Across the world, mass vaccination campaigns are beginning, or just about to.
Russia began its campaign on Saturday. The United Kingdom will start its campaign on Tuesday. The United States hopes to start large-scale vaccinations this month, as does Turkey. Hundreds of thousands of people have already been vaccinated in China, and thousands in the United Arab Emirates and elsewhere.
But the mass vaccination efforts differ in one profound way: Some rely on a vaccine that has completed human trials — and some do not.
The vaccines that have, like the Pfizer/BioNTech vaccine approved in Britain and expected to be approved shortly in the United States, have more evidence of efficacy and safety. Those that have not — the Russian and Chinese vaccines — carry uncertainties that vaccine experts say should be settled before being given to millions of healthy people.
For one thing, researchers want to be assured that if people get Covid-19, despite having been vaccinated, they develop a milder form of the disease rather than an enhanced one.
The race for a coronavirus vaccine has been a global undertaking from the start. When Chinese scientists shared the genome of the virus on Jan. 10, researchers around the world leapt to begin designing vaccines.
In March, the first clinical trials of coronavirus vaccines in humans were launched by Moderna in the United States and Sinovac in China. More vaccine makers joined the effort, including in India, Thailand and Cuba. Today there are 13 vaccines in final, Phase 3 human trials and a total of 58 vaccines being tested on people. Dozens more are in preclinical tests.
The vaccines vary in how they prompt the body’s immune response. Moderna and Pfizer use a relatively new technology, creating genetic molecules encased in oily bubbles. The Sputnik vaccine uses adenoviruses to shuttle in genes. China’s Sinovac and Sinopharm vaccines contain dead coronaviruses.
No one has ever created a licensed human vaccine for any coronavirus before, and the world has been eagerly waiting to see what works best and most safely. Vaccine skepticism exists in countries like the United States and Brazil anyway, and Covid vaccines are open to much more, given the speed of their development and the nationalistic rivalries involved.
As governments around the world jockeyed to place advance orders, without knowing which vaccine — if any — would turn out to work, global health experts began warning that vaccine nationalism would undermine the worldwide fight against a virus that respects no borders.
The United States used its Operation Warp Speed program to make purchases from six vaccine makers. Russia and China have promoted their vaccines to a number of developing countries, using them as a medical form of soft diplomacy.
Last month, the first results of Phase 3 clinical trials for four vaccines came to light, showing high efficacy rates for Sputnik V and the vaccines from Pfizer/BioNTech, Moderna and AstraZeneca. The news was heartening. But researchers are still waiting in most cases for something more than company news releases to dig their teeth into.
In some cases, the initial announcements have left them confused.
The announcement about the Sputnik V vaccine claimed an efficacy rate of 91.4 percent based on the first 39 cases of Covid-19 in the trial — a relatively small number to base such big conclusions on. But the announcement also claimed that an analysis of an unspecified number of volunteers three weeks after the second dose revealed an efficacy rate of 95 percent.
While China has five vaccines in Phase 3 clinical trials, there has been no announcement about whether any are safe and effective. That has not stopped the Chinese government from getting a nationwide vaccination program ready and planning to approve a staggering 600 million doses for sale by the end of the year.
The U.S. Food and Drug Administration is scrutinizing the raw data from the vaccine trials by Pfizer and BioNTech, and the companies will provide more detailed public documents in advance of a meeting on Thursday of a special F.D.A. panel of experts. The panel is expected to turn to the Moderna vaccine after that. Full scientific reports are expected to start appearing in medical journals shortly.
Healthcare workers began vaccinating thousands of people in Moscow against the coronavirus on Saturday, a campaign that will expand nationally next week despite relying on a vaccine that has not been fully proven to be safe and effective.
Doctors, health-care workers, social workers, and teachers — all judged to run the highest risk of exposure to the virus — are receiving the vaccine in 70 locations across the city, and are to receive a second 21 days later.
Russia drew widespread criticism when it registered its Sputnik V vaccine for emergency use in August, before beginning a clinical trial to measure its efficacy. But President Vladimir Putin boasted that it was the first vaccine in the world to receive government approval.
Last month, the makers of the Sputnik vaccine from a clinical trial, but the vaccine had been tested on a small and unspecified number of people. The final trial has also yet to be completed.
Still, in Moscow, vaccination is now open to workers between the ages of 18 and 60 who face high risks of exposure. Pregnant women and people suffering from a cold or chronic conditions are barred from receiving it.
On Friday, Mayor Sergei Sobyanin said that 5,000 people had registered to get the vaccine, and Deputy Prime Minister Tatiana Golikova cautioned those receiving it to avoid public places and reduce their intake of medicine and alcohol within the first 42 days after the first jab, because it could suppress the immune system, Reuters reported.
Since the beginning of the pandemic, Russia has recorded nearly 2.4 million cases, the fourth largest number in the world, and more than 41,000 deaths. Moscow, with around 13 million people, has been the epicenter of the country’s outbreak.
With the coronavirus pandemic surging and initial vaccine supplies limited, the United States has a tough decision to make: Should the country’s immunization program focus in the early months on the elderly and people with serious medical conditions, who are dying of the virus at the highest rates, or on essential workers, an expansive category encompassing Americans who have borne the greatest risk of infection?
Health care workers and the frailest of the elderly — residents of long-term-care facilities — will almost certainly get the first shots, under guidelines that the Centers for Disease Control and Prevention issued on Thursday. But with vaccinations expected to start this month, the debate among federal and state health officials about who goes next, and lobbying from outside groups to be included, is growing more urgent.
It’s a question increasingly guided by concerns over the inequities laid bare by the pandemic, from disproportionately high rates of infection and death among poor people and people of color to disparate access to testing, child care and technology for remote learning.
Ultimately, the choice comes down to which is the higher priority: preventing death, or curbing the spread of the virus and returning to some semblance of normalcy. “If your goal is to maximize the preservation of human life, then you would bias the vaccine toward older Americans,” Dr. Scott Gottlieb, the former Food and Drug Administration commissioner, said recently. “If your goal is to reduce the rate of infection, then you would prioritize essential workers. So it depends what impact you’re trying to achieve.”
Adding to the complexity of any choice, the definition of “essential workers” used by the C.D.C. covers nearly 70 percent of the American work force, sweeping in not just grocery store clerks and emergency responders, but also weather forecasters, tugboat operators, exterminators, nuclear energy workers, those working in animal shelters and workers in laundry services. Some labor economists and public health officials consider the category overbroad and say it should be narrowed to only those who interact in person with the public.
An independent committee of medical experts that advises the C.D.C. on immunization practices will meet on Thursday to decide which group to recommend for the second phase of vaccination. In a meeting last month, all voting members of the committee indicated support for putting essential workers ahead of people 65 and older and those with high-risk health conditions.
On the heels of last month’s news of stunning results from Pfizer’s and Moderna’s experimental Covid-19 vaccines, Senator Rand Paul tweeted a provocative comparison.
The new vaccines were 90 percent and 94.5 percent effective, Mr. Paul, Republican of Kentucky, said. But “naturally acquired” Covid-19 was even better, at 99.9982 percent effective, claimed the senator, a Covid survivor.
The trouble with that logic is that it’s difficult to predict who will survive an infection unscathed, said Jennifer Gommerman, an immunologist at the University of Toronto.
We asked Dr. Gommerman and other experts to weigh in on the latest evidence.
Which produces a stronger immune response: a natural infection or a vaccine?
The short answer: We don’t know. But Covid-19 vaccines have predictably prevented illness, and they are a far safer bet, experts said. Vaccines for some pathogens, like pneumococcal bacteria, induce better immunity than the natural infection does. Early evidence suggests that the Covid-19 vaccines may fall into this category. Volunteers who received the Moderna shot had more antibodies — one marker of immune response — in their blood than did people who had been sick with Covid-19. Sometimes a natural infection is more powerful than a vaccine. For example, having mumps — which can cause sterility in men — generates lifelong immunity, but some people who have received one or two doses of the vaccine still get the disease.
I’m young, healthy and at low risk of Covid. Why not take my chances rather than get a rushed vaccine?
The experts were unanimous: Covid-19 is by far the more dangerous option.
People who are obese, or who have diseases like diabetes are particularly susceptible to severe cases of Covid-19. On average, the virus seems to be less risky for younger people, and women tend to fare better than men. But beyond those broad generalizations, doctors don’t know why some people get very sick and die while others have no symptoms.
In a study of more than 3,000 people ages 18 to 34 who were hospitalized for Covid-19, 20 percent required intensive care and 3 percent died.
Britain’s approval of a coronavirus vaccine this week, leaping ahead of every other Western country, would be a political gift for any leader. But perhaps no one needs it as much as Prime Minister Boris Johnson.
A successful vaccine rollout could be the last chance for Mr. Johnson’s government to show competence, after botching virtually every other step of its response to the pandemic, from tardy lockdowns to a costly, ineffective test-and-trace program — all of which contributed to the country having the highest death toll in Europe.
It also comes just as Britain has reached a climactic stage in its long negotiations with the European Union for a post-Brexit trading relationship. The mass vaccination program will be an early test of how well Britain works once it is fully untethered from Europe.
“The British government is looking for ways to claim a victory because they’ve made such a bloody mess of the epidemic,” said David King, a former chief scientific adviser to the government who has become a vocal critic of its performance. “The nationalistic response is brutish and rather distasteful.”
As the first vials of the Pfizer-BioNTech vaccine rolled into Britain in refrigerated trucks from Belgium this week, negotiators in London were in the last stages of trying to stitch together a long-term, E.U.-British trade agreement. European officials expressed hope that they could come to terms as soon as Sunday, though stumbling blocks remained.
The pandemic has raised pressure on Mr. Johnson to strike a deal since a failure could deepen economic damage caused by multiple lockdowns. Yet the convergence of events could also be fortuitous, allowing the beleaguered prime minister to resolve an issue that has divided Britain for more than four years at the very moment that relief finally begins to arrive for a country ravaged by the virus.
In other developments around the world:
South Korea reported 583 new cases on Saturday, as new rules took effect that require many businesses in Seoul, the capital, to close by 9 p.m. Authorities said they would decide on Sunday whether to tighten restrictions any further. The country’s latest outbreak is mostly driven by cases in greater Seoul, where half of the country’s 51 million people live, and the 629 infections reported nationwide on Friday were a nine-month high.
In Japan, the Tokyo metropolitan area reported a record 584 new cases on Saturday, eclipsing a previous record of 570 that was set on Nov. 27. The national government has, so far, stopped short of declaring a state of emergency, as it did in April, and Prime Minister Yoshihide Suga on Friday reiterated his commitment to hosting the Summer Olympics in Tokyo next year.
In the dispiriting, continuing surge of coronavirus cases across the United States, one region has a reason to be hopeful. Seven states in the Midwest have seen a sustained decrease in case numbers over the past 14 days, something health experts say is not necessarily definitive but undeniably encouraging.
Cases in Illinois, Iowa, Missouri, Kansas, Nebraska, North Dakota and South Dakota all began climbing after Labor Day, as cold weather pushed people in the Midwest indoors, creating incubators for infection.
The worst-hit part of the country still, the Midwest has suffered thousands of deaths and been dealing with overwhelmed hospitals for months. Thanksgiving may be affecting the rising numbers of cases, with a big wave of tests before the holiday.
Nationally, the picture is looking only worse: On Friday, more than 229,000 cases were reported and the seven-day rolling average of new cases passed 183,700, both records. Nine states set single-day case records. More than 101,000 Americans are in hospitals now, double the number from just a month ago.
And the country topped 2,800 deaths for the first time on Wednesday, and then did so again on Thursday. The seven-day average for new deaths rose to more than 2,000 for the first time since April with Tennessee and Oregon setting single-day records; 16 states reported more deaths in the past week than in any previous week.
California, where daily case reports have tripled in the past month, is just one of several states that had appeared to have gained control of the virus, only to see it spread rapidly throughout the fall. More than 23,000 new cases were reported by Friday night, the third consecutive single-day record.
In the Midwest, Illinois, Iowa, Missouri, Kansas, Nebraska and North Dakota have had varied mask mandates and other restrictions, with South Dakota doing very little at all, but all of them have been declining in cases, according to a New York Times database. North Dakota, for example, after leading the nation in daily new cases per person for weeks, has seen its rate fall by more than half since mid-November.
In part, the news media may have had a role in the change, said Carl Bergstrom, a professor of biology at the University of Washington in Seattle. Before the virus slammed into the region, news outlets were not necessarily giving as much coverage to the pandemic there as in other areas, like the Northeast. But once cases became prevalent, he said, news reports heightened public awareness of the danger, and more residents took action to protect themselves.
“One of the big lessons in the pandemic is, no matter how good you are at predicting how a disease spreads through a population, that’s not going to help you that much because the enormous drivers are behavioral changes,” Mr. Bergstrom said.
Holiday paperwork slowdowns may have diminished reporting as well, so there is a chance numbers could tick back up soon. Deaths — which tend to lag behind case counts — were still increasing in a number of Midwestern states over the past two weeks.
Mr. Bergstrom said he believed the apparent improvement might be a Midwestern mirage. He said he was alarmed by rates of positive tests in the seven Midwestern states where cases had been declining.
As an example, he pointed to South Dakota, where nearly half of tests came back positive on average over the past 14 days, according to Johns Hopkins University. Deaths in the state also remain at their peak level, the highest per person rate in the country.
“I think it’s going to be a really rough next few months basically everywhere,” he said.
With a record number of Covid patients in Tennessee’s hospitals, Gov. Bill Lee has authorized National Guard troops to drive ambulances, test patients and perform nursing tasks to relieve stress on the overwhelmed health facilities.
Mr. Lee, a Republican, is just the latest governor to reach for the help of Guard members to assist nurses and doctors struggling to handle a flood of virus patients who are quickly filling intensive care beds. There are now more than 101,000 Covid patients in hospitals in the United States, and more than 2,700 in Tennessee, both of which are record highs, according to the Covid Tracking Project.
Tens of thousands of Guard members have assisted with the coronavirus response nationwide, helping to swab people’s noses, clean public buildings or unload medical aid and food supplies. But as the pandemic has worsened, their missions have become more dire. Last month, Guard members in Texas helped move bodies in El Paso as the virus’s grim toll overwhelmed morgues. In Idaho, the troops are helping to direct patients outside of a busy urgent care clinic. And Guard members in Massachusetts set up equipment this week for a once-closed field hospital now forced to reopen as more fall ill.
Mr. Lee’s executive order allows Guard members with “appropriate training or skills” to perform functions that would usually be carried out by nurses or other hospital staff.
Lt. Col. Chris Messina, a spokesman for the Tennessee National Guard, said in an email that 353 Guard members are helping with virus testing, including 19 who had been deployed in response to the latest order. Those included 11 troops who were sent to help with testing at a clinic in Memphis and another eight to help test patients at several urgent care centers in eastern Tennessee, he said.
A state health official told The Commercial Appeal newspaper in Memphis that hospitals had been calling for the state to send them support from the Guard. And one hospital executive told the newspaper that Guard members were already helping to test people for the coronavirus, allowing hospital staff to turn to other tasks.
“We were able to use the National Guard to free up some of our clinical team to come back into the hospital,” said Alan Levine, the chief executive of Ballad Health. “Already it’s been helpful.”
In other U.S. news:
A state-mandated stay-at-home order will soon take effect for the San Joaquin Valley region in California — the most recent in a new round of coronavirus restrictions. The order, triggered when a region falls below a threshold of 15 percent intensive care unit availability, is set to begin Dec. 6 at 11:59 p.m. and last for at least three weeks. Under the order, private gatherings are prohibited along with in-person dining and retail businesses are allowed to operate under limited capacity.
Three prison workers in Nebraska have tested positive for the coronavirus, bringing the state’s total number of corrections workers confirmed to have contracted the virus to almost 400, The Associated Press reported. Public officials across the U.S. have grappled with outbreaks in prisons, as at least 1,450 inmates and correctional officers have died from the coronavirus.
The United States is winding up a particularly devastating week, one of the very worst since the coronavirus pandemic began nine months ago.
The country set a single-day record for new daily infections on Thursday, with more than 217,000, only to jump to a new high of more than 228,000 on Friday. Many other data points that illustrated the depth and spread of a virus that has killed more than 279,000 people in the United States, more than the entire population of Lubbock, Texas; or Modesto, Calif.; or Jersey City, N.J.
“It’s just an astonishing number,” said Caitlin Rivers, a senior scholar at the Johns Hopkins Center for Health Security. “We’re in the middle of this really severe wave and I think as we go through the day to day of this pandemic, it can be easy to lose sight of how massive and deep the tragedy is.”
As the virus has spread, infectious-disease experts have gained a better understanding of who among the nation’s nearly 330 million residents is the most vulnerable.
Nursing home deaths have consistently represented about 40 percent of the country’s Covid-19 deaths since midsummer, even as facilities kept visitors away and took other precautions and as the share of infections related to long-term care facilities fell substantially.
Underlying conditions have played a pivotal role in determining who survives the virus. Americans who have conditions like diabetes, hypertension and obesity — about 45 percent of the population — are more vulnerable.
And new evidence has emerged that people in lower-income neighborhoods experienced higher exposure risk to the virus because of their need to work outside the home.
The poor, in particular, have been more at risk than the rich, according to analyses of those who have been sickened by the virus or succumbed to it.
Studies suggest that the reason the virus has affected Black and Latino communities more than white neighborhoods is tied to social and environmental factors, not any innate vulnerability.
According to one recent study of cellphone data, people in lower-income neighborhoods experienced significantly higher exposure risk to the virus because they were compelled to go to jobs outside their homes.
NEW ROCHELLE, N.Y. — There are lines again at Glen Island Park, the drive-through coronavirus testing center that state officials set up when the coronavirus was discovered in this city in March.
Nurses at the hospital went on a two-day strike this week over fears that their working conditions made them vulnerable to infection as hospitalization rates climb.
And at the synagogue where the first case here was detected nine months ago, a sign on the door now turns away people who live in coronavirus hot zones.
As the virus rages across Westchester County, it has returned to New Rochelle, a city of 80,000 hit so hard during the outbreak’s earliest days that it was, for a time, the epicenter of the pandemic in the region. In early March, when Gov. Andrew M. Cuomo announced the state’s first so-called containment zone in this New York City suburb, New Rochelle’s fate proclaimed that the virus had arrived.
And now it is back.
Westchester County’s caseload is rising by an average of more than 580 a day. New Rochelle contributed 73 new cases on Friday, adding to a profound sense of defeat.
That the coronavirus could re-emerge here, in a city and county scarred by loss and praised as a model of how to stop the spread of the virus, is a testament to the pandemic’s intractability. Local leaders and health experts fear the city is also a bellwether for the rest of the country: If the disease can roar back here, it can happen anywhere.
In the ongoing conversation about how to defeat the coronavirus, experts have made reference to the “Swiss cheese model” of pandemic defense.
The metaphor is easy enough to grasp: Multiple layers of protection, imagined as cheese slices, block the spread of the virus that causes Covid-19. No one layer is perfect: Each has holes, and when the holes align, the risk of infection increases. But several layers combined — social distancing, masks, hand-washing, testing and tracing, ventilation, government messaging — significantly reduce the overall risk. Vaccination will add one more protective layer.
“Pretty soon you’ve created an impenetrable barrier, and you really can quench the transmission of the virus,” said Dr. Julie Gerberding, executive vice president and chief patient officer at Merck, who recently referenced the Swiss cheese model.
“But it requires all of those things, not just one of those things,” she added. “I think that’s what our population is having trouble getting their head around. We want to believe that there is going to come this magic day when suddenly 300 million doses of vaccine will be available and we can go back to work and things will return to normal. That is absolutely not going to happen fast.”
In October, Bill Hanage, an epidemiologist at the Harvard T.H. Chan School of Public Health, retweeted an infographic rendering of the Swiss cheese model, noting that it included “things that are personal *and* collective responsibility — note the ‘misinformation mouse’ busy eating new holes for the virus to pass through.”
The Swiss cheese concept originated with James T. Reason, a cognitive psychologist, now a professor emeritus at the University of Manchester, England, in his 1990 book, “Human Error.” A succession of disasters — including the Challenger shuttle explosion, Bhopal and Chernobyl — motivated the concept, and it became known as the “Swiss cheese model of accidents,” with the holes in the cheese slices representing errors that accumulate and lead to adverse events.
The metaphor now pairs well with the coronavirus pandemic. Ian M. Mackay, a virologist at the University of Queensland, in Brisbane, Australia, saw a version on Twitter, but thought that it could do with more slices, more information. So he created, with collaborators, the “Swiss Cheese Respiratory Pandemic Defense.”
THOSE WE’VE LOST
Irina A. Antonova, a commanding art historian who led the Pushkin State Museum of Fine Arts in Moscow for more than a half century, used it to bring outside culture to isolated Soviet citizens and turned it into a major cultural institution, died on Tuesday in that city. She was 98.
The cause was heart failure complicated by a coronavirus infection, the museum said.
Ms. Antonova steered the museum through the isolationist and rigid cultural policies of the Soviet Union and into the period after the fall of Communism. In recent years, she expanded it to adjacent buildings — sometimes angering their tenants — to accommodate mushrooming exhibitions.
From early on, Ms. Antonova used her inexhaustible energy to build connections with the world’s leading museums. In 1974, she brought Leonardo da Vinci’s Mona Lisa from the Louvre in Paris. Hundreds of thousands of people lined up to see it, the only queues the Soviet government was proud of at the time. Many knew that with the country’s borders shut, it might be the sole opportunity to see that famous work during their lifetimes.
She further opened the world to the Soviet people with exhibitions of 100 paintings from the Metropolitan Museum of Art in New York and of the treasures of Tutankhamen.
On Ms. Antonova’s watch, the Pushkin museum also exhibited abstract and avant-garde works by Russian and international artists. That was generally unimaginable in a country where an unofficial art show was once broken up with the help of a bulldozer, and whose leader at the time, Nikita S. Khrushchev, while visiting an exhibition of new Soviet art in 1962, shouted that some abstract paintings were made with a “donkey’s tail” and that even his grandson could do better.
In 1981, the museum hosted “Moscow-Paris, 1900-1930,” a landmark exhibition that mixed works by French artists like Matisse and Picasso together with highlights of the Russian avant-garde of the time, including works by Chagall, Malevich and Kandinsky. The exhibition showed how Russian artists fit in well with Western European trends and how they had sometimes helped form them.
In an effort to stimulate its economy, Hawaii is offering 50 people from the mainland United States free round trip tickets to temporarily relocate to Oahu.
The 50 people chosen for the initiative, called “Movers and Shakas,” will receive significant discounts on housing, co-working space and dining. They will have to commit to doing some nonprofit work on the island and also to work with local people. They will also be expected to stay on the island for at least one month, but the hope is that they will stay longer.
“Movers and Shakas aims at engaging former residents and out-of-state individuals to work remotely from Hawai’i while receiving exclusive incentives and committing to give back to the local community,” according to the relocation program’s website.
On social media, mainland residents have largely expressed excitement at the prospect of moving to the islands, and supporters in Hawaii see the initiative as an innovative and thoughtful way to help a state battered by the downturn in tourism, which makes up a quarter of Hawaii’s economy.
However, many local activists criticize the program, saying that instead of creating new programs to attract mainlanders, state authorities should focus on helping islanders.
In 2019, Hawaii had more than 10 million visitors, an all-time high, according to data from the state’s Tourism Authority. That number had been expected to continue rising before the pandemic, but after Hawaii imposed a mandatory quarantine for anyone flying into the state, arrivals fell drastically; at one point they were down 99 percent.
Still, by enforcing the quarantines with fines and giving citations for those not wearing masks, Hawaii was able to bring cases down significantly. The state currently has the lowest daily coronavirus case average of all states, with a single day average of 82 for the past seven days. Tourists were welcomed back starting in October, and more than 100,000 people from the mainland have visited since.
Since Nov. 24, Hawaii has allowed visitors to skip the 14-day quarantine as long as they had a negative test for the virus within 72 hours of boarding an inbound flight. Airlines, hotels and other travel industry insiders have been watching Hawaii’s reopening for lessons on how to restart travel in other states and with other countries.