The handwritten doctor’s order was just eight words long, but it solved a problem for Dundee Manor, a nursing home in rural South Carolina struggling to handle a new resident with severe dementia.
David Blakeney, 63, was restless and agitated. The home’s doctor wanted him on an antipsychotic medication called Haldol, a powerful sedative.
“Add Dx of schizophrenia for use of Haldol,” read the doctor’s order, using the medical shorthand for “diagnosis.”
But there was no evidence that Mr. Blakeney actually had schizophrenia.
Antipsychotic drugs — which for decades have faced criticism as “chemical straitjackets” — are dangerous for older people with dementia, nearly doubling their chance of death from heart problems, infections, falls and other ailments. But understaffed nursing homes have often used the sedatives so they don’t have to hire more staff to handle residents.
one in 150 people.
Schizophrenia, which often causes delusions, hallucinations and dampened emotions, is almost always diagnosed before the age of 40.
“People don’t just wake up with schizophrenia when they are elderly,” said Dr. Michael Wasserman, a geriatrician and former nursing home executive who has become a critic of the industry. “It’s used to skirt the rules.”
refuge of last resort for people with the disorder, after large psychiatric hospitals closed decades ago.
But unfounded diagnoses are also driving the increase. In May, a report by a federal oversight agency said nearly one-third of long-term nursing home residents with schizophrenia diagnoses in 2018 had no Medicare record of being treated for the condition.
hide serious problems — like inadequate staffing and haphazard care — from government audits and inspectors.
One result of the inaccurate diagnoses is that the government is understating how many of the country’s 1.1 million nursing home residents are on antipsychotic medications.
According to Medicare’s web page that tracks the effort to reduce the use of antipsychotics, fewer than 15 percent of nursing home residents are on such medications. But that figure excludes patients with schizophrenia diagnoses.
To determine the full number of residents being drugged nationally and at specific homes, The Times obtained unfiltered data that was posted on another, little-known Medicare web page, as well as facility-by-facility data that a patient advocacy group got from Medicare via an open records request and shared with The Times.
The figures showed that at least 21 percent of nursing home residents — about 225,000 people — are on antipsychotics.
The Centers for Medicare and Medicaid Services, which oversees nursing homes, is “concerned about this practice as a way to circumvent the protections these regulations afford,” said Catherine Howden, a spokeswoman for the agency, which is known as C.M.S.
“It is unacceptable for a facility to inappropriately classify a resident’s diagnosis to improve their performance measures,” she said. “We will continue to identify facilities which do so and hold them accountable.”
significant drop since 2012 in the share of residents on the drugs.
But when residents with diagnoses like schizophrenia are included, the decline is less than half what the government and industry claim. And when the pandemic hit in 2020, the trend reversed and antipsychotic drug use increased.
A Doubled Risk of Death
For decades, nursing homes have been using drugs to control dementia patients. For nearly as long, there have been calls for reform.
In 1987, President Ronald Reagan signed a law banning the use of drugs that serve the interest of the nursing home or its staff, not the patient.
But the practice persisted. In the early 2000s, studies found that antipsychotic drugs like Seroquel, Zyprexa and Abilify made older people drowsy and more likely to fall. The drugs were also linked to heart problems in people with dementia. More than a dozen clinical trials concluded that the drugs nearly doubled the risk of death for older dementia patients.
11 percent from less than 7 percent, records show.
The diagnoses rose even as nursing homes reported a decline in behaviors associated with the disorder. The number of residents experiencing delusions, for example, fell to 4 percent from 6 percent.
A Substitute for Staff
Caring for dementia patients is time- and labor-intensive. Workers need to be trained to handle challenging behaviors like wandering and aggression. But many nursing homes are chronically understaffed and do not pay enough to retain employees, especially the nursing assistants who provide the bulk of residents’ daily care.
Studies have found that the worse a home’s staffing situation, the greater its use of antipsychotic drugs. That suggests that some homes are using the powerful drugs to subdue patients and avoid having to hire extra staff. (Homes with staffing shortages are also the most likely to understate the number of residents on antipsychotics, according to the Times’s analysis of Medicare data.)
more than 200,000 since early last year and is at its lowest level since 1994.
As staffing dropped, the use of antipsychotics rose.
Even some of the country’s leading experts on elder care have been taken aback by the frequency of false diagnoses and the overuse of antipsychotics.
Barbara Coulter Edwards, a senior Medicaid official in the Obama administration, said she had discovered that her father was given an incorrect diagnosis of psychosis in the nursing home where he lived even though he had dementia.
“I just was shocked,” Ms. Edwards said. “And the first thing that flashed through my head was this covers a lot of ills for this nursing home if they want to give him drugs.”
Homes that violate the rules face few consequences.
In 2019 and 2021, Medicare said it planned to conduct targeted inspections to examine the issue of false schizophrenia diagnoses, but those plans were repeatedly put on hold because of the pandemic.
In an analysis of government inspection reports, The Times found about 5,600 instances of inspectors citing nursing homes for misusing antipsychotic medications. Nursing home officials told inspectors that they were dispensing the powerful drugs to frail patients for reasons that ranged from “health maintenance” to efforts to deal with residents who were “whining” or “asking for help.”
a state inspector cited Hialeah Shores for giving a false schizophrenia diagnosis to a woman. She was so heavily dosed with antipsychotics that the inspector was unable to rouse her on three consecutive days.
There was no evidence that the woman had been experiencing the delusions common in people with schizophrenia, the inspector found. Instead, staff at the nursing home said she had been “resistive and noncooperative with care.”
Dr. Jonathan Evans, a medical director for nursing homes in Virginia who reviewed the inspector’s findings for The Times, described the woman’s fear and resistance as “classic dementia behavior.”
“This wasn’t five-star care,” said Dr. Evans, who previously was president of a group that represents medical staff in nursing homes. He said he was alarmed that the inspector had decided the violation caused only “minimal harm or potential for harm” to the patient, despite her heavy sedation. As a result, he said, “there’s nothing about this that would deter this facility from doing this again.”
Representatives of Hialeah Shores declined to comment.
Seven of the 52 homes on the inspector general’s list were owned by a large Texas company, Daybreak Venture. At four of those homes, the official rate of antipsychotic drug use for long-term residents was zero, while the actual rate was much higher, according to the Times analysis comparing official C.M.S. figures with unpublished data obtained by the California advocacy group.
make people drowsy and increases the risk of falls. Peer-reviewed studies have shown that it does not help with dementia, and the government has not approved it for that use.
But prescriptions of Depakote and similar anti-seizure drugs have accelerated since the government started publicly reporting nursing homes’ use of antipsychotics.
Between 2015 and 2018, the most recent data available, the use of anti-seizure drugs rose 15 percent in nursing home residents with dementia, according to an analysis of Medicare insurance claims that researchers at the University of Michigan prepared for The Times.
in a “sprinkle” form that makes it easy to slip into food undetected.
“It’s a drug that’s tailor-made to chemically restrain residents without anybody knowing,” he said.
In the early 2000s, Depakote’s manufacturer, Abbott Laboratories, began falsely pitching the drug to nursing homes as a way to sidestep the 1987 law prohibiting facilities from using drugs as “chemical restraints,” according to a federal whistle-blower lawsuit filed by a former Abbott saleswoman.
According to the lawsuit, Abbott’s representatives told pharmacists and nurses that Depakote would “fly under the radar screen” of federal regulations.
Abbott settled the lawsuit in 2012, agreeing to pay the government $1.5 billion to resolve allegations that it had improperly marketed the drugs, including to nursing homes.
Nursing homes are required to report to federal regulators how many of their patients take a wide variety of psychotropic drugs — not just antipsychotics but also anti-anxiety medications, antidepressants and sleeping pills. But homes do not have to report Depakote or similar drugs to the federal government.
“It is like an arrow pointing to that class of medications, like ‘Use us, use us!’” Dr. Maust said. “No one is keeping track of this.”
published a brochure titled “Nursing Homes: Times have changed.”
“Nursing homes have replaced restraints and antipsychotic medications with robust activity programs, religious services, social workers and resident councils so that residents can be mentally, physically and socially engaged,” the colorful two-page leaflet boasted.
Last year, though, the industry teamed up with drug companies and others to push Congress and federal regulators to broaden the list of conditions under which antipsychotics don’t need to be publicly disclosed.
“There is specific and compelling evidence that psychotropics are underutilized in treating dementia and it is time for C.M.S. to re-evaluate its regulations,” wrote Jim Scott, the chairman of the Alliance for Aging Research, which is coordinating the campaign.
The lobbying was financed by drug companies including Avanir Pharmaceuticals and Acadia Pharmaceuticals. Both have tried — and so far failed — to get their drugs approved for treating patients with dementia. (In 2019, Avanir agreed to pay $108 million to settle charges that it had inappropriately marketed its drug for use in dementia patients in nursing homes.)
‘Hold His Haldol’
Ms. Blakeney said that only after hiring a lawyer to sue Dundee Manor for her husband’s death did she learn he had been on Haldol and other powerful drugs. (Dundee Manor has denied Ms. Blakeney’s claims in court filings.)
During her visits, though, Ms. Blakeney noticed that many residents were sleeping most of the time. A pair of women, in particular, always caught her attention. “There were two of them, laying in the same room, like they were dead,” she said.
In his first few months at Dundee Manor, Mr. Blakeney was in and out of the hospital, for bedsores, pneumonia and dehydration. During one hospital visit in December, a doctor noted that Mr. Blakeney was unable to communicate and could no longer walk.
“Hold the patient’s Ambien, trazodone and Zyprexa because of his mental status changes,” the doctor wrote. “Hold his Haldol.”
Mr. Blakeney continued to be prescribed the drugs after he returned to Dundee Manor. By April 2017, the bedsore on his right heel — a result, in part, of his rarely getting out of bed or his wheelchair — required the foot to be amputated.
In June, after weeks of fruitless searching for another nursing home, Ms. Blakeney found one and transferred him there. Later that month, he died.
“I tried to get him out — I tried and tried and tried,” his wife said. “But when I did get him out, it was too late.”
While most of the provider aid has been distributed, the Biden administration is expected to begin doling out the remaining funds, estimated at $25 billion of the original $178 billion, said Kristen O’Brien, a vice president for McDermott+Consulting in Washington, D.C. Hospitals are asking for more time to spend the money.
How the aid was spent has not been fully documented. While the larger hospital networks aggressively sought the funds from the start, smaller organizations, children’s hospitals and those in rural areas or serving large numbers of low-income patients had more difficulty securing the aid because of the way the funding formula was structured.
In a later round of funding decisions, officials with the Department of Health and Human Services reviewed applications more closely, and in some cases, reduced or denied requests, Ms. O’Brien said.
Grants given after the initial rush were more targeted, to those hospitals in Covid hot spots or rural areas. A few large chains, including HCA Healthcare and the Mayo Clinic, returned at least some of the money, in the wake of disclosures that wealthier hospitals had received far more aid while reporting healthy profits.
Overall, the aid program did prevent hospital closings, said Ken Marlow, a lawyer with K&L Gates in Nashville, who advises hospitals. “We haven’t seen a real avalanche of these distressed hospitals coming on the market.”
But some may no longer be able to resist takeovers or mergers. “Those providers are potentially more distressed as a result of the stress of the pandemic and will have to be thinking hard about the future, their survival,” said Torrey McClary, a lawyer with Ropes & Gray who also counsels hospitals.
People in Africa who become critically ill from Covid-19 are more likely to die than patients in other parts of the world, according to a report published on Thursday in the medical journal The Lancet.
The report, based on data from 64 hospitals in 10 countries, is the first broad look at what happens to critically ill Covid patients in Africa, the authors say.
The increased risk of death applies only to those who become severely ill, not to everyone who catches the disease. Over all, the rates of illness and death from Covid in Africa appear lower than in the rest of the world. But if the virus begins to spread more rapidly in Africa, as it has in other regions, these findings suggest that the death toll could worsen.
Among 3,077 critically ill patients admitted to the African hospitals, 48.2 percent died within 30 days, compared with a global average of 31.5 percent, the Lancet study found.
The study was observational, meaning that the researchers followed the patients’ progress, but did not experiment with treatments. The work was done by a large team called The African Covid-19 Critical Care Outcomes Study Investigators.
For Africa as a whole, the death rate among severely ill Covid patients may be even higher than it was in the study, the researchers said, because much of their information came from relatively well-equipped hospitals, and 36 percent of those facilities were in South Africa and Egypt, which have better resources than many other African countries. In addition, the patients in the study, with an average age of 56, were younger than many other critically ill Covid patients, indicating that death rates outside the study could be higher.
The other eight countries in the study were Ethiopia, Ghana, Kenya, Libya, Malawi, Mozambique, Niger and Nigeria. Leaders of 16 other African nations had also agreed to participate, but ultimately did not.
Reasons for the higher death rates include a lack of resources such as surge capacity in intensive care units, equipment to measure patients’ oxygen levels, dialysis machines and so-called ECMO devices to pump oxygen into the bloodstream of patients whose lungs become so impaired that even a ventilator is not enough to keep them alive.
But there was also an apparent failure to use resources that were available, the authors of the study suggested. Proning — turning patients onto their stomachs to help them breathe — was underused, performed for only about a sixth of the patients who needed it.
Almost 16 percent of the hospitals had ECMO, but it was offered to less than 1 percent of patients. Similarly, although 68 percent of the sites had access to dialysis to treat kidney failure, which is common in severe Covid cases, only 10 percent of the critically ill patients received it. Half the patients who died were never given oxygen, but the authors of the study said they had little data to explain why.
A Lancet editorial by experts not involved in the study said, “It is common in Africa to have expensive equipment that is non-functional due to poor maintenance or lack of skilled human resources.” Some 40 percent of the medical equipment in Africa was out of service, according to a 2017 report by the Tropical Health and Education Trust, the editorial said.
Another factor is that few doctors in Africa have the training in pulmonary and critical care that is considered essential in treating Covid patients.
As in other studies, chronic conditions like diabetes, high blood pressure, and diseases affecting the heart, kidney or liver increased the risk of death from Covid. This study was the first to include a large proportion of patients with H.I.V., which nearly doubled the risk of death. The report states, “Our data suggests that H.I.V./AIDS is an important risk factor for Covid-19 mortality.” But the authors also said they did not have data on how the severity of the H.I.V. infection might affect the risk.
An unexpected finding of the study was that, unlike Covid patients in the rest of the world, men in Africa were no more likely than women to die. That result suggests that African women are at higher risk than women in other regions.
The authors suggested that women in Africa might face “barriers to accessing care and limitations or biases in care when critically ill.”
The editorial asked whether new variants could be causing the high death rate found in the study, but also said, “This is a question which, in a continent with severe shortage of sequencing, could take a long time to answer.”
At Fort Bragg, soldiers who have gotten their coronavirus vaccines can go to a gym where no masks are required, with no limits on who can work out together. Treadmills are on and zipping, unlike those in 13 other gyms where unvaccinated troops can’t use the machines, everyone must mask up and restrictions remain on how many can bench-press at one time.
Inside Dodgers Stadium in Los Angeles, where lines not long ago snaked for miles with people seeking coronavirus vaccines, a special seating area allows those who are fully inoculated to enjoy games side by side with other fans.
When Bill Duggan reopens Madam’s Organ, his legendary blues bar in Washington, D.C., people will not be allowed in to work, drink or play music unless they can prove they have had their shots. “I have a saxophone player who is among the best in the world. He was in the other day, and I said, ‘Walter, take a good look around because you’re not walking in here again unless you get vaccinated.’”
Evite and Paperless Post are seeing a big increase in hosts requesting that their guests be vaccinated.
actually doughnuts, beers and cheesecake — to prod laggards along. Some have even offered cold hard cash: In Ohio, Gov. Mike DeWine this week went so far as to say that the state would give five vaccinated people $1 million each as part of a weekly lottery program.
On Thursday, federal health officials offered the ultimate incentive for many when they advised that fully vaccinated Americans may stop wearing masks.
Now, private employers, restaurants and entertainment venues are looking for ways to make those who are vaccinated feel like V.I.P.s, both to protect workers and guests, and to possibly entice those not yet on board.
Come summer, the nation may become increasingly bifurcated between those who are permitted to watch sports, take classes, get their hair cut and eat barbecue with others, and those who are left behind the spike protein curtain.
for children ages 12 through 15.
But even without a mandate, a nudge can feel like a shove. The military has been strongly encouraging vaccines among the troops. Acceptance has been low in some branches, like the Marines, with only 40 percent having gotten one or more shots. At Fort Bragg, one of the largest military installations in the country and among the first to offer the vaccine, just under 70 percent have been jabbed.
podcast designed to knock down misinformation — a common misbelief is that the vaccines affect fertility — plays around the base. In addition to their freedom gym, vaccinated soldiers may now eat in groups as they please, while the unvaccinated look on as they grab their grub and go.
With soldiers, experts “talk up to decliners versus talk down,” said Col. Joseph Buccino, a spokesman at Fort Bragg.
promoting inoculations, and stadiums have become a new line of demarcation, where vaccinated sections are highlighted as perks akin to V.I.P. skyboxes.
In Washington, Gov. Jay Inslee recently announced that sporting venues and churches would be able to increase their capacity by adding sections for the vaccinated.
Some businesses — like gyms and restaurants — where the coronavirus was known to spread easily are also embracing a reward system. Even though many gyms have reopened around the country, some still haven’t allowed large classes to resume.
Others are inclined to follow the lead of gyms like solidcore in Washington, D.C., which seeks proof of inoculation to enroll in classes listed as “Vaccine Required: Full Body.” “Our teams are now actively evaluating where else we think there will be client demand and will be potentially introducing it to other markets in the weeks ahead,” said Bryan Myers, chief executive officer of the national fitness studio chain, in an email.
specific invitation designs with the inoculated in mind, vaccinated only please RSVP.
Not everyone endorses this type of exclusion as good public policy. “I worry about the operational feasibility,” said Jennifer Nuzzo, an epidemiologist at the Johns Hopkins Coronavirus Resource Center. “In the U.S., we don’t yet have a standard way to prove vaccination status. I hope we’ll see by fall such low levels of infection in the U.S. that our level of concern about the virus will be very low.”
But few dispute that it is legal. “Having dedicated spaces at events reserved for vaccinated people is both lawful and ethical,” said Lawrence O. Gostin, an expert in health law at Georgetown Law School. “Businesses have a major economic incentive to create safer environments for their customers, who would otherwise be reluctant to attend crowded events. Government recommendations about vaccinated-only sections will encourage businesses and can help us back to more normal.”
so far to impose vaccine mandates for workers, especially in a tight labor market. “Our association came out in favor of masks,” said Emily Williams Knight, president of the Texas Restaurant Association. “We probably will not be taking a position on mandates, which are incredibly divisive.”
But some companies are moving that way. Norwegian Cruise Line is threatening to keep its ships out of Florida ports if the state stands by a law prohibiting businesses from requiring vaccines in exchange for services.
Public health mandates — from smoking bans to seatbelt laws to containing tuberculosis outbreaks by requiring TB patients to take their medicines while observed — have a long history in the United States.
“They fall into a cluster of things in which someone is essentially making the argument that what I do is only my business,” said Dr. Frieden, who is now chief executive of Resolve to Save Lives, a program designed to prevent epidemics and cardiovascular disease. “A lot of times that’s true, unless what you do might kill someone else.”
Dr. Frieden was the main official who pushed for a smoking ban in bars and restaurants in 2003 when he was the New York City health commissioner under former Mayor Michael R. Bloomberg. Other senior aides at the time felt certain the ban would cost Mr. Bloomberg a second term. “When I was fighting for that, a City Council member who was against the ban said of bars, ‘That is my place of entertainment.’ And I said, ‘Well, that’s someone’s place of employment.’ It did have impact.”
Mr. Duggan, the bar owner in Washington, said protecting his workers and patrons are of a piece. “As we hit a plateau with vaccines, I don’t think we can sit and wait for all the nonbelievers,” he said. “If we are going to convince them, it’s going to be through them not being able to do the things that vaccinated people are able to do.”
Clean water in 1842, food safety in 1906, a ban on lead-based paint in 1971. These sweeping public health reforms transformed not just our environment but expectations for what governments can do.
Now it’s time to do the same for indoor air quality, according to a group of 39 scientists. In a manifesto of sorts published on Thursday in the journal Science, the researchers called for a “paradigm shift” in how citizens and government officials think about the quality of the air we breathe indoors.
The timing of the scientists’ call to action coincides with the nation’s large-scale reopening as coronavirus cases steeply decline: Americans are anxiously facing a return to offices, schools, restaurants and theaters — exactly the type of crowded indoor spaces in which the coronavirus is thought to thrive.
There is little doubt now that the coronavirus can linger in the air indoors, floating far beyond the recommended six feet of distance, the experts declared. The accumulating research puts the onus on policymakers and building engineers to provide clean air in public buildings and to minimize the risk of respiratory infections, they said.
new workplace standards for air quality, but the scientists maintained that the remedies do not have to be onerous. Air quality in buildings can be improved with a few simple fixes, they said: adding filters to existing ventilation systems, using portable air cleaners and ultraviolet lights — or even just opening the windows where possible.
Dr. Morawska led a group of 239 scientists who last year called on the World Health Organization to acknowledge that the coronavirus can spread in tiny droplets, or aerosols, that drift through the air. The W.H.O. had insisted that the virus spreads only in larger, heavier droplets and by touching contaminated surfaces, contradicting its own 2014 rule to assume all new viruses are airborne.
The W.H.O. conceded on July 9 that transmission of the virus by aerosols could be responsible for “outbreaks of Covid-19 reported in some closed settings, such as restaurants, nightclubs, places of worship or places of work where people may be shouting, talking or singing,” but only at short range.
detailed 10 lines of evidence that support the importance of airborne transmission indoors.
On April 30, the W.H.O. inched forward and allowed that in poorly ventilated spaces, aerosols “may remain suspended in the air or travel farther than 1 meter (long-range).” The Centers for Disease Control and Prevention, which had also been slow to update its guidelines, recognized last week that the virus can be inhaled indoors, even when a person is more than six feet away from an infected individual.
“They have ended up in a much better, more scientifically defensible place,” said Linsey Marr, an expert in airborne viruses at Virginia Tech, and a signatory to the letter.
“It would be helpful if they were to undertake a public service messaging campaign to publicize this change more broadly,” especially in parts of the world where the virus is surging, she said. For example, in some East Asian countries, stacked toilet systems could transport the virus between floors of a multistory building, she noted.
More research is also needed on how the virus moves indoors. Researchers at the Department of Energy’s Pacific Northwest National Laboratory modeled the flow of aerosol-size particles after a person has had a five-minute coughing bout in one room of a three-room office with a central ventilation system. Clean outdoor air and air filters both cut down the flow of particles in that room, the scientists reported in April.
But rapid air exchanges — more than 12 in an hour — can propel particles into connected rooms, much as secondhand smoke can waft into lower levels or nearby rooms.
guidance for Covid does not require improvements to ventilation, except for health care settings.
“Ventilation is really built into the approach that OSHA takes to all airborne hazards,” said Peg Seminario, who served as director of occupational safety and health for the A.F.L.-C.I.O. from 1990 until her retirement in 2019. “With Covid being recognized as an airborne hazard, those approaches should apply.”
In January, President Biden directed OSHA to issue emergency temporary guidelines for Covid by March 15. But OSHA missed the deadline: Its draft is reportedly being reviewed by the White House’s regulatory office.
only during medical procedures known to produce aerosols, or if they have close contact with an infected patient. Those are the same guidelines the W.H.O. and the C.D.C. offered early in the pandemic. Face masks and plexiglass barriers would protect the rest, the association said in March in a statement to the House Committee on Education and Labor.
“They’re still stuck in the old paradigm, they have not accepted the fact that talking and coughing often generate more aerosols than do these so-called aerosol-generating procedures,” Dr. Marr said of the hospital group.
increase the risk, perhaps because they inhibit proper airflow in a room.
The improvements do not have to be expensive: In-room air filters are reasonably priced at less than 50 cents per square foot, although a shortage of supply has raised prices, said William Bahnfleth, professor of architectural engineering at Penn State University, and head of the Epidemic Task Force at Ashrae (the American Society of Heating, Refrigerating and Air-Conditioning Engineers), which sets standards for such devices. UV lights that are incorporated into a building’s ventilation system can cost up to roughly $1 per square foot; those installed room by room perform better but could be 10 times as expensive, he said.
If OSHA rules do change, demand could inspire innovation and slash prices. There is precedent to believe that may happen, according to David Michaels, a professor at George Washington University who served as OSHA director under President Barack Obama.
When OSHA moved to control exposure to a carcinogen called vinyl chloride, the building block of vinyl, the plastics industry warned it would threaten 2.1 million jobs. In fact, within months, companies “actually saved money and not a single job was lost,” Dr. Michaels recalled.
In any case, absent employees and health care costs can prove to be more costly than updates to ventilation systems, the experts said. Better ventilation will help thwart not just the coronavirus, but other respiratory viruses that cause influenza and common colds, as well as pollutants.
Before people realized the importance of clean water, cholera and other waterborne pathogens claimed millions of lives worldwide every year.
“We live with colds and flus and just accept them as a way of life,” Dr. Marr said. “Maybe we don’t really have to.”
The vaccines produced similar responses in all three groups of women, eliciting both antibody and T-cell responses against the coronavirus, the scientists found. Of particular note, experts said, was the fact that the shots produced high levels of neutralizing antibodies, which can prevent the virus from entering cells, in both pregnant and nonpregnant women.
“Clearly, the vaccines were working in these people,” said Akiko Iwasaki, an immunologist at Yale University who was not involved in the research. “These levels are expected to be quite protective.”
The researchers also found neutralizing antibodies in the breast milk of vaccinated mothers and in umbilical cord blood collected from infants at delivery. “Vaccination of pregnant people and lactating people actually leads to transfer of some immunity to their newborns and lactating infants,” said Dr. Ai-ris Y. Collier, a physician-scientist at Beth Israel who is the first author of the paper.
The results are “really encouraging,” Dr. Iwasaki said. “There is this added benefit of conferring protective antibodies to the newborn and the fetus, which is all the more reason to get vaccinated.”
The scientists also measured the women’s immune responses to two variants of concern: B.1.1.7, which was first identified in Britain, and B.1.351, which was first identified in South Africa. All three groups of women produced antibody and T-cell responses to both variants after vaccination, although their antibody responses were weaker against the variants, especially B.1.351, than against the original strain of the virus, according to the study.
“These women developed immune responses to the variants, although the asterisk is that the antibody responses were reduced several-fold,” said Dr. Dan Barouch, a study author and virologist at Beth Israel.(Dr. Barouch and his colleagues developed the Johnson & Johnson vaccine, which was not included in this study.)
“Overall, it’s good news,” he added. “And it increases the data that suggests that there is a substantial benefit for pregnant women to be vaccinated.”
Some countries were not even aware that the regulations existed, his group reported. Others lacked laws vital to responding to outbreaks, such as those authorizing quarantines.
Changing those regulations would require “negotiations for years,” Dr. Wieler said, noting that the latest set took a decade to finalize. Instead, one of his committee’s major recommendations was to increase countries’ accountability for their obligations, including though a pandemic treaty and a periodic review of their preparedness that would involve other countries.
The independent panel also proposed creating an international council led by heads of state to keep attention on health threats and to oversee a multibillion-dollar financing program that governments would contribute to based on their ability. It would promise quick payouts to countries contending with a new outbreak, giving them an incentive to report.
“There’s only going to be the political will to create those things when something catastrophic happens,” said Dr. Mark Dybul, one of the panel members. These recommendations stemmed in part from his experience leading the President’s Emergency Program for AIDS Relief, known as Pepfar, and the Global Fund to Fight AIDS, Tuberculosis and Malaria, he said.
But Dr. Wieler, who led the other international review, said that in general, creating new institutions rather than focusing on improving existing ones could increase costs, complicate coordination and damage the W.H.O.
The recommendations of panels after global emergencies have sometimes been embraced. The Ebola outbreak of 2014 and 2015 led to the creation of the W.H.O.’s health emergencies program, aimed at boosting the agency’s role in managing health crises as well as providing technical guidance. A report released this month noted that the new program had received “increasingly positive feedback” from countries, donors and partner agencies as it managed dozens of health and humanitarian emergencies.
The W.H.O. before the Ebola outbreak and after it are “two different agencies basically,” said Dr. Joanne Liu, a former international president of Doctors Without Borders and a member of the independent panel. Dr. Liu was one of the W.H.O.’s most trenchant critics during the Ebola response, and she noted a “marked improvement” in how quickly the agency had declared an international emergency this time.
Not all teenagers long for the vaccine. Many hate getting shots. Others say that because young people often get milder cases of Covid, why risk a new vaccine?
Patsy Stinchfield, a nurse practitioner who oversees vaccination for Children’s Minnesota, has stark evidence that some cases in young people can be serious. Not only have more children with Covid been admitted to the hospital recently, but its intensive care unit also has Covid patients who are 13, 15, 16 and 17 years old.
The F.D.A.’s new authorization means all those patients would be eligible for the shots, she noted. “If you can prevent your child ending up in the I.C.U. with a safe vaccine, why wouldn’t you ?” she said.
Mr. Quesnel, the East Hartford, Conn., superintendent, said the most powerful message for reaching older adolescents would probably appeal just as much to younger ones. Rather than focusing on the fact that the shot will protect them, he said, they seize on the idea that it will keep them from having to quarantine if they are exposed.
“They’re not so afraid of the health care dangers from Covid but the social losses that come along with it,” he said, adding that 60 percent of his district’s seniors, or about 300 students, got their first dose at a mass vaccination site run by Community Health Center on April 26. “Some of our greatest leverage right now is that social component — ‘You won’t be quarantined.’”
Michael Jackson of North Port, Fla., can’t wait for his 14-year-old son, Devin, to get the vaccine. During the past year, he said, his son’s beloved Little League games went on hiatus and the family had to suspend their regular Sunday suppers with grandparents And Devin, an eighth grader, had to quarantine three times after being exposed to Covid.
“We in the laboratory are preparing for another big boom in testing,” said Dr. Baird, whose team has run more than two million coronavirus tests since the beginning of the pandemic. “Even if people are vaccinated, they’re going to wonder, ‘Am I the breakthrough case?’”
In addition to Cepheid, other companies have developed tests that look for influenza and the coronavirus at the same time, including Roche, which has received emergency use authorization for a test that looks for the coronavirus, influenza A and influenza B at once.
In recent years various hospitals have developed in-house versions of these combination tests as well, some of which look for more than a dozen different respiratory pathogens simultaneously using P.C.R. technology. Those “multiplex” tests are especially helpful in diagnosing illnesses in people with weak immune systems because they allow doctors to swiftly discern what pathogen is making a person sick before it is too late to start the right treatments.
A French company, bioMérieux, sells a P.C.R. test that looks for the coronavirus as well as 21 other viruses and bacteria simultaneously. And Roche recently bought a company that sells a machine that can screen for more than 20 pathogens in one go.
Testing for multiple pathogens does not always lead to a simple treatment, however. Co-infections, in which a person is infected with multiple viruses simultaneously, are more common than doctors expected, and sometimes the multiplex tests might detect a viral infection but miss a bacterial one, said Dr. Daniel Griffin, chief of infectious diseases at ProHealth New York. A patient could carry the influenza virus but also test positive for a bacterium such as pneumococcus, for example.
“We initially thought that every time we identified a virus, we would just be able stop all antibiotics and just treat the virus if effective antiviral therapy was available,” Dr. Griffin said. “We now know that we often need to continue antibiotics,” he explained, because sometimes the multiplex tests are not sensitive enough to rule out a bacterial culprit.
Doctors and test developers are still grappling with how many pathogens to test patients for in different settings. “A burning question at every company is what panel is best — is it one, two, four, 20?” said Dr. Mark Miller, chief medical officer at bioMérieux. Relatively young and healthy adults might just need a quad test to know if they should start on Tamiflu for influenza, for example, but patients with underlying chronic diseases who are very sick might benefit from receiving the test for 22 different pathogens so that doctors can decide whether they need to be admitted to a hospital.
Even before the pandemic began 14 months ago, nursing homes had become the source for rampant, antibiotic-resistant infections. The facilities also faced systemic problems like high turnover among nursing home staff and the gaming of the federal government’s rating system, which made it hard for families to judge the quality of homes.
For years, federal health officials and some insurers have tried to encourage more stay-at-home care, and the pandemic has created a sense of urgency.
“It’s really changed the paradigm on how older adults want to live,” said Dr. Sarita Mohanty, the chief executive of the SCAN Foundation, a nonprofit group focused on issues facing older adults. The vast majority of those adults would prefer to stay at home as they age, she said.
“What’s happened is a welcome sort of market correction for nursing homes,” said Tony Chicotel, a staff attorney for California Advocates for Nursing Home Reform in San Francisco. Some families, he said, “ended up agreeing to a nursing home without giving it a lot of deliberation.” But after trying home care during the pandemic, many families found keeping an older relative at home was a viable alternative, he said.
Nursing homes rose from the almshouses in England and America that cared for the poor. In the United States, passage of the Social Security Act in 1935 provided money for states to care for the elderly. Thirty years later, the Medicaid program expanded funding, making long-term care homes central to elder care, said Terry Fulmer, the president of the John A. Hartford Foundation, an advocacy group for older adults. “If you pay the nursing homes, that’s where you go,” Dr. Fulmer said.
It wasn’t until the 1970s that some programs began to pay for home care, and the number of nursing home residents nationwide started to slowly decline, with occupancy levels in recent years flattened to about 80 percent, according to data from the Kaiser Family Foundation.