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To Speed Vaccination, Some Call for Delaying Second Shots

The prospect of a fourth wave of the coronavirus, with new cases climbing sharply in the Upper Midwest, has reignited a debate among vaccine experts over how long to wait between the first and second doses. Extending that period would swiftly increase the number of people with the partial protection of a single shot, but some experts fear it could also give rise to dangerous new variants.

In the United States, two-dose vaccines are spaced three to four weeks apart, matching what was tested in clinical trials. But in Britain, health authorities have delayed doses by up to 12 weeks in order to reach more people more quickly. And in Canada, which has precious few vaccines to go around, a government advisory committee recommended on Wednesday that second doses be delayed even longer, up to four months.

Some health experts think the United States should follow suit. Dr. Ezekiel J. Emanuel, a co-director of the Healthcare Transformation Institute at the University of Pennsylvania, has proposed that for the next few weeks, all U.S. vaccines should go to people receiving their first dose.

“That should be enough to quell the fourth surge, especially in places like Michigan, like Minnesota,” he said in an interview. Dr. Emanuel and his colleagues published the proposal in an op-ed on Thursday in USA Today.

10 days after the first dose, researchers could see that the volunteers were getting sick less often than those who got the placebo.

In the same month, Britain experienced a surge of cases caused by a new, highly transmissible variant called B.1.1.7. Once the British government authorized two vaccines — from Pfizer-BioNTech and AstraZeneca — it decided to fight the variant by delaying the second doses of both formulations by 12 weeks.

said on Jan. 31 on NBC’s “Meet the Press.”

But the government stayed the course, arguing that it would be unwise to veer off into the unknown in the middle of a pandemic. Although the clinical trials did show some early protection from the first dose, no one knew how well that partial protection would last.

“When you’re talking about doing something that may have real harm, you need empirical data to back that,” said Dr. Céline R. Gounder, an infectious-disease specialist at Bellevue Hospital Center and a member of Mr. Biden’s coronavirus advisory board. “I don’t think you can logic your way out of this.”

But in recent weeks, proponents of delaying doses have been able to point to mounting evidence suggesting that a first dose can provide potent protection that lasts for a number of weeks.

The Centers for Disease Control and Prevention reported that two weeks after a single dose of either the Moderna or the Pfizer-BioNTech vaccine, a person’s risk of coronavirus infection dropped by 80 percent. And researchers in Britain have found that first-dose protection is persistent for at least 12 weeks.

Dr. Emanuel argued that Britain’s campaign to get first doses into more people had played a role in the 95 percent drop in cases since their peak in January. “It’s been pretty stunning,” Dr. Emanuel said.

studies that show that a single dose of Moderna or Pfizer-BioNTech does not work as well against certain variants, such as B.1.351, which was first found in South Africa.

“Relying on one dose of Moderna or Pfizer to stop variants like B.1.351 is like using a BB gun to stop a charging rhino,” said John P. Moore, a virologist at Weill Cornell Medicine.

Dr. Moore said he also worried that delaying doses could promote the spread of new variants that can better resist vaccines. As coronaviruses replicate inside the bodies of some vaccinated people, they may acquire mutations that allow them to evade the antibodies generated by the vaccine.

But Dr. Cobey, who studies the evolution of viruses, said she wasn’t worried about delayed doses breeding more variants. “I would put my money on it having the opposite effect,” she said.

Last week, she and her colleagues published a commentary in Nature Reviews Immunology in defense of delaying doses. Getting more people vaccinated — even with moderately less protection — could translate into a bigger brake on the spread of the virus in a community than if fewer people had stronger protection, they said. And that decline wouldn’t just mean more lives were saved. Variants would also have a lower chance of emerging and spreading.

“There are fewer infected people in which variants can arise,” she said.

Dr. Adam S. Lauring, a virologist at the University of Michigan who was not involved in the commentary, said he felt that Dr. Cobey and her colleagues had made a compelling case. “The arguments in that piece really resonate with me,” he said.

Although it seems unlikely that the United States will shift course, its neighbor to the north has embraced a delayed strategy to cope with a booming pandemic and a short supply of vaccines.

Dr. Catherine Hankins, a public health specialist at McGill University in Montreal and a member of Canada’s Covid-19 Immunity Task Force, endorsed that decision, based on the emerging evidence about single doses. And she said she thought that other countries facing even worse shortfalls should consider it as well.

“I will be advocating at the global level that countries take a close look at Canada’s strategy and think seriously about it,” Dr. Haskins said.

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Restaurant Workers Are in a Race to Get Vaccines

Over the course of the pandemic, some of the most dangerous activities were those many Americans dearly missed: scarfing up nachos, canoodling with a date or yelling sports scores at a group of friends at a crowded, sticky bar inside a restaurant.

Now, as more states loosen restrictions on indoor dining and expand access to vaccines, restaurant employees — who have morphed from cheerful facilitators of everyone’s fun to embattled frontline workers — are scrambling to protect themselves against the new slosh of business.

“It’s been really stressful,” said Julia Piscioniere, a server at Butcher & Bee in Charleston. “People are OK with masks, but it is not like it was before. I think people take restaurants and their workers for granted. It’s taken a toll.”

The return to economic vitality in the United States is led by places to eat and drink, which also suffered among the highest losses in the last year. Balancing the financial benefits of a return to regular hours with worker safety, particularly in states where theoretical vaccine access outstrips actual supply, is the industry’s latest hurdle.

priority groups this spring. Immigrants, who make up a large segment of the restaurant work force, are often fearful of signing up, worrying that the process will legally entangle them.

Some states have dropped mask mandates and capacity limits inside establishments — which the Centers for Disease Control and Prevention still deem a potentially risky setting — further endangering employees.

“It is critical for food and beverage workers to have access to the vaccine, especially as patrons who come have no guarantee that they will be vaccinated and obviously will not be masked when eating or drinking,” said Dr. Alex Jahangir, the chairman of a coronavirus task force in Nashville. “This has been a major concern for me as we balance the competing interests of vaccinating everyone as soon as possible before more and more restrictions are lifted.”

Servers in Texas are dealing with all of the above. The state strictly limited early eligibility for shots, but last week opened access to all residents 16 and over, creating an overwhelming demand for slots. The governor recently dropped the state’s loosely enforced mask mandate, and allowed restaurants to go forth and serve all comers, with zero limitations.

require their workers be vaccinated in the future.

Many business sectors were battered by the coronavirus pandemic, but there is broad agreement that hospitality was hardest hit and that low wage workers sustained some of the biggest blows. In February 2020, for instance, restaurant worker hours were up 2 percent over a previously strong period the year before; two months later those hours were cut by more than half.

While hours and wages have recovered somewhat, the industry remains hobbled by rules that most other businesses — including airlines and retail stores — have not had to face. The reasons point to a sadly unfortunate reality that never changed: indoor dining, by nature of its actual existence, helped spread the virus.

report by the C.D.C. found that after mask and other restrictions were lifted, on-premise restaurants led to daily increase in cases and death rates between 40 and 100 days later. Although other settings have turned into super-spreading events — funerals, wedding and large indoor events — many community outbreaks have found their roots in restaurants and bars.

“Masks would normally help to protect people in indoor settings but because people remove masks when dining,” said Christine K. Johnson, professor of epidemiology and ecosystem health at the University of California, Davis, “there are no barriers to prevent transmission.”

Not all governments have viewed restaurant workers as “essential,” even as restaurants have been a very active part of the American food chains — from half-open sites to takeout operations to cooking for those in need — during the entire pandemic. The National Restaurant Association helped push the C.D.C. to recommend that food service workers be included in priority groups of workers to get vaccines although not all states followed the guidelines.

Almost every state in the nation has accelerated its vaccination program, targeting nearly all adult populations.

“Most people in our government have considered restaurants nonessential luxuries,” said Rick Bayless, the well-known Chicago restaurateur, whose staff scoured all vaccines sites for weeks to get workers shots. “I think that’s shortsighted. The human race is at its core social and when we deny that aspect of our nature, we do harm to ourselves. Restaurants provide that very essential service. It can be done safely, but to minimize the risk for our staff, we should be prioritized for vaccination.”

Texas did not designate as early vaccine recipients any workers beyond those in the health care and education sectors, but is now open to all.

the Breadfruit and Rum Bar, declined unemployment insurance, and have shied from signing up for a shot. “Before you can even make an appointment you have to put in your name and date of birth and email,” Ms. Leoni said. “Those are questions that are deterrents for people trying to keep a low profile.”

In Charleston, Mr. Shemtov was inspired by accounts of the immunization program in Israel, which was considered successful in part because the government took vaccines to job sites. “If people can’t get appointments, let’s bring them to them.”

Other restaurants are devoting hours to making sure workers know how to sign up, locating leftover shots and networking with their peers. Some offer time off for a shot and the recovery period for side effects.

Katie Button, the owner of Curate and La Bodega in Asheville, N.C.

Still, some owners are not taking chances. “If we go out of business because we are one of the few restaurants in Arizona that won’t reopen, so be it,” Ms. Leoni said. “Nothing is more important than someone else’s health or safety.”

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Doctors Accuse UnitedHealthcare of Stifling Competition

UnitedHealth directly competes with U.S. Anesthesia, according to the Texas lawsuit, through an ownership interest in Sound Physicians, a large medical practice that provides emergency and anesthesiology services. Sound Physicians is looking to expand in markets like Fort Worth and Houston, and U.S. Anesthesia claims in the lawsuit that its doctors were contacted by Sound Physicians “to induce them to leave” and challenge the noncompete provisions in their contracts to work with the United group.

The major insurer throws its weight around in other ways, the lawsuit claims. While the company’s Optum unit, which operates the surgery centers and clinics, is technically separate from the health insurer, the doctors accuse United of forcing its OptumCare facilities to sever their relationships with the anesthesiology group and pushing in-network surgeons to move their operations to hospitals or facilities that do not have contracts with U.S. Anesthesia.

“United and its affiliates have extended their tentacles into virtually every aspect of health care, allowing United to squeeze, choke and crush any market participant that stands in the way of United’s increased profits,” the doctors claim in their lawsuit.

It is standard practice, United said, for an insurer to encourage the use of hospitals and doctors within its network.

In contrast to many smaller physician groups that are struggling because of the pandemic, United has maintained a strong financial position, shoring up profits while elective surgeries and other procedures were shut down, resulting in fewer medical claims. So it has continued to expand, hiring more doctors and buying up additional practices. The company says it plans to add more than 10,000 employed or affiliated doctors this year.

The relationship between insurers and providers has become more complicated as more insurance carriers own doctors’ groups or clinics. “They want to be the referee and play on the other team,” said Michael Turpin, a former United executive who is now an executive vice president at USI, an insurance brokerage.

Employers that rely on UnitedHealthcare to cover their workers have a difficult time judging who benefits when insurers fail to reach an agreement to keep a provider in network. “This is just as much about profit as it is about principle,” Mr. Turpin said.

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Doctors Sue UnitedHealthcare

UnitedHealth directly competes with U.S. Anesthesia, according to the Texas lawsuit, through an ownership interest in Sound Physicians, a large medical practice that provides emergency and anesthesiology services. Sound Physicians is looking to expand in markets like Fort Worth and Houston, and U.S. Anesthesia claims in the lawsuit that its doctors were contacted by Sound Physicians “to induce them to leave” and challenge the noncompete provisions in their contracts to work with the United group.

The major insurer throws its weight around in other ways, the lawsuit claims. While the company’s Optum unit, which operates the surgery centers and clinics, is technically separate from the health insurer, the doctors accuse United of forcing its OptumCare facilities to sever their relationships with the anesthesiology group and pushing in-network surgeons to move their operations to hospitals or facilities that do not have contracts with U.S. Anesthesia.

“United and its affiliates have extended their tentacles into virtually every aspect of health care, allowing United to squeeze, choke and crush any market participant that stands in the way of United’s increased profits,” the doctors claim in their lawsuit.

It is standard practice, United said, for an insurer to encourage the use of hospitals and doctors within its network.

In contrast to many smaller physician groups that are struggling because of the pandemic, United has maintained a strong financial position, shoring up profits while elective surgeries and other procedures were shut down, resulting in fewer medical claims. So it has continued to expand, hiring more doctors and buying up additional practices. The company says it plans to add more than 10,000 employed or affiliated doctors this year.

The relationship between insurers and providers has become more complicated as more insurance carriers own doctors’ groups or clinics. “They want to be the referee and play on the other team,” said Michael Turpin, a former United executive who is now an executive vice president at USI, an insurance brokerage.

Employers that rely on UnitedHealthcare to cover their workers have a difficult time judging who benefits when insurers fail to reach an agreement to keep a provider in network. “This is just as much about profit as it is about principle,” Mr. Turpin said.

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In Search of a Vaccine, Some Tourists Find Luck in the Caribbean

This boom has been aided by the fact that since March 1, everyone over 16 has been eligible to get the vaccine in the Virgin Islands — so tourists don’t even have to worry about cutting in line. The territory accommodates about 100 walk-ins each day, too. “Nowhere else in the U.S. can you actually just walk in and get the vaccine, anybody over 16,” Mr. Bryan said on Monday. On March 1, the islands also opened two federally supported community vaccination centers on St. Thomas and St. Croix.

U.S. travelers also face less red tape when visiting the U.S. Virgin Islands compared with other Caribbean destinations. If they submit a negative coronavirus test within five days of leaving for the territory, or a positive antibody test taken within four months, they do not have to quarantine upon arrival. Travelers to Jamaica and Barbados, in contrast, are asked to quarantine no matter what. And U.S. travelers can’t visit the Cayman Islands unless they conform to strict eligibility criteria.

Dr. Hunte-Ceasar said that, at this point, the Department of Health did not consider vaccine tourism to be a problem. “We definitely want to ensure the local residents get vaccinated,” she said. But “we have not had any shortages by serving both populations.” The Virgin Islands currently have 27,000 doses of the Pfizer vaccine, 18,900 doses of the Moderna vaccine, and 600 doses of the Johnson & Johnson vaccine available, said Monife Stout, the department’s immunization director.

Noreen Michael, a scientist at the University of the Virgin Islands who studies health disparities, agreed that it was crucial to ensure that vaccines are available to residents who want them, but said she had not seen evidence to suggest that tourists are taking vaccines away from residents who want them. “On the public health side, it’s a plus,” she said. “On the equity side, I don’t see it as significant issue.”

Perhaps, too, vaccine tourism could be used as a force for good — to secure doses for marginalized groups in other regions. Although the Virgin Islands provide free Covid-19 vaccines, the islands could charge tourists for their vaccines, and the funds could be used to send vaccines to regions that need them, said Felicia Knaul, an international health economist at the University of Miami. “Could we send those vaccines to Jamaica, or to the Dominican Republic or Haiti?” she asked. “Once you’ve gotten past the key welfare and human rights aspects, if you can use that funding to pay for people who right now have no access, I think it’s worth thinking about.”

For now, health authorities are focused on ways to reduce vaccine hesitancy in the territory. “People access misinformation and perpetuate lies and things that are harmful,” Dr. Hunte-Ceasar said in a news conference last week. As a result, the islands have been experiencing a surge in cases and hospitalizations that she said give her “chest pain and heartburn every night.” Although vaccine hesitancy does seem to be decreasing, residents will need to start widely embracing the vaccine if the islands are to meet their goal of vaccinating 50,000 Virgin Islanders by July 1.

In the meantime, visitors from the continental U.S. will continue to take advantage of the extra doses. Some have stayed longer than they planned, too — and have even contemplated moving to the islands for good.

“I started falling in love with the culture of St. Croix,” said Hemal Trivedi, a documentary filmmaker who lives in Weehawken, N.J., and was vaccinated in St. Croix in February. “Toward the end of the trip, we were actually looking for a place to buy.”

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How to Virtually Become a Doctor

Jerrel Catlett’s eyes narrowed on the large intestine, a gloppy, glow stick-like object whose color matched the stool stored inside of it. He chose to isolate the organ, and it expanded on his screen as the body parts surrounding it receded — the gall bladder bright green with bile, the ribs white and curved like half moons.

“My old boss used to tell me that when I did this, I’d be so wowed by how complex the human body is,” said Mr. Catlett, 25, a first-year student at Icahn School of Medicine at Mount Sinai, gesturing to the image of a body on his laptop screen. “But it feels like there’s something missing from the experience right now.”

For generations, medical students were initiated to their training by a ritual as gory as it was awe-inducing: the cadaver dissection. Since at least the 14th century, physicians have honed their understanding of human anatomy by examining dead bodies. But amid the coronavirus pandemic, the cadaver dissection — like many hands-on aspects of the medical curriculum — turned virtual, using a three-dimensional simulation software.

Of the country’s 155 medical schools, a majority transitioned at least part of their first and second-year curriculums to remote learning during the pandemic. Nearly three-quarters offered lectures virtually, according to a survey by the Association of American Medical Colleges, and 40 percent used virtual platforms to teach students how to interview patients about their symptoms and take their medical histories. Though the cadaver dissection posed a trickier challenge, nearly 30 percent of medical schools, including Mount Sinai, used online platforms to teach anatomy.

expands. Through remote clerkships at schools like Sidney Kimmel Medical College at Thomas Jefferson University, medical students assisted hospital staff by following up virtually with patients who had been discharged earlier than usual because of the pandemic.

“Other doctors got thrown into the deep end but we get to practice using this technology,” said Ernesto Rojas, a second-year student at University of California San Francisco School of Medicine. “We learned how to build rapport and ask the patient things like, ‘Are you in a place where you can talk privately?’”

Students have also said they’ve felt particularly motivated to complete their training amid the pandemic. Medical school applications are up by 18 percent compared with this time last year, according to the A.A.M.C.

For Prerana Katiyar, 22, a first-year medical student at Columbia, the first few months of medical school didn’t look anything like she had anticipated. She started the semester living in her childhood home in Fairfax, Va., where she shared lessons from her anatomy classes with her family over dinner. “When my dad said his abdomen hurt, I was able to talk to him about the quadrants of the abdomen,” Ms. Katiyar said.

Halfway into the semester, she had an exciting update for her parents. “My skull finally arrived in the mail,” she said. Ms. Katiyar’s anatomy professor arranged for each student to order a plastic model of the skull.

“Now I can see the bony landmarks and where the nerves are,” she continued. “I’m a very visual person so it’s been helpful to trace it with my finger.”

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