant of the coronavirus, which sent new case reports soaring over the summer and worsened shortages of basic medical supplies in Cuba. A lack of medicines, medical oxygen and coronavirus tests increased social tensions and prompted anti-government protests in July. Mexico shipped supplies of oxygen to Cuba last month, and activists in the United States sent two million syringes to the island.

As proud as the Cuban government is of its vaccines, the shots have yet to receive approval from the World Health Organization. Data from clinical trials of the vaccines have yet to be published in international peer-reviewed journals.

Even so, Cuba’s claimed self-sufficiency in vaccinating against Covid-19 is conspicuous in the landscape of vaccination inequality around the world, where most of the vaccine doses made so far have gone to the most affluent nations, while many people in poorer countries have yet to get their first doses.

This month Cuba began vaccinating children as young as 2 against the coronavirus, making it the only country so far to immunize children that young.

The move came against the backdrop of prolonged closures of Cuba’s schools through most of the pandemic, which has generated enormous frustration among parents. Online learning is not a practical option in Cuba because of the high cost of internet access there.







Afghanistan’s Health System Is on the ‘Brink of Collapse,’ W.H.O. Says

Dr. Tedros Adhanom Ghebreyesus, the W.H.O. director general, warned of an “imminent humanitarian catastrophe” as the country’s health care system struggles with a loss of foreign funding and dwindling supplies.

Over the past 20 years, significant health gains have been made in Afghanistan in reducing maternal and child mortality, moving towards polio eradication, and more. Those gains are now at severe risk with the country’s health system on the brink of collapse. There has been a surge in cases of measles and diarrhea. Almost 50 percent of children are at high — at risk of malnutrition. The resurgence of polio is a major risk, and 2.1 million doses of Covid-19 vaccine remain unused. Unless urgent action is taken, Afghanistan faces an imminent humanitarian catastrophe. Health workers are leaving, creating a brain drain that will have consequences for years to come. We visited a hospital where we met some nurses who have stayed. My heart broke when they told me they have not been paid in three months. The focus of our efforts now is to support and sustain the Sehatmandi Project, which is the backbone of Afghanistan’s health system, providing care for millions of people through 2,300 health facilities, including in remote areas. But a funding pause by major donors — only 17 percent of these facilities are fully functional. And two-thirds have stockouts of essential medicines.

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Dr. Tedros Adhanom Ghebreyesus, the W.H.O. director general, warned of an “imminent humanitarian catastrophe” as the country’s health care system struggles with a loss of foreign funding and dwindling supplies.CreditCredit…Victor J. Blue for The New York Times

Nearly one-quarter of the hospitals treating Covid-19 in Afghanistan have closed in recent weeks, and the country’s efforts to respond to the pandemic have declined, World Health Organization officials said Wednesday.

The W.H.O. issued an urgent warning on Wednesday, saying that Afghanistan is on the brink of “an imminent humanitarian catastrophe.”

The notice followed a recent visit to Kabul, the capital of Afghanistan, where W.H.O. leaders met with the leadership of the Taliban, which is now in control of the country. The W.H.O. officials also met with United Nations partners, health care workers and patients.

“Cuts in donor support to the country’s largest health project, Sehatmandi, has left thousands of health facilities without funding for medical supplies and salaries for health staff,” Dr. Tedros Adhanom Ghebreyesus, director-general of the W.H.O., and Dr. Ahmed Al-Mandhari, the organization’s regional director for the Eastern Mediterranean, said in a joint statement on Wednesday.

Roughly two-thirds of the country’s health facilities are part of Sehatmandi, a three-year, $600 million project administered by the World Bank and financed by the U.S. Agency for International Development, the European Union, the World Bank and other donors.

Because funds for the project were funneled through the Ministry of Public Health, donors withdrew their support after the Taliban seized power. Now, only one-sixth of all Sehatmandi facilities are fully functional, according to the W.H.O.

“Many of these facilities have now reduced operations or shut down, forcing health providers to make hard decisions on who to save and who to let die,” the statement said.

Officials also said that nine of the 37 hospitals treating Covid-19 in Afghanistan have closed, and coronavirus surveillance, testing and vaccination efforts have contracted.

Afghanistan, which emerged from a surge in virus infections at the end of June, is starting to see cases rise again, this time involving the highly contagious Delta variant.

Before last month, the W.H.O. said, about 2.2 million people, or about 6 percent of Afghanistan’s population, had been vaccinated against Covid-19. But in recent weeks, the organization said, vaccination rates have slowed markedly, and some 1.8 million vaccine doses in the country remain unused.

The country’s acting health minister and last remaining holdover from the pre-Taliban Cabinet, Dr. Wahid Majrooh, stepped down on Tuesday.

Martin Griffiths, the U.N.’s under secretary for emergency relief, said on Wednesday that he was releasing $45 million to help prevent Afghanistan’s health care system from collapsing.

“Medicines, medical supplies and fuel are running out in Afghanistan,” Mr. Griffiths said in a statement. “Cold chains are compromised. Essential health care workers are not being paid.”

On top of the threat of a public health crisis, new figures released by the World Food Program suggest that 95 percent of Afghans lack secure access to adequate food, a situation that could worsen in the winter, when many remote communities are likely to be cut off from outside support for several months.

Credit…John Lamparski/NurPhoto via Getty Images

Dr. Howard A. Zucker, the New York State health commissioner, has submitted his resignation, following political pressure for his removal over his role in the state’s pandemic response under former Gov. Andrew M. Cuomo.

Gov. Kathy Hochul, who announced Dr. Zucker’s resignation on Thursday, said that she agreed with his decision and that he would “stay on board” until she found a replacement.

Dr. Zucker, whom Mr. Cuomo appointed to the position in 2015, came under fire for his possible involvement in helping obscure the coronavirus death toll in the state’s nursing homes, and in withholding health data from the Legislature last year.

Since Mr. Cuomo resigned last month, Ms. Hochul has been pressed by Republicans, and even some Democrats, to dismiss Dr. Zucker. Urging patience, Ms. Hochul had said she would take up to 45 days, or until early October, to decide whether to retain Dr. Zucker and other cabinet officials from the Cuomo era.

“I thank Dr. Zucker for his willingness to stay on board, so we don’t have a gap in leadership until a person is identified,” Governor Hochul said on Thursday. “I think I made it very clear on my first day in office that I’d be looking to build a new team.”

The state’s response to the pandemic’s ravaging of nursing homes, and the handling of death data from the facilities, is the subject of a federal investigation, as well as an inquiry being led by the State Assembly.

Credit…Daniel Pockett/EPA, via Shutterstock

Australia’s second most populous state announced that some residents stranded in surrounding regions because of the pandemic would be able to travel back home starting Sept. 30.

On Thursday, the state premier, Daniel Andrews, said that people who had been stuck in New South Wales for “a lengthy period of time” could return to Victoria, if they were fully vaccinated and tested negative for the coronavirus. They must quarantine for 14 days.

“We have on numerous occasions sent our apologies to them and made it clear we understand just how challenging it is and we wish things were different,” he said.

Australia has imposed some of the harshest restrictions in the world to help contain the spread of the virus, with individual states employing lockdowns that have prevented people from returning to their cities.

The daily average of new cases has dropped 13 percent in the past two weeks in Australia, which has lived through several lockdowns since the start of the pandemic. While its vaccination kickoff had a slow start, the nation has to date fully vaccinated 39 percent of its population. Recently the country began vaccinating children as young as 12.

While travel restrictions have eased for many Australians, and the tourism ministry has even announced a possible reopening of its borders by Christmas, the country is still facing setbacks with new infections breaking out.

A makeup artist working on an Australian reality television program tested positive for the coronavirus earlier this week, sending over 130,000 Australians into yet another lockdown, according to Chris Cherry, the mayor of Tweed Shire, part of the area in northern New South Wales that has been placed under restrictions for seven days.

According to ABC News, the 31-year-old woman visited various businesses like restaurants and cafes without checking in via QR code. The police have charged her with breaching several public health regulations, including her work travel exemption guidelines.

Michael Lyon, the mayor of neighboring Byron Shire, shared his frustration over going back into lockdown in a Facebook post on Wednesday.

“It is so devastating to be in lockdown again and it is clear the ‘honour’ system relied on by the state government is deeply flawed,” he wrote. “Perhaps our calls for a tightening of restrictions will now finally be heeded.”

Credit…Tom Grillo

When the Biden administration announced a mandate that employees be vaccinated or tested regularly at companies with 100 or more employees, business leaders responded with a barrage of questions. Among smaller companies, one loomed especially large: Why 100?

It’s an appealingly round, easy-to-remember number, and it captures a broad section of the American work force. President Biden estimated that his order would apply to 80 million employees and cover two-thirds of all workers.

But as a dividing line between a “big” business and a “small” one, it’s a threshold not found in any other major federal or state law. There was no explanation for how or why the number was chosen. And for entrepreneurs who employ a smattering of workers, that’s an increasingly common challenge: Every time lawmakers invent a new regulation, they also make up a new definition of which businesses count as small.

The Affordable Care Act set 50 as the number of workers after which employers would be required to offer health insurance. That edict, which took full effect in 2016, led to an intense, vocal backlash from owners who feared that the requirement would bankrupt them, with some even paring back their business to keep their employee roster under the limit.

The mandate’s actual costs turned out to be fairly muted for most — the law helped stabilize insurance prices in the notoriously erratic market for small-group plans — and, after surviving many legal and political efforts to dismantle it, the health care law has become a bedrock piece of federal policy. So why not use 50 employees as the boundary for the vaccination mandate?

The White House isn’t saying; officials did not respond to repeated questions about the 100-person criterion. The Labor Department’s Occupational Safety and Health Administration, which is responsible for drawing up the rules, has not yet explained how and when the mandate will be enforced.

Credit…Karsten Moran for The New York Times

The fate of unvaccinated employees in New York City’s largest private hospital system was uncertain Wednesday night, as the deadline to get a first shot of a Covid-19 vaccine drew near.

New York State’s vaccination mandate for workers at hospitals and nursing homes doesn’t require a first shot until Monday, Sept. 27. But NewYork-Presbyterian, the city’s largest private hospital network, has ordered its 48,000 employees to get vaccinated on a faster timeline, requiring a first dose no later than Wednesday.

In recent weeks, the hospital had warned employees that those who remained unvaccinated without a legitimate exemption “will be deemed to have opted to resign,” according to an email sent to some employees.

A hospital spokeswoman, Alexandra Langan, declined to comment on Wednesday afternoon about how many employees faced the loss of their jobs.

More than 90 percent of NewYork-Presbyterian employees had gotten a first dose by early last week, according to a court affidavit by Shaun E. Smith, NewYork-Presbyterian’s chief human resources officer. In recent days, more holdouts have gotten vaccinated, according to interviews. But that still left hundreds, if not thousands, of employees unvaccinated.

About 200 employees have valid medical exemptions, according to Mr. Smith’s affidavit. And at least 1,364 employees had sought religious exemptions, Mr. Smith said. The hospital had granted about 129 of those requests before the state’s Department of Health reversed course in late August and said religious beliefs no longer qualified for an exemption.

A federal judge has since temporarily ordered the state to refrain from enforcing that policy. For now, NewYork-Presbyterian has said it will not take action against unvaccinated employees who had previously received a religious exemption or had a request pending, according to court filings.

One nurse in an intensive care unit, Maureen A. Buckley, said in a lawsuit that NewYork-Presbyterian suspended her without pay last week because she remained unvaccinated against Covid-19. In court papers, she said that the hospital system denied her a medical exemption and ignored her efforts to obtain a religious exemption. Reached by phone Wednesday evening, she declined to comment further, explaining that she was “still in the middle of negotiating with the hospital.”

At more than 90 percent, the vaccination rate within the NewYork-Presbyterian system is higher than at many other hospitals. At St. Barnabas Hospital, an independent safety-net hospital in the Bronx, just under 80 percent of staff are vaccinated against Covid-19, the hospital’s chief medical officer, Eric Appelbaum, said. He expressed hope the rate would climb as Monday — the state-mandated deadline — approached. “Some folks are like that: ‘If the deadline is Friday morning, I’ll do it Friday morning,’” he said.

Holdouts at New York hospitals have cited a range of reasons for not getting vaccinated: some say they distrust the safety of the vaccine, or worry about fertility, while others object to the use of cell lines derived from aborted fetuses in the development or production or testing of Covid-19 vaccines, according to interviews and court records.

Another major New York hospital network, Mount Sinai Health System, had told employees to get vaccinated by Sept. 13, but a spokeswoman said she did not know if anyone had yet been placed on leave or fired for not complying.


Because of an editing error, a caption for a photograph in an earlier version of this article incorrectly stated the number of employees in the NewYork-Presbyterian Hospital network. There are 48,000, not 36,000.

Credit…Laura Beebe/BooneOakley

It was a tailgate unlike any other on Sunday morning, as a strange truck circled the Bank of America Stadium in Charlotte, N.C.

“Don’t get vaccinated,” the side of the truck said, much to the bewilderment of the Carolina Panthers fans who were there to watch a game against the New Orleans Saints.

Underneath that text was the name of the apparent sponsor, Wilmore Funeral Home, with a link to its website and a phone number.

Images of the mobile advertising truck quickly drew widespread attention on Twitter, as people who were in on the joke applauded the advertisement. “Dope ad campaign,” one tweet said.

The twist was that Wilmore Funeral Home was a fictional business, and its website sent visitors to a vaccine registration page. The phone number belonged to Crenshaw Visions, the advertising agency that owned the truck.

“My voice mail is filled up,” said Garrett Crenshaw, the president of the agency. People have been calling him for days to criticize or compliment the ad, or simply to ask questions about the Covid vaccine.

That discourse is exactly why BooneOakley, a North Carolina advertising agency, created and funded the ad, said David Oakley, the president of the agency.

“A lot of the advertising that’s out there right now is just, ‘Get the shot,’” he said. “We wanted something that made people think.”

The advertisement was created as government officials across the country struggle to vaccinate people who are hesitant about the vaccine’s origins and side effects, among other things. In North Carolina, just under half of all people are fully vaccinated, according to a New York Times database.

Mr. Oakley said that the company didn’t realize how much the message would resonate with people.

An hour after the truck left the company’s parking lot on Sunday, pictures of the ad were already drawing attention on social media.

“Clearly, it has hit a chord,” he said. “For every penny that we spent for the board, if one person got vaccinated for it, it would have been worthwhile.”

Sunday’s ad wasn’t the agency’s first to draw widespread attention. In October 2000, just weeks before the presidential election, BooneOakley ran a billboard advertisement for a job-listing site that said “Gore 2000” next to a picture of George W. Bush.

A few days later, it added a banner at the bottom of the ad that said, “Today’s job opening: proofreader.”

Credit…Joe Rondone/The Tennessean, via Associated Press

Hospitals near a grocery store shooting in Collierville, Tenn., were already struggling to keep up with Covid-19 patients when those injured in the attack arrived in emergency rooms on Thursday.

National Guard troops had been stationed at medical centers to help cope with the influx of Covid-19 patients, and emergency medical providers had recently issued a dire warning to local officials about the strain on hospitals.

“Currently our system emergency departments are operating dangerously over capacity,” the medical providers wrote on Aug. 16. They added, “We may be unable to provide timely care to everyone and will have to make choices about delivering care to patients based on their probability of survival.”

They expressed particular concern about what could happen in the event of a disaster, given that “the city has no surge capacity to accommodate any additional disaster or unplanned events.”

An average of 96 percent of I.C.U. beds were occupied in Shelby County, Tenn., on Thursday, according to New York Times data. One nearby facility, St. Francis Hospital, reported that its I.C.U. was 100 percent full; another said its I.C.U. was 97 percent full. There were 15 I.C.U. beds available in the five counties in and around Memphis as of 5 p.m. Wednesday, according to the Shelby County Health Department.

Officials said at least a dozen people were hurt and one killed inside the Kroger store in Collierville, about 30 miles east of Memphis in Shelby County.

Regional One Health, a hospital in Memphis, had received nine patients injured in the shooting, according to a spokeswoman. She said the hospital had the capacity to accommodate those patients. Baptist Memorial Hospital in Collierville received one patient, who was discharged, and Baptist Memorial Hospital in Memphis received two, according to a spokeswoman.

Shelby County reported its highest number of Covid-19 cases during the pandemic last month. Those numbers have decreased slightly in recent weeks but remain high, with a seven-day average of 409 cases.

Only 44 percent of the state’s population has been fully vaccinated. Governor Bill Lee recently signed an executive order overruling attempts by local officials to require masks in schools. A federal judge blocked the governor’s order from taking effect in Shelby County on Friday after opponents fought it in court.


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