COVID-19 Updates

On March 16, the world was witness to a horrific act of violence when a gunman killed six Asian American women and two others at spas in the Atlanta, Georgia area. The attack prompted a national outcry and protests against the rising levels of hate and violence directed at Asian Americans and Pacific Islanders (AAPI), a community that has experienced a profound and disturbing legacy of racism in American history.

Despite this fact, my own understanding and awareness of the hate and racism experienced by the AAPI community, then and now, would be described as limited at best. Was I aware on some level? Perhaps. But if I’m being honest, I have not fully appreciated the unique experiences of AAPI colleagues, friends, and students.

That changed when I attended a White Coats Against Asian Hate & Racism rally, held by the George Washington University School of Medicine and Health Sciences 2 months after the Atlanta killings. Hearing my colleagues speak of their personal experiences, I quickly realized my lack of education on the subject of how systemic racism has long affected Asian Americans in this country.
 

Measuring the alarming rise in anti-Asian hate

The data supporting a rise in anti-Asian hate crimes have been staring us in the face for decades but have drawn increasing attention since the beginning of the COVID-19 pandemic, when these already distressingly high numbers experienced a steep rise.

Before looking at these figures, though, we must begin by defining what is considered a hate crime versus a hate incident. The National Asian Pacific American Bar Association and Asian & Pacific Islander American Health Forum have produced a beneficial summary document on precisely what separates these terms:

• A hate crime is a crime committed on the basis of the victim’s perceived or actual race, color, religion, national origin, sexual orientation, gender identity, or disability. It differs from “regular” crime in that its victims include the immediate crime target and others like them. Hate crimes affect families, communities, and, at times, an entire nation.
• A hate incident describes acts of prejudice that are not crimes and do not involve violence, threats, or property damage. The most common examples are isolated forms of speech, such as racial slurs.

Stop AAPI Hate (SAH) was founded in March 2020 as a coalition to track and analyze incidents of hate against this community. SAH’s 2020-2021 national report details 3,795 hate incidents that occurred from March 19, 2020, to Feb. 28, 2021. In a notable parallel to the Georgia killings, SAH found that Asian American women reported hate incidents 2.3 times more often than men and that businesses were the primary site of discrimination.

This rise in hate incidents has occurred in parallel with an increase in Asian American hate crimes. Recently, the Center for the Study of Hate and Extremism (CSUSB) released its Report to the Nation: Anti-Asian Prejudice & Hate Crime. CSUSB found that anti-Asian hate crimes increased by 164% in the first quarter of 2021. I re-read that data point multiple times, thinking it must be in error. If you’re asking exactly why I was having difficulty accepting this data, you have to appreciate these two critical points:

• Per the CSUSB, anti-Asian hate crimes were already surging by 146% in 2020.
• This surge occurred while overall hate crimes dropped by 7%.

So, if 2020 was a surge, the first quarter of 2021 is a hurricane. What’s perhaps most concerning is that these data only capture reported cases and therefore are a fraction of the total.

Undoubtedly, we are living through an unprecedented rise in anti-Asian hate incidents and hate crimes since the start of the pandemic. This rise in hate-related events paralleled the many pandemic-related stressors (disease, isolation, economics, mental health, etc.). Should anyone have been surprised when this most recent deadly spike of anti-Asian hate occurred in the first quarter of 2021?
 

Hate’s toll on mental health

As a psychiatrist, I’ve spent my entire career working with dedicated teams to treat patients with mental health disorders. Currently, hate is not classified by the Diagnostic and Statistical Manual of Mental Disorders as a mental illness. However, I can’t think of another emotion that is a better candidate for further research and scientific instigation, if for no other reason than to better understand when prejudice and bias transform into hatred and crime.

Surprisingly, there has been relatively little research on the topic of hate in the fields of psychology and psychiatry. I’d be willing to wager that if you asked a typical graduating class of medical students to give you an actual working definition of the emotion of hate, most would be at a loss for words.

Dr. Fischer and Dr. Halperin published a helpful article that gives a functional perspective on hate. The authors cover a great deal of research on hate and offer the following four starting points valuable in considering it:

• “Hate is different from anger because an anger target is appraised as someone whose behavior can be influenced and changed.”
• “A hate target, on the contrary, implies appraisals of the other’s malevolent nature and malicious intent.”
• “Hate is characterized by appraisals that imply a stable perception of a person or group and thus the incapability to change the extremely negative characteristics attributed to the target of hate.”
• “Everyday observations also suggest that hate is so powerful that it does, not just temporarily but permanently, destroy relations between individuals or groups.”

When I view hate with these insights in mind, it completely changes how I choose to utilize the word or concept. Hate is an emotion whose goal/action tendency is to eliminate groups (not just people or obstacles) and destroy any current or future relationships. We can take this a step further in noting that hate spreads, not only to the intended targets but potentially my “own” group. Similar to secondhand smoke, there is no risk-free exposure to hate or racism.

In the past decade, a robust body of evidence has emerged that clearly illustrates the negative health impacts of racism. Dr. Paradies and colleagues performed a systematic meta-analysis explicitly focused on racism as a determinant of health, finding that it was associated with poorer mental health, including depression, anxiety, and psychological distress. Over the past two decades, researchers have increasingly looked at the effects of racial discrimination on the AAPI community. In their 2009 review article, Dr. Gee and colleagues identified 62 empirical articles assessing the relation between discrimination and health among Asian Americans. Most of the studies found that discrimination was associated with poorer health. Of the 40 studies focused on mental health, 37 reported that discrimination was associated with poorer outcomes.

SAH recently released its very illuminating Mental Health Report. Among several key findings, two in particular caught my attention. First, Asian Americans who have experienced racism are more stressed by anti-Asian hate than the pandemic itself. Second, one in five Asian Americans who have experienced racism display racial trauma, the psychological and emotional harm caused by racism. Given the rise in hate crimes, there must be concern regarding the level of trauma being inflicted upon the Asian American community.

A complete review of the health effects of racism is beyond this article’s scope. Still, the previously mentioned studies further support the need to treat racism in general, and specifically anti-Asian hate, as the urgent public health concern that it truly is. The U.S. government recently outlined an action plan to respond to anti-Asian violence, xenophobia, and bias. These are helpful first steps, but much more is required on a societal and individual level, given the mental health disparities faced by the AAPI community.

Determining the best ways to address this urgent public health concern can be overwhelming, exhausting, and outright demoralizing. The bottom line is that if we do nothing, communities and groups will continue to suffer the effects of racial hatred. These consequences are severe and transgenerational.

But we must start somewhere. For me, that begins by gaining a better understanding of the emotion of hate and my role in either facilitating or stopping it, and by listening, listening, and listening some more to AAPI colleagues, friends, and family about their lived experience with anti-Asian hate.

A version of this article first appeared on Medscape.com.

On March 16, the world was witness to a horrific act of violence when a gunman killed six Asian American women and two others at spas in the Atlanta, Georgia area. The attack prompted a national outcry and protests against the rising levels of hate and violence directed at Asian Americans and Pacific Islanders (AAPI), a community that has experienced a profound and disturbing legacy of racism in American history.

Despite this fact, my own understanding and awareness of the hate and racism experienced by the AAPI community, then and now, would be described as limited at best. Was I aware on some level? Perhaps. But if I’m being honest, I have not fully appreciated the unique experiences of AAPI colleagues, friends, and students.

That changed when I attended a White Coats Against Asian Hate & Racism rally, held by the George Washington University School of Medicine and Health Sciences 2 months after the Atlanta killings. Hearing my colleagues speak of their personal experiences, I quickly realized my lack of education on the subject of how systemic racism has long affected Asian Americans in this country.
 

Measuring the alarming rise in anti-Asian hate

The data supporting a rise in anti-Asian hate crimes have been staring us in the face for decades but have drawn increasing attention since the beginning of the COVID-19 pandemic, when these already distressingly high numbers experienced a steep rise.

Before looking at these figures, though, we must begin by defining what is considered a hate crime versus a hate incident. The National Asian Pacific American Bar Association and Asian & Pacific Islander American Health Forum have produced a beneficial summary document on precisely what separates these terms:

• A hate crime is a crime committed on the basis of the victim’s perceived or actual race, color, religion, national origin, sexual orientation, gender identity, or disability. It differs from “regular” crime in that its victims include the immediate crime target and others like them. Hate crimes affect families, communities, and, at times, an entire nation.
• A hate incident describes acts of prejudice that are not crimes and do not involve violence, threats, or property damage. The most common examples are isolated forms of speech, such as racial slurs.

Stop AAPI Hate (SAH) was founded in March 2020 as a coalition to track and analyze incidents of hate against this community. SAH’s 2020-2021 national report details 3,795 hate incidents that occurred from March 19, 2020, to Feb. 28, 2021. In a notable parallel to the Georgia killings, SAH found that Asian American women reported hate incidents 2.3 times more often than men and that businesses were the primary site of discrimination.

This rise in hate incidents has occurred in parallel with an increase in Asian American hate crimes. Recently, the Center for the Study of Hate and Extremism (CSUSB) released its Report to the Nation: Anti-Asian Prejudice & Hate Crime. CSUSB found that anti-Asian hate crimes increased by 164% in the first quarter of 2021. I re-read that data point multiple times, thinking it must be in error. If you’re asking exactly why I was having difficulty accepting this data, you have to appreciate these two critical points:

• Per the CSUSB, anti-Asian hate crimes were already surging by 146% in 2020.
• This surge occurred while overall hate crimes dropped by 7%.

So, if 2020 was a surge, the first quarter of 2021 is a hurricane. What’s perhaps most concerning is that these data only capture reported cases and therefore are a fraction of the total.

Undoubtedly, we are living through an unprecedented rise in anti-Asian hate incidents and hate crimes since the start of the pandemic. This rise in hate-related events paralleled the many pandemic-related stressors (disease, isolation, economics, mental health, etc.). Should anyone have been surprised when this most recent deadly spike of anti-Asian hate occurred in the first quarter of 2021?
 

Hate’s toll on mental health

As a psychiatrist, I’ve spent my entire career working with dedicated teams to treat patients with mental health disorders. Currently, hate is not classified by the Diagnostic and Statistical Manual of Mental Disorders as a mental illness. However, I can’t think of another emotion that is a better candidate for further research and scientific instigation, if for no other reason than to better understand when prejudice and bias transform into hatred and crime.

Surprisingly, there has been relatively little research on the topic of hate in the fields of psychology and psychiatry. I’d be willing to wager that if you asked a typical graduating class of medical students to give you an actual working definition of the emotion of hate, most would be at a loss for words.

Dr. Fischer and Dr. Halperin published a helpful article that gives a functional perspective on hate. The authors cover a great deal of research on hate and offer the following four starting points valuable in considering it:

• “Hate is different from anger because an anger target is appraised as someone whose behavior can be influenced and changed.”
• “A hate target, on the contrary, implies appraisals of the other’s malevolent nature and malicious intent.”
• “Hate is characterized by appraisals that imply a stable perception of a person or group and thus the incapability to change the extremely negative characteristics attributed to the target of hate.”
• “Everyday observations also suggest that hate is so powerful that it does, not just temporarily but permanently, destroy relations between individuals or groups.”

When I view hate with these insights in mind, it completely changes how I choose to utilize the word or concept. Hate is an emotion whose goal/action tendency is to eliminate groups (not just people or obstacles) and destroy any current or future relationships. We can take this a step further in noting that hate spreads, not only to the intended targets but potentially my “own” group. Similar to secondhand smoke, there is no risk-free exposure to hate or racism.

In the past decade, a robust body of evidence has emerged that clearly illustrates the negative health impacts of racism. Dr. Paradies and colleagues performed a systematic meta-analysis explicitly focused on racism as a determinant of health, finding that it was associated with poorer mental health, including depression, anxiety, and psychological distress. Over the past two decades, researchers have increasingly looked at the effects of racial discrimination on the AAPI community. In their 2009 review article, Dr. Gee and colleagues identified 62 empirical articles assessing the relation between discrimination and health among Asian Americans. Most of the studies found that discrimination was associated with poorer health. Of the 40 studies focused on mental health, 37 reported that discrimination was associated with poorer outcomes.

SAH recently released its very illuminating Mental Health Report. Among several key findings, two in particular caught my attention. First, Asian Americans who have experienced racism are more stressed by anti-Asian hate than the pandemic itself. Second, one in five Asian Americans who have experienced racism display racial trauma, the psychological and emotional harm caused by racism. Given the rise in hate crimes, there must be concern regarding the level of trauma being inflicted upon the Asian American community.

A complete review of the health effects of racism is beyond this article’s scope. Still, the previously mentioned studies further support the need to treat racism in general, and specifically anti-Asian hate, as the urgent public health concern that it truly is. The U.S. government recently outlined an action plan to respond to anti-Asian violence, xenophobia, and bias. These are helpful first steps, but much more is required on a societal and individual level, given the mental health disparities faced by the AAPI community.

Determining the best ways to address this urgent public health concern can be overwhelming, exhausting, and outright demoralizing. The bottom line is that if we do nothing, communities and groups will continue to suffer the effects of racial hatred. These consequences are severe and transgenerational.

But we must start somewhere. For me, that begins by gaining a better understanding of the emotion of hate and my role in either facilitating or stopping it, and by listening, listening, and listening some more to AAPI colleagues, friends, and family about their lived experience with anti-Asian hate.

A version of this article first appeared on Medscape.com.

On March 16, the world was witness to a horrific act of violence when a gunman killed six Asian American women and two others at spas in the Atlanta, Georgia area. The attack prompted a national outcry and protests against the rising levels of hate and violence directed at Asian Americans and Pacific Islanders (AAPI), a community that has experienced a profound and disturbing legacy of racism in American history.

Despite this fact, my own understanding and awareness of the hate and racism experienced by the AAPI community, then and now, would be described as limited at best. Was I aware on some level? Perhaps. But if I’m being honest, I have not fully appreciated the unique experiences of AAPI colleagues, friends, and students.

That changed when I attended a White Coats Against Asian Hate & Racism rally, held by the George Washington University School of Medicine and Health Sciences 2 months after the Atlanta killings. Hearing my colleagues speak of their personal experiences, I quickly realized my lack of education on the subject of how systemic racism has long affected Asian Americans in this country.
 

Measuring the alarming rise in anti-Asian hate

The data supporting a rise in anti-Asian hate crimes have been staring us in the face for decades but have drawn increasing attention since the beginning of the COVID-19 pandemic, when these already distressingly high numbers experienced a steep rise.

Before looking at these figures, though, we must begin by defining what is considered a hate crime versus a hate incident. The National Asian Pacific American Bar Association and Asian & Pacific Islander American Health Forum have produced a beneficial summary document on precisely what separates these terms:

• A hate crime is a crime committed on the basis of the victim’s perceived or actual race, color, religion, national origin, sexual orientation, gender identity, or disability. It differs from “regular” crime in that its victims include the immediate crime target and others like them. Hate crimes affect families, communities, and, at times, an entire nation.
• A hate incident describes acts of prejudice that are not crimes and do not involve violence, threats, or property damage. The most common examples are isolated forms of speech, such as racial slurs.

Stop AAPI Hate (SAH) was founded in March 2020 as a coalition to track and analyze incidents of hate against this community. SAH’s 2020-2021 national report details 3,795 hate incidents that occurred from March 19, 2020, to Feb. 28, 2021. In a notable parallel to the Georgia killings, SAH found that Asian American women reported hate incidents 2.3 times more often than men and that businesses were the primary site of discrimination.

This rise in hate incidents has occurred in parallel with an increase in Asian American hate crimes. Recently, the Center for the Study of Hate and Extremism (CSUSB) released its Report to the Nation: Anti-Asian Prejudice & Hate Crime. CSUSB found that anti-Asian hate crimes increased by 164% in the first quarter of 2021. I re-read that data point multiple times, thinking it must be in error. If you’re asking exactly why I was having difficulty accepting this data, you have to appreciate these two critical points:

• Per the CSUSB, anti-Asian hate crimes were already surging by 146% in 2020.
• This surge occurred while overall hate crimes dropped by 7%.

So, if 2020 was a surge, the first quarter of 2021 is a hurricane. What’s perhaps most concerning is that these data only capture reported cases and therefore are a fraction of the total.

Undoubtedly, we are living through an unprecedented rise in anti-Asian hate incidents and hate crimes since the start of the pandemic. This rise in hate-related events paralleled the many pandemic-related stressors (disease, isolation, economics, mental health, etc.). Should anyone have been surprised when this most recent deadly spike of anti-Asian hate occurred in the first quarter of 2021?
 

Hate’s toll on mental health

As a psychiatrist, I’ve spent my entire career working with dedicated teams to treat patients with mental health disorders. Currently, hate is not classified by the Diagnostic and Statistical Manual of Mental Disorders as a mental illness. However, I can’t think of another emotion that is a better candidate for further research and scientific instigation, if for no other reason than to better understand when prejudice and bias transform into hatred and crime.

Surprisingly, there has been relatively little research on the topic of hate in the fields of psychology and psychiatry. I’d be willing to wager that if you asked a typical graduating class of medical students to give you an actual working definition of the emotion of hate, most would be at a loss for words.

Dr. Fischer and Dr. Halperin published a helpful article that gives a functional perspective on hate. The authors cover a great deal of research on hate and offer the following four starting points valuable in considering it:

• “Hate is different from anger because an anger target is appraised as someone whose behavior can be influenced and changed.”
• “A hate target, on the contrary, implies appraisals of the other’s malevolent nature and malicious intent.”
• “Hate is characterized by appraisals that imply a stable perception of a person or group and thus the incapability to change the extremely negative characteristics attributed to the target of hate.”
• “Everyday observations also suggest that hate is so powerful that it does, not just temporarily but permanently, destroy relations between individuals or groups.”

When I view hate with these insights in mind, it completely changes how I choose to utilize the word or concept. Hate is an emotion whose goal/action tendency is to eliminate groups (not just people or obstacles) and destroy any current or future relationships. We can take this a step further in noting that hate spreads, not only to the intended targets but potentially my “own” group. Similar to secondhand smoke, there is no risk-free exposure to hate or racism.

In the past decade, a robust body of evidence has emerged that clearly illustrates the negative health impacts of racism. Dr. Paradies and colleagues performed a systematic meta-analysis explicitly focused on racism as a determinant of health, finding that it was associated with poorer mental health, including depression, anxiety, and psychological distress. Over the past two decades, researchers have increasingly looked at the effects of racial discrimination on the AAPI community. In their 2009 review article, Dr. Gee and colleagues identified 62 empirical articles assessing the relation between discrimination and health among Asian Americans. Most of the studies found that discrimination was associated with poorer health. Of the 40 studies focused on mental health, 37 reported that discrimination was associated with poorer outcomes.

SAH recently released its very illuminating Mental Health Report. Among several key findings, two in particular caught my attention. First, Asian Americans who have experienced racism are more stressed by anti-Asian hate than the pandemic itself. Second, one in five Asian Americans who have experienced racism display racial trauma, the psychological and emotional harm caused by racism. Given the rise in hate crimes, there must be concern regarding the level of trauma being inflicted upon the Asian American community.

A complete review of the health effects of racism is beyond this article’s scope. Still, the previously mentioned studies further support the need to treat racism in general, and specifically anti-Asian hate, as the urgent public health concern that it truly is. The U.S. government recently outlined an action plan to respond to anti-Asian violence, xenophobia, and bias. These are helpful first steps, but much more is required on a societal and individual level, given the mental health disparities faced by the AAPI community.

Determining the best ways to address this urgent public health concern can be overwhelming, exhausting, and outright demoralizing. The bottom line is that if we do nothing, communities and groups will continue to suffer the effects of racial hatred. These consequences are severe and transgenerational.

But we must start somewhere. For me, that begins by gaining a better understanding of the emotion of hate and my role in either facilitating or stopping it, and by listening, listening, and listening some more to AAPI colleagues, friends, and family about their lived experience with anti-Asian hate.

A version of this article first appeared on Medscape.com.

To the Editor:

A range of dermatologic manifestations of COVID-19 have been reported, including nonspecific maculopapular exanthems, urticaria, and varicellalike eruptions.¹ Additionally, there have been sporadic accounts of cutaneous vasculopathic signs such as perniolike lesions, acro-ischemia, livedo reticularis, and retiform purpura.² We describe exuberant hemorrhagic bullae occurring on the extremities of 2 critically ill patients with COVID-19. We hypothesized that the bullae were vasculopathic in nature and possibly exacerbated by peripheral intravenous (IV)–related injury.

A 62-year-old woman with a history of diabetes mellitus and chronic obstructive pulmonary disease was admitted to the intensive care unit for acute hypoxemic respiratory failure secondary to COVID-19 infection. Dermatology was consulted for evaluation of blisters on the right arm. A new peripheral IV line was inserted into the patient’s right forearm for treatment of secondary methicillin-resistant Staphylococcus aureus pneumonia. The peripheral IV was inserted into the right proximal forearm for 2 days prior to development of ecchymosis and blisters. Intravenous medications included vancomycin, cefepime, methylprednisolone, and famotidine, as well as maintenance fluids (normal saline). Physical examination revealed extensive confluent ecchymoses with overlying tense bullae (Figure 1). Notable laboratory findings included an elevated D-dimer (peak of 8.67 μg/mL fibrinogen-equivalent units [FEUs], reference range <0.5 μg/mL FEU) and fibrinogen (789 mg/dL, reference range 200–400 mg/dL) levels. Three days later she developed worsening edema of the right arm, accompanied by more extensive bullae formation (Figure 2). Computed tomography of the right arm showed extensive subcutaneous stranding and subcutaneous edema. An orthopedic consultation determined that there was no compartment syndrome, and surgical intervention was not recommended. The patient’s course was complicated by multiorgan failure, and she died 18 days after admission.

Extravasation injury results from unintentional administration of potentially vesicant substances into tissues surrounding the intended vascular channel.⁴ The mechanism of action of these injuries is postulated to arise from direct tissue injury from cytotoxic substances, elevated osmotic pressure, and reduced blood supply if vasoconstrictive substances are infused.⁵ In our patients, these injuries also may have promoted vascular occlusion leading to the brisk reaction observed. Although ecchymoses typically are associated with hypocoagulable states, both of our patients were noted to have normal platelet levels throughout hospitalization. Additionally, findings of elevated D-dimer and fibrinogen levels point to a hypercoagulable state. However, there is a possibility of platelet dysfunction leading to the observed cutaneous findings of ecchymoses. Thrombocytopenia is a common finding in patients with COVID-19 and is found to be associated with increased in-hospital mortality.⁶ Additional study of these reactions is needed given the propensity for multiorgan failure and death in patients with COVID-19 from suspected diffuse microvascular damage.³

To the Editor:

A range of dermatologic manifestations of COVID-19 have been reported, including nonspecific maculopapular exanthems, urticaria, and varicellalike eruptions.¹ Additionally, there have been sporadic accounts of cutaneous vasculopathic signs such as perniolike lesions, acro-ischemia, livedo reticularis, and retiform purpura.² We describe exuberant hemorrhagic bullae occurring on the extremities of 2 critically ill patients with COVID-19. We hypothesized that the bullae were vasculopathic in nature and possibly exacerbated by peripheral intravenous (IV)–related injury.

A 62-year-old woman with a history of diabetes mellitus and chronic obstructive pulmonary disease was admitted to the intensive care unit for acute hypoxemic respiratory failure secondary to COVID-19 infection. Dermatology was consulted for evaluation of blisters on the right arm. A new peripheral IV line was inserted into the patient’s right forearm for treatment of secondary methicillin-resistant Staphylococcus aureus pneumonia. The peripheral IV was inserted into the right proximal forearm for 2 days prior to development of ecchymosis and blisters. Intravenous medications included vancomycin, cefepime, methylprednisolone, and famotidine, as well as maintenance fluids (normal saline). Physical examination revealed extensive confluent ecchymoses with overlying tense bullae (Figure 1). Notable laboratory findings included an elevated D-dimer (peak of 8.67 μg/mL fibrinogen-equivalent units [FEUs], reference range <0.5 μg/mL FEU) and fibrinogen (789 mg/dL, reference range 200–400 mg/dL) levels. Three days later she developed worsening edema of the right arm, accompanied by more extensive bullae formation (Figure 2). Computed tomography of the right arm showed extensive subcutaneous stranding and subcutaneous edema. An orthopedic consultation determined that there was no compartment syndrome, and surgical intervention was not recommended. The patient’s course was complicated by multiorgan failure, and she died 18 days after admission.

Extravasation injury results from unintentional administration of potentially vesicant substances into tissues surrounding the intended vascular channel.⁴ The mechanism of action of these injuries is postulated to arise from direct tissue injury from cytotoxic substances, elevated osmotic pressure, and reduced blood supply if vasoconstrictive substances are infused.⁵ In our patients, these injuries also may have promoted vascular occlusion leading to the brisk reaction observed. Although ecchymoses typically are associated with hypocoagulable states, both of our patients were noted to have normal platelet levels throughout hospitalization. Additionally, findings of elevated D-dimer and fibrinogen levels point to a hypercoagulable state. However, there is a possibility of platelet dysfunction leading to the observed cutaneous findings of ecchymoses. Thrombocytopenia is a common finding in patients with COVID-19 and is found to be associated with increased in-hospital mortality.⁶ Additional study of these reactions is needed given the propensity for multiorgan failure and death in patients with COVID-19 from suspected diffuse microvascular damage.³

To the Editor:

A range of dermatologic manifestations of COVID-19 have been reported, including nonspecific maculopapular exanthems, urticaria, and varicellalike eruptions.¹ Additionally, there have been sporadic accounts of cutaneous vasculopathic signs such as perniolike lesions, acro-ischemia, livedo reticularis, and retiform purpura.² We describe exuberant hemorrhagic bullae occurring on the extremities of 2 critically ill patients with COVID-19. We hypothesized that the bullae were vasculopathic in nature and possibly exacerbated by peripheral intravenous (IV)–related injury.

A 62-year-old woman with a history of diabetes mellitus and chronic obstructive pulmonary disease was admitted to the intensive care unit for acute hypoxemic respiratory failure secondary to COVID-19 infection. Dermatology was consulted for evaluation of blisters on the right arm. A new peripheral IV line was inserted into the patient’s right forearm for treatment of secondary methicillin-resistant Staphylococcus aureus pneumonia. The peripheral IV was inserted into the right proximal forearm for 2 days prior to development of ecchymosis and blisters. Intravenous medications included vancomycin, cefepime, methylprednisolone, and famotidine, as well as maintenance fluids (normal saline). Physical examination revealed extensive confluent ecchymoses with overlying tense bullae (Figure 1). Notable laboratory findings included an elevated D-dimer (peak of 8.67 μg/mL fibrinogen-equivalent units [FEUs], reference range <0.5 μg/mL FEU) and fibrinogen (789 mg/dL, reference range 200–400 mg/dL) levels. Three days later she developed worsening edema of the right arm, accompanied by more extensive bullae formation (Figure 2). Computed tomography of the right arm showed extensive subcutaneous stranding and subcutaneous edema. An orthopedic consultation determined that there was no compartment syndrome, and surgical intervention was not recommended. The patient’s course was complicated by multiorgan failure, and she died 18 days after admission.

Extravasation injury results from unintentional administration of potentially vesicant substances into tissues surrounding the intended vascular channel.⁴ The mechanism of action of these injuries is postulated to arise from direct tissue injury from cytotoxic substances, elevated osmotic pressure, and reduced blood supply if vasoconstrictive substances are infused.⁵ In our patients, these injuries also may have promoted vascular occlusion leading to the brisk reaction observed. Although ecchymoses typically are associated with hypocoagulable states, both of our patients were noted to have normal platelet levels throughout hospitalization. Additionally, findings of elevated D-dimer and fibrinogen levels point to a hypercoagulable state. However, there is a possibility of platelet dysfunction leading to the observed cutaneous findings of ecchymoses. Thrombocytopenia is a common finding in patients with COVID-19 and is found to be associated with increased in-hospital mortality.⁶ Additional study of these reactions is needed given the propensity for multiorgan failure and death in patients with COVID-19 from suspected diffuse microvascular damage.³

Because the Delta variant of SARS-CoV-2 spreads more easily than the original virus, the proportion of the population that needs to be vaccinated to reach herd immunity could be upward of 80% or more, experts say.

Also, it could be time to consider wearing an N95 mask in public indoor spaces regardless of vaccination status, according to a media briefing on Aug. 3 sponsored by the Infectious Diseases Society of America.

Furthermore, giving booster shots to the fully vaccinated is not the top public health priority now. Instead, third vaccinations should be reserved for more vulnerable populations – and efforts should focus on getting first vaccinations to unvaccinated people in the United States and around the world.

“The problem here is that the Delta variant is ... more transmissible than the original virus. That pushes the overall population herd immunity threshold much higher,” Ricardo Franco, MD, assistant professor of medicine at the University of Alabama at Birmingham, said during the briefing.

“For Delta, those threshold estimates go well over 80% and may be approaching 90%,” he said.

To put that figure in context, the original SARS-CoV-2 virus required an estimated 67% of the population to be vaccinated to achieve herd immunity. Also, measles has one of the highest herd immunity thresholds at 95%, Dr. Franco added.

Herd immunity is the point at which enough people are immunized that the entire population gains protection. And it’s already happening. “Unvaccinated people are actually benefiting from greater herd immunity protection in high-vaccination counties compared to low-vaccination ones,” he said.
 

Maximize mask protection

Unlike early in the COVID-19 pandemic with widespread shortages of personal protective equipment, face masks are now readily available. This includes N95 masks, which offer enhanced protection against SARS-CoV-2, Ezekiel J. Emanuel, MD, PhD, said during the briefing.

Following the July 27 CDC recommendation that most Americans wear masks indoors when in public places, “I do think we need to upgrade our masks,” said Dr. Emanuel, who is Diane v.S. Levy & Robert M. Levy professor at the University of Pennsylvania, Philadelphia.

“It’s not just any mask,” he added. “Good masks make a big difference and are very important.”

Mask protection is about blocking 0.3-mcm particles, “and I think we need to make sure that people have masks that can filter that out,” he said. Although surgical masks are very good, he added, “they’re not quite as good as N95s.” As their name implies, N95s filter out 95% of these particles.

Dr. Emanuel acknowledged that people are tired of COVID-19 and complying with public health measures but urged perseverance. “We’ve sacrificed a lot. We should not throw it away in just a few months because we are tired. We’re all tired, but we do have to do the little bit extra getting vaccinated, wearing masks indoors, and protecting ourselves, our families, and our communities.”
 

Dealing with a disconnect

In response to a reporter’s question about the possibility that the large crowd at the Lollapalooza music festival in Chicago could become a superspreader event, Dr. Emanuel said, “it is worrisome.”

“I would say that, if you’re going to go to a gathering like that, wearing an N95 mask is wise, and not spending too long at any one place is also wise,” he said.

On the plus side, the event was held outdoors with lots of air circulation, Dr. Emanuel said.

However, “this is the kind of thing where we’ve got a sort of disconnect between people’s desire to get back to normal ... and the fact that we’re in the middle of this upsurge.”

Another potential problem is the event brought people together from many different locations, so when they travel home, they could be “potentially seeding lots of other communities.”
 

Boosters for some, for now

Even though not officially recommended, some fully vaccinated Americans are seeking a third or booster vaccination on their own.

Asked for his opinion, Dr. Emanuel said: “We’re probably going to have to be giving boosters to immunocompromised people and people who are susceptible. That’s where we are going to start.”

More research is needed regarding booster shots, he said. “There are very small studies – and the ‘very small’ should be emphasized – given that we’ve given shots to over 160 million people.”

“But it does appear that the boosters increase the antibodies and protection,” he said.

Instead of boosters, it is more important for people who haven’t been vaccinated to get fully vaccinated.

“We need to put our priorities in the right places,” he said.

Emanuel noted that, except for people in rural areas that might have to travel long distances, access to vaccines is no longer an issue. “It’s very hard not to find a vaccine if you want it.”

A remaining hurdle is “battling a major disinformation initiative. I don’t think this is misinformation. I think there’s very clear evidence that it is disinformation – false facts about the vaccines being spread,” Dr. Emanuel said.
 

The breakthrough infection dilemma

Breakthrough cases “remain the vast minority of infections at this time ... that is reassuring,” Dr. Franco said.

Also, tracking symptomatic breakthrough infections remains easier than studying fully vaccinated people who become infected with SARS-CoV-2 but remain symptom free.

“We really don’t have a good handle on the frequency of asymptomatic cases,” Dr. Emanuel said. “If you’re missing breakthrough infections, a lot of them, you may be missing some [virus] evolution that would be very important for us to follow.” This missing information could include the emergence of new variants.

The asymptomatic breakthrough cases are the most worrisome group,” Dr. Emanuel said. “You get infected, you’re feeling fine. Maybe you’ve got a little sneeze or cough, but nothing unusual. And then you’re still able to transmit the Delta variant.”
 

The big picture

The upsurge in cases, hospitalizations, and deaths is a major challenge, Dr. Emanuel said. “We need to address that by getting many more people vaccinated right now with what are very good vaccines.”

“But it also means that we have to stop being U.S. focused alone.” He pointed out that Delta and other variants originated overseas, “so getting the world vaccinated ... has to be a top priority.”

“We are obviously all facing a challenge as we move into the fall,” Dr. Emanuel said. “With schools opening and employers bringing their employees back together, even if these groups are vaccinated, there are going to be major challenges for all of us.”

A version of this article first appeared on Medscape.com.

Because the Delta variant of SARS-CoV-2 spreads more easily than the original virus, the proportion of the population that needs to be vaccinated to reach herd immunity could be upward of 80% or more, experts say.

Also, it could be time to consider wearing an N95 mask in public indoor spaces regardless of vaccination status, according to a media briefing on Aug. 3 sponsored by the Infectious Diseases Society of America.

Furthermore, giving booster shots to the fully vaccinated is not the top public health priority now. Instead, third vaccinations should be reserved for more vulnerable populations – and efforts should focus on getting first vaccinations to unvaccinated people in the United States and around the world.

“The problem here is that the Delta variant is ... more transmissible than the original virus. That pushes the overall population herd immunity threshold much higher,” Ricardo Franco, MD, assistant professor of medicine at the University of Alabama at Birmingham, said during the briefing.

“For Delta, those threshold estimates go well over 80% and may be approaching 90%,” he said.

To put that figure in context, the original SARS-CoV-2 virus required an estimated 67% of the population to be vaccinated to achieve herd immunity. Also, measles has one of the highest herd immunity thresholds at 95%, Dr. Franco added.

Herd immunity is the point at which enough people are immunized that the entire population gains protection. And it’s already happening. “Unvaccinated people are actually benefiting from greater herd immunity protection in high-vaccination counties compared to low-vaccination ones,” he said.
 

Maximize mask protection

Unlike early in the COVID-19 pandemic with widespread shortages of personal protective equipment, face masks are now readily available. This includes N95 masks, which offer enhanced protection against SARS-CoV-2, Ezekiel J. Emanuel, MD, PhD, said during the briefing.

Following the July 27 CDC recommendation that most Americans wear masks indoors when in public places, “I do think we need to upgrade our masks,” said Dr. Emanuel, who is Diane v.S. Levy & Robert M. Levy professor at the University of Pennsylvania, Philadelphia.

“It’s not just any mask,” he added. “Good masks make a big difference and are very important.”

Mask protection is about blocking 0.3-mcm particles, “and I think we need to make sure that people have masks that can filter that out,” he said. Although surgical masks are very good, he added, “they’re not quite as good as N95s.” As their name implies, N95s filter out 95% of these particles.

Dr. Emanuel acknowledged that people are tired of COVID-19 and complying with public health measures but urged perseverance. “We’ve sacrificed a lot. We should not throw it away in just a few months because we are tired. We’re all tired, but we do have to do the little bit extra getting vaccinated, wearing masks indoors, and protecting ourselves, our families, and our communities.”
 

Dealing with a disconnect

In response to a reporter’s question about the possibility that the large crowd at the Lollapalooza music festival in Chicago could become a superspreader event, Dr. Emanuel said, “it is worrisome.”

“I would say that, if you’re going to go to a gathering like that, wearing an N95 mask is wise, and not spending too long at any one place is also wise,” he said.

On the plus side, the event was held outdoors with lots of air circulation, Dr. Emanuel said.

However, “this is the kind of thing where we’ve got a sort of disconnect between people’s desire to get back to normal ... and the fact that we’re in the middle of this upsurge.”

Another potential problem is the event brought people together from many different locations, so when they travel home, they could be “potentially seeding lots of other communities.”
 

Boosters for some, for now

Even though not officially recommended, some fully vaccinated Americans are seeking a third or booster vaccination on their own.

Asked for his opinion, Dr. Emanuel said: “We’re probably going to have to be giving boosters to immunocompromised people and people who are susceptible. That’s where we are going to start.”

More research is needed regarding booster shots, he said. “There are very small studies – and the ‘very small’ should be emphasized – given that we’ve given shots to over 160 million people.”

“But it does appear that the boosters increase the antibodies and protection,” he said.

Instead of boosters, it is more important for people who haven’t been vaccinated to get fully vaccinated.

“We need to put our priorities in the right places,” he said.

Emanuel noted that, except for people in rural areas that might have to travel long distances, access to vaccines is no longer an issue. “It’s very hard not to find a vaccine if you want it.”

A remaining hurdle is “battling a major disinformation initiative. I don’t think this is misinformation. I think there’s very clear evidence that it is disinformation – false facts about the vaccines being spread,” Dr. Emanuel said.
 

The breakthrough infection dilemma

Breakthrough cases “remain the vast minority of infections at this time ... that is reassuring,” Dr. Franco said.

Also, tracking symptomatic breakthrough infections remains easier than studying fully vaccinated people who become infected with SARS-CoV-2 but remain symptom free.

“We really don’t have a good handle on the frequency of asymptomatic cases,” Dr. Emanuel said. “If you’re missing breakthrough infections, a lot of them, you may be missing some [virus] evolution that would be very important for us to follow.” This missing information could include the emergence of new variants.

The asymptomatic breakthrough cases are the most worrisome group,” Dr. Emanuel said. “You get infected, you’re feeling fine. Maybe you’ve got a little sneeze or cough, but nothing unusual. And then you’re still able to transmit the Delta variant.”
 

The big picture

The upsurge in cases, hospitalizations, and deaths is a major challenge, Dr. Emanuel said. “We need to address that by getting many more people vaccinated right now with what are very good vaccines.”

“But it also means that we have to stop being U.S. focused alone.” He pointed out that Delta and other variants originated overseas, “so getting the world vaccinated ... has to be a top priority.”

“We are obviously all facing a challenge as we move into the fall,” Dr. Emanuel said. “With schools opening and employers bringing their employees back together, even if these groups are vaccinated, there are going to be major challenges for all of us.”

A version of this article first appeared on Medscape.com.

Because the Delta variant of SARS-CoV-2 spreads more easily than the original virus, the proportion of the population that needs to be vaccinated to reach herd immunity could be upward of 80% or more, experts say.

Also, it could be time to consider wearing an N95 mask in public indoor spaces regardless of vaccination status, according to a media briefing on Aug. 3 sponsored by the Infectious Diseases Society of America.

Furthermore, giving booster shots to the fully vaccinated is not the top public health priority now. Instead, third vaccinations should be reserved for more vulnerable populations – and efforts should focus on getting first vaccinations to unvaccinated people in the United States and around the world.

“The problem here is that the Delta variant is ... more transmissible than the original virus. That pushes the overall population herd immunity threshold much higher,” Ricardo Franco, MD, assistant professor of medicine at the University of Alabama at Birmingham, said during the briefing.

“For Delta, those threshold estimates go well over 80% and may be approaching 90%,” he said.

To put that figure in context, the original SARS-CoV-2 virus required an estimated 67% of the population to be vaccinated to achieve herd immunity. Also, measles has one of the highest herd immunity thresholds at 95%, Dr. Franco added.

Herd immunity is the point at which enough people are immunized that the entire population gains protection. And it’s already happening. “Unvaccinated people are actually benefiting from greater herd immunity protection in high-vaccination counties compared to low-vaccination ones,” he said.
 

Maximize mask protection

Unlike early in the COVID-19 pandemic with widespread shortages of personal protective equipment, face masks are now readily available. This includes N95 masks, which offer enhanced protection against SARS-CoV-2, Ezekiel J. Emanuel, MD, PhD, said during the briefing.

Following the July 27 CDC recommendation that most Americans wear masks indoors when in public places, “I do think we need to upgrade our masks,” said Dr. Emanuel, who is Diane v.S. Levy & Robert M. Levy professor at the University of Pennsylvania, Philadelphia.

“It’s not just any mask,” he added. “Good masks make a big difference and are very important.”

Mask protection is about blocking 0.3-mcm particles, “and I think we need to make sure that people have masks that can filter that out,” he said. Although surgical masks are very good, he added, “they’re not quite as good as N95s.” As their name implies, N95s filter out 95% of these particles.

Dr. Emanuel acknowledged that people are tired of COVID-19 and complying with public health measures but urged perseverance. “We’ve sacrificed a lot. We should not throw it away in just a few months because we are tired. We’re all tired, but we do have to do the little bit extra getting vaccinated, wearing masks indoors, and protecting ourselves, our families, and our communities.”
 

Dealing with a disconnect

In response to a reporter’s question about the possibility that the large crowd at the Lollapalooza music festival in Chicago could become a superspreader event, Dr. Emanuel said, “it is worrisome.”

“I would say that, if you’re going to go to a gathering like that, wearing an N95 mask is wise, and not spending too long at any one place is also wise,” he said.

On the plus side, the event was held outdoors with lots of air circulation, Dr. Emanuel said.

However, “this is the kind of thing where we’ve got a sort of disconnect between people’s desire to get back to normal ... and the fact that we’re in the middle of this upsurge.”

Another potential problem is the event brought people together from many different locations, so when they travel home, they could be “potentially seeding lots of other communities.”
 

Boosters for some, for now

Even though not officially recommended, some fully vaccinated Americans are seeking a third or booster vaccination on their own.

Asked for his opinion, Dr. Emanuel said: “We’re probably going to have to be giving boosters to immunocompromised people and people who are susceptible. That’s where we are going to start.”

More research is needed regarding booster shots, he said. “There are very small studies – and the ‘very small’ should be emphasized – given that we’ve given shots to over 160 million people.”

“But it does appear that the boosters increase the antibodies and protection,” he said.

Instead of boosters, it is more important for people who haven’t been vaccinated to get fully vaccinated.

“We need to put our priorities in the right places,” he said.

Emanuel noted that, except for people in rural areas that might have to travel long distances, access to vaccines is no longer an issue. “It’s very hard not to find a vaccine if you want it.”

A remaining hurdle is “battling a major disinformation initiative. I don’t think this is misinformation. I think there’s very clear evidence that it is disinformation – false facts about the vaccines being spread,” Dr. Emanuel said.
 

The breakthrough infection dilemma

Breakthrough cases “remain the vast minority of infections at this time ... that is reassuring,” Dr. Franco said.

Also, tracking symptomatic breakthrough infections remains easier than studying fully vaccinated people who become infected with SARS-CoV-2 but remain symptom free.

“We really don’t have a good handle on the frequency of asymptomatic cases,” Dr. Emanuel said. “If you’re missing breakthrough infections, a lot of them, you may be missing some [virus] evolution that would be very important for us to follow.” This missing information could include the emergence of new variants.

The asymptomatic breakthrough cases are the most worrisome group,” Dr. Emanuel said. “You get infected, you’re feeling fine. Maybe you’ve got a little sneeze or cough, but nothing unusual. And then you’re still able to transmit the Delta variant.”
 

The big picture

The upsurge in cases, hospitalizations, and deaths is a major challenge, Dr. Emanuel said. “We need to address that by getting many more people vaccinated right now with what are very good vaccines.”

“But it also means that we have to stop being U.S. focused alone.” He pointed out that Delta and other variants originated overseas, “so getting the world vaccinated ... has to be a top priority.”

“We are obviously all facing a challenge as we move into the fall,” Dr. Emanuel said. “With schools opening and employers bringing their employees back together, even if these groups are vaccinated, there are going to be major challenges for all of us.”

A version of this article first appeared on Medscape.com.

Double-dose vaccination against SARS-CoV-2 in patients with rheumatic and musculoskeletal diseases (RMDs) doesn’t appear to boost the risk of flares, a new study shows. The risk of adverse effects after vaccination is high, just as it is in the general population, but no patients experienced allergic reactions.

“Our findings suggest that COVID-19 vaccines are safe in patients with rheumatic and musculoskeletal diseases. Overall, rates of flare are low and mild, while local and systemic reactions should be anticipated,” lead author Caoilfhionn Connolly, MD, MSc, a rheumatology fellow at Johns Hopkins University, Baltimore, said in an interview. “Many of our patients are at increased risk of severe infection and or complications from COVID-19. It has been shown that patients with RMDs are more willing to reconsider vaccination if it is recommended by a physician, and these data should help inform these critical discussions.”

The study appeared Aug. 4 in Arthritis & Rheumatology.

According to Dr. Connolly, the researchers launched their study to better understand the effect of two-dose SARS-CoV-2 messenger RNA vaccinations authorized for emergency use by the Food and Drug Administration (Pfizer and Moderna vaccines) on immunosuppressed patients. As she noted, patients with RMDs were largely excluded from vaccine trials, and “studies have shown that some patients with RMDs are hesitant about vaccination due to the lack of safety data.”

Some data about this patient population have started to appear. A study published July 21 in Lancet Rheumatology found that patients with systemic lupus erythematosus (SLE) reported few flares within a median of 3 days after receiving one or two doses of various COVID-19 vaccines. Side effects were common but were mainly mild or moderate.

For the new study, researchers surveyed 1,377 patients with RMDs who’d received two vaccination doses between December 2020 and April 2021. The patients had a median age of 47, 92% were female, and 10% were non-White. The patients had a variety of RMDs, including inflammatory arthritis (47%), SLE (20%), overlap connective tissue disease (20%), and Sjögren’s syndrome and myositis (each 5%).

A total of 11% said they’d experienced a flare that required treatment, but none were severe. In comparison, 56% of patients said they had experienced a flare of their RMD in the 6 months prior to their first vaccine dose. Several groups had a greater likelihood of flares, including those who’d had COVID-19 previously (adjusted incidence rate ratio [IRR], 2.09; P = .02). “COVID-19 can cause both acute and delayed inflammatory syndromes through activation of the immune system,” Dr. Connolly said. “Vaccination possibly triggered further activation of the immune system resulting in disease flare. This is an area that warrants further research.”

Patients who took combination immunomodulatory therapy were also more likely to flare after vaccination (IRR, 1.95; P < .001). And patients were more likely to report flares after vaccination if they experienced a flare in the 6 months preceding vaccination (IRR, 2.36; P < .001). “This may suggest more active disease at baseline,” Dr. Connolly said. “It is difficult to differentiate whether these patients would have experienced flare even without the vaccine.”

A number of factors didn’t appear to affect the likelihood of flares: gender, age, ethnicity, type of RMD, and type of vaccine.

Local and systemic side effects were frequently reported, including injection site pain (87% and 86% after first and second doses, respectively) and fatigue (60% and 80%, respectively). As is common among people receiving COVID-19 vaccines, side effects were more frequent after the second dose.

As for future research, “we are evaluating the long-term safety and efficacy of the COVID-19 vaccines in patients with RMDs,” study coauthor Julie J. Paik, MD, assistant professor of medicine at Johns Hopkins, said in an interview. “We are also evaluating the impact of changes in immunosuppression around vaccination.”

The study was funded by the Ben-Dov family and grants from several institutes of the National Institutes of Health. Dr. Connolly and Dr. Paik reported no relevant disclosures. Other study authors reported various financial relationships with pharmaceutical companies.

Double-dose vaccination against SARS-CoV-2 in patients with rheumatic and musculoskeletal diseases (RMDs) doesn’t appear to boost the risk of flares, a new study shows. The risk of adverse effects after vaccination is high, just as it is in the general population, but no patients experienced allergic reactions.

“Our findings suggest that COVID-19 vaccines are safe in patients with rheumatic and musculoskeletal diseases. Overall, rates of flare are low and mild, while local and systemic reactions should be anticipated,” lead author Caoilfhionn Connolly, MD, MSc, a rheumatology fellow at Johns Hopkins University, Baltimore, said in an interview. “Many of our patients are at increased risk of severe infection and or complications from COVID-19. It has been shown that patients with RMDs are more willing to reconsider vaccination if it is recommended by a physician, and these data should help inform these critical discussions.”

The study appeared Aug. 4 in Arthritis & Rheumatology.

According to Dr. Connolly, the researchers launched their study to better understand the effect of two-dose SARS-CoV-2 messenger RNA vaccinations authorized for emergency use by the Food and Drug Administration (Pfizer and Moderna vaccines) on immunosuppressed patients. As she noted, patients with RMDs were largely excluded from vaccine trials, and “studies have shown that some patients with RMDs are hesitant about vaccination due to the lack of safety data.”

Some data about this patient population have started to appear. A study published July 21 in Lancet Rheumatology found that patients with systemic lupus erythematosus (SLE) reported few flares within a median of 3 days after receiving one or two doses of various COVID-19 vaccines. Side effects were common but were mainly mild or moderate.

For the new study, researchers surveyed 1,377 patients with RMDs who’d received two vaccination doses between December 2020 and April 2021. The patients had a median age of 47, 92% were female, and 10% were non-White. The patients had a variety of RMDs, including inflammatory arthritis (47%), SLE (20%), overlap connective tissue disease (20%), and Sjögren’s syndrome and myositis (each 5%).

A total of 11% said they’d experienced a flare that required treatment, but none were severe. In comparison, 56% of patients said they had experienced a flare of their RMD in the 6 months prior to their first vaccine dose. Several groups had a greater likelihood of flares, including those who’d had COVID-19 previously (adjusted incidence rate ratio [IRR], 2.09; P = .02). “COVID-19 can cause both acute and delayed inflammatory syndromes through activation of the immune system,” Dr. Connolly said. “Vaccination possibly triggered further activation of the immune system resulting in disease flare. This is an area that warrants further research.”

Patients who took combination immunomodulatory therapy were also more likely to flare after vaccination (IRR, 1.95; P < .001). And patients were more likely to report flares after vaccination if they experienced a flare in the 6 months preceding vaccination (IRR, 2.36; P < .001). “This may suggest more active disease at baseline,” Dr. Connolly said. “It is difficult to differentiate whether these patients would have experienced flare even without the vaccine.”

A number of factors didn’t appear to affect the likelihood of flares: gender, age, ethnicity, type of RMD, and type of vaccine.

Local and systemic side effects were frequently reported, including injection site pain (87% and 86% after first and second doses, respectively) and fatigue (60% and 80%, respectively). As is common among people receiving COVID-19 vaccines, side effects were more frequent after the second dose.

As for future research, “we are evaluating the long-term safety and efficacy of the COVID-19 vaccines in patients with RMDs,” study coauthor Julie J. Paik, MD, assistant professor of medicine at Johns Hopkins, said in an interview. “We are also evaluating the impact of changes in immunosuppression around vaccination.”

The study was funded by the Ben-Dov family and grants from several institutes of the National Institutes of Health. Dr. Connolly and Dr. Paik reported no relevant disclosures. Other study authors reported various financial relationships with pharmaceutical companies.

Double-dose vaccination against SARS-CoV-2 in patients with rheumatic and musculoskeletal diseases (RMDs) doesn’t appear to boost the risk of flares, a new study shows. The risk of adverse effects after vaccination is high, just as it is in the general population, but no patients experienced allergic reactions.

“Our findings suggest that COVID-19 vaccines are safe in patients with rheumatic and musculoskeletal diseases. Overall, rates of flare are low and mild, while local and systemic reactions should be anticipated,” lead author Caoilfhionn Connolly, MD, MSc, a rheumatology fellow at Johns Hopkins University, Baltimore, said in an interview. “Many of our patients are at increased risk of severe infection and or complications from COVID-19. It has been shown that patients with RMDs are more willing to reconsider vaccination if it is recommended by a physician, and these data should help inform these critical discussions.”

The study appeared Aug. 4 in Arthritis & Rheumatology.

According to Dr. Connolly, the researchers launched their study to better understand the effect of two-dose SARS-CoV-2 messenger RNA vaccinations authorized for emergency use by the Food and Drug Administration (Pfizer and Moderna vaccines) on immunosuppressed patients. As she noted, patients with RMDs were largely excluded from vaccine trials, and “studies have shown that some patients with RMDs are hesitant about vaccination due to the lack of safety data.”

Some data about this patient population have started to appear. A study published July 21 in Lancet Rheumatology found that patients with systemic lupus erythematosus (SLE) reported few flares within a median of 3 days after receiving one or two doses of various COVID-19 vaccines. Side effects were common but were mainly mild or moderate.

For the new study, researchers surveyed 1,377 patients with RMDs who’d received two vaccination doses between December 2020 and April 2021. The patients had a median age of 47, 92% were female, and 10% were non-White. The patients had a variety of RMDs, including inflammatory arthritis (47%), SLE (20%), overlap connective tissue disease (20%), and Sjögren’s syndrome and myositis (each 5%).

A total of 11% said they’d experienced a flare that required treatment, but none were severe. In comparison, 56% of patients said they had experienced a flare of their RMD in the 6 months prior to their first vaccine dose. Several groups had a greater likelihood of flares, including those who’d had COVID-19 previously (adjusted incidence rate ratio [IRR], 2.09; P = .02). “COVID-19 can cause both acute and delayed inflammatory syndromes through activation of the immune system,” Dr. Connolly said. “Vaccination possibly triggered further activation of the immune system resulting in disease flare. This is an area that warrants further research.”

Patients who took combination immunomodulatory therapy were also more likely to flare after vaccination (IRR, 1.95; P < .001). And patients were more likely to report flares after vaccination if they experienced a flare in the 6 months preceding vaccination (IRR, 2.36; P < .001). “This may suggest more active disease at baseline,” Dr. Connolly said. “It is difficult to differentiate whether these patients would have experienced flare even without the vaccine.”

A number of factors didn’t appear to affect the likelihood of flares: gender, age, ethnicity, type of RMD, and type of vaccine.

Local and systemic side effects were frequently reported, including injection site pain (87% and 86% after first and second doses, respectively) and fatigue (60% and 80%, respectively). As is common among people receiving COVID-19 vaccines, side effects were more frequent after the second dose.

As for future research, “we are evaluating the long-term safety and efficacy of the COVID-19 vaccines in patients with RMDs,” study coauthor Julie J. Paik, MD, assistant professor of medicine at Johns Hopkins, said in an interview. “We are also evaluating the impact of changes in immunosuppression around vaccination.”

The study was funded by the Ben-Dov family and grants from several institutes of the National Institutes of Health. Dr. Connolly and Dr. Paik reported no relevant disclosures. Other study authors reported various financial relationships with pharmaceutical companies.

New COVID-19 cases in children soared by almost 86% over the course of just 1 week, while the number of 12- to 17-year-old children who have received at least one dose of vaccine rose by 5.4%, according to two separate sources.

There were 71,726 new cases reported during the week of July 23-29, compared with 38,654 the previous week, an increase of 85.6%. Meanwhile, the increase over the past 2 weeks – from 23,551 new cases for July 16-22 to almost 72,000 – works out to almost 205%, according to a report from the American Academy of Pediatrics and the Children’s Hospital Association.

Children represented 19.0% of the cases reported during the week of July 23-29, and they have made up 14.3% of all cases since the pandemic began, with the total number of cases in children now approaching 4.2 million, the AAP and CHA said in their weekly COVID report. About 22% of the U.S. population is under the age of 18 years.

As of Aug. 2, just over 9.8 million children aged 12-17 years had received at least one dose of the COVID vaccine, which was up by about 500,000, or 5.4%, from a week earlier, based on data from the Centers for Disease Control and Prevention.

Children aged 16-17 have reached a notable milestone on the journey that started with vaccine approval in December: 50.2% have gotten at least one dose and 40.3% are fully vaccinated. Among children aged 12-15 years, the proportion with at least one dose of vaccine is up to 39.5%, compared with 37.1% the previous week, while 29.0% are fully vaccinated (27.8% the week before), the CDC said on its COVID Data Tracker.

The national rates for child vaccination, however, tend to hide the disparities between states. There is a gap between Mississippi (lowest), where just 17% of children aged 12-17 years have gotten at least one dose, and Vermont (highest), which is up to 69%. Vermont also has the highest rate of vaccine completion (60%), while Alabama and Mississippi have the lowest (10%), according to a solo report from the AAP.

[email protected]

New COVID-19 cases in children soared by almost 86% over the course of just 1 week, while the number of 12- to 17-year-old children who have received at least one dose of vaccine rose by 5.4%, according to two separate sources.

There were 71,726 new cases reported during the week of July 23-29, compared with 38,654 the previous week, an increase of 85.6%. Meanwhile, the increase over the past 2 weeks – from 23,551 new cases for July 16-22 to almost 72,000 – works out to almost 205%, according to a report from the American Academy of Pediatrics and the Children’s Hospital Association.

Children represented 19.0% of the cases reported during the week of July 23-29, and they have made up 14.3% of all cases since the pandemic began, with the total number of cases in children now approaching 4.2 million, the AAP and CHA said in their weekly COVID report. About 22% of the U.S. population is under the age of 18 years.

As of Aug. 2, just over 9.8 million children aged 12-17 years had received at least one dose of the COVID vaccine, which was up by about 500,000, or 5.4%, from a week earlier, based on data from the Centers for Disease Control and Prevention.

Children aged 16-17 have reached a notable milestone on the journey that started with vaccine approval in December: 50.2% have gotten at least one dose and 40.3% are fully vaccinated. Among children aged 12-15 years, the proportion with at least one dose of vaccine is up to 39.5%, compared with 37.1% the previous week, while 29.0% are fully vaccinated (27.8% the week before), the CDC said on its COVID Data Tracker.

The national rates for child vaccination, however, tend to hide the disparities between states. There is a gap between Mississippi (lowest), where just 17% of children aged 12-17 years have gotten at least one dose, and Vermont (highest), which is up to 69%. Vermont also has the highest rate of vaccine completion (60%), while Alabama and Mississippi have the lowest (10%), according to a solo report from the AAP.

[email protected]

New COVID-19 cases in children soared by almost 86% over the course of just 1 week, while the number of 12- to 17-year-old children who have received at least one dose of vaccine rose by 5.4%, according to two separate sources.

There were 71,726 new cases reported during the week of July 23-29, compared with 38,654 the previous week, an increase of 85.6%. Meanwhile, the increase over the past 2 weeks – from 23,551 new cases for July 16-22 to almost 72,000 – works out to almost 205%, according to a report from the American Academy of Pediatrics and the Children’s Hospital Association.

Children represented 19.0% of the cases reported during the week of July 23-29, and they have made up 14.3% of all cases since the pandemic began, with the total number of cases in children now approaching 4.2 million, the AAP and CHA said in their weekly COVID report. About 22% of the U.S. population is under the age of 18 years.

As of Aug. 2, just over 9.8 million children aged 12-17 years had received at least one dose of the COVID vaccine, which was up by about 500,000, or 5.4%, from a week earlier, based on data from the Centers for Disease Control and Prevention.

Children aged 16-17 have reached a notable milestone on the journey that started with vaccine approval in December: 50.2% have gotten at least one dose and 40.3% are fully vaccinated. Among children aged 12-15 years, the proportion with at least one dose of vaccine is up to 39.5%, compared with 37.1% the previous week, while 29.0% are fully vaccinated (27.8% the week before), the CDC said on its COVID Data Tracker.

The national rates for child vaccination, however, tend to hide the disparities between states. There is a gap between Mississippi (lowest), where just 17% of children aged 12-17 years have gotten at least one dose, and Vermont (highest), which is up to 69%. Vermont also has the highest rate of vaccine completion (60%), while Alabama and Mississippi have the lowest (10%), according to a solo report from the AAP.

[email protected]

I have been a proud hospitalist for more than 20 years, and yet I have never been prouder to be a hospitalist than now. The pandemic has been brutal, killing more than 600,000 Americans as of this writing. It has stretched the health care system, its doctors, nurses, and other providers to the limit. Yet we will get through it, we are getting through it, and hospitalists deserve a huge portion of the credit.

According to the CDC, there have been over 2.3 million COVID-19 hospitalizations. In my home state of Maryland, between two-thirds and three-quarters of hospitalized COVID patients are cared for on general medical floors, the domain of hospitalists. When hospitals needed COVID units, hospitalists stepped up to design and staff them. When our ICU colleagues needed support, especially in those early dark days, hospitalists stepped in. When our outpatient colleagues were called into the hospital, hospitalists were there to help them on board. When the House of Medicine was in chaos due to COVID-19, hospitalists ran towards that fire. Our previous 20+ years of collective experience made us the ideal specialty to manage the inpatient challenges over the last 18 months.

Need a new clinical schedule by Sunday? Check.

Need help with new clinical protocols? Check.

Need to help other colleagues? Check.

Need to reprogram the EMR? Check.

Need a new way to teach residents and students on the wards? Check.

Need a whole new unit – no, wait – a new hospital wing? No, scratch that – a whole new COVID hospital in a few weeks? Check. (I personally did that last one at the Baltimore Convention Center!)

For me and many hospitalists like me, it is as if the last 20 years were prep work for the pandemic.

Here at SHM, we know the pandemic is hard work – exhausting, even. SHM has been actively focused on supporting hospitalists during this crisis so that hospitalists can focus on patients. Early in the pandemic, SHM quickly pivoted to supply hospitalists with COVID-19 resources in their fight against the coronavirus. Numerous COVID-19 webinars, a COVID addendum to the State of Hospital Medicine Report, and a dedicated COVID issue of the Journal of Hospital Medicine were early and successful information dissemination strategies.

As the world – and hospitalists – dug in for a multi-year pandemic, SHM continued to advance the care of patients by opening our library of educational content for free to anyone. Our Public Policy Committee was active around both COVID-19- and hospitalist-related topics: immigration, telehealth, wellbeing, and financial impacts, to name a few.

As the pandemic slogged on, our Wellbeing Task Force came up with innovative support measures, including a check-in guide for hospitalists and fellow health care workers and dedicated wellness sessions complete with a licensed therapist for members. All the while, despite the restrictions and hurdles the pandemic has thrown our way, SHM members keep meeting and collaborating through virtual chapter events, committee work, special interest groups, and our annual conference, SHM Converge. Thank you to the countless members who donated their time to SHM, so that SHM could support hospitalists and their patients.

Now, we are transitioning into a new phase of the pandemic. The medical miracles that are the COVID-19 vaccines have made that possible. Fully vaccinated, I no longer worry that every time someone sneezes, or when I care for patients with a fever, that I am playing a high stakes poker game with my life. Don’t get me wrong; as I write, the Delta variant has a hold on the nation, and I know it’s not over yet. But it does appear as if the medical war on COVID is shifting from national to regional (or even local) responses.

During this new phase, we must rebuild our personal and professional lives. If you haven’t read Retired Lieutenant General Mark Hertling’s perspective piece in the August issue of the Journal of Hospital Medicine, I strongly encourage you to do so. He shares profound lessons on transitioning from active combat that are directly applicable to hospitalists who have been “deployed” battling COVID-19.

SHM will continue to pivot to meet our members’ needs too. We are already gearing up for more in-person education and networking. Chapters are starting to meet in person, and SHM is happy to provide visiting faculty. I will visit members from Florida to Maine and places in between starting this fall! Our Board of Directors and other SHM leaders are also starting to meet with members in person. Our own Leadership Academy will take place at Amelia Island in Florida in October, where we can learn, network, and even decompress. We also can’t wait for SHM Converge 2022 in Nashville, where we hope to reunite with many of you after 2 years of virtual conferences.

Our response to the pandemic, a once in a century crisis where our own safety was at risk, where doing the right thing might mean death or harming loved ones, our response of running into the fire to save lives is truly inspiring. The power of care – for our patients, for our family and friends, and for our hospital medicine community and the community at large – is evident more now than ever.

There have always been good reasons to be proud of being a hospitalist: taking care of the acutely ill, helping hospitals improve, teaching young doctors, and watching my specialty grow by leaps and bounds, to name just a few. But I’ve never been prouder than I am now.

Dr. Howell is the CEO of the Society of Hospital Medicine.

I have been a proud hospitalist for more than 20 years, and yet I have never been prouder to be a hospitalist than now. The pandemic has been brutal, killing more than 600,000 Americans as of this writing. It has stretched the health care system, its doctors, nurses, and other providers to the limit. Yet we will get through it, we are getting through it, and hospitalists deserve a huge portion of the credit.

According to the CDC, there have been over 2.3 million COVID-19 hospitalizations. In my home state of Maryland, between two-thirds and three-quarters of hospitalized COVID patients are cared for on general medical floors, the domain of hospitalists. When hospitals needed COVID units, hospitalists stepped up to design and staff them. When our ICU colleagues needed support, especially in those early dark days, hospitalists stepped in. When our outpatient colleagues were called into the hospital, hospitalists were there to help them on board. When the House of Medicine was in chaos due to COVID-19, hospitalists ran towards that fire. Our previous 20+ years of collective experience made us the ideal specialty to manage the inpatient challenges over the last 18 months.

Need a new clinical schedule by Sunday? Check.

Need help with new clinical protocols? Check.

Need to help other colleagues? Check.

Need to reprogram the EMR? Check.

Need a new way to teach residents and students on the wards? Check.

Need a whole new unit – no, wait – a new hospital wing? No, scratch that – a whole new COVID hospital in a few weeks? Check. (I personally did that last one at the Baltimore Convention Center!)

For me and many hospitalists like me, it is as if the last 20 years were prep work for the pandemic.

Here at SHM, we know the pandemic is hard work – exhausting, even. SHM has been actively focused on supporting hospitalists during this crisis so that hospitalists can focus on patients. Early in the pandemic, SHM quickly pivoted to supply hospitalists with COVID-19 resources in their fight against the coronavirus. Numerous COVID-19 webinars, a COVID addendum to the State of Hospital Medicine Report, and a dedicated COVID issue of the Journal of Hospital Medicine were early and successful information dissemination strategies.

As the world – and hospitalists – dug in for a multi-year pandemic, SHM continued to advance the care of patients by opening our library of educational content for free to anyone. Our Public Policy Committee was active around both COVID-19- and hospitalist-related topics: immigration, telehealth, wellbeing, and financial impacts, to name a few.

As the pandemic slogged on, our Wellbeing Task Force came up with innovative support measures, including a check-in guide for hospitalists and fellow health care workers and dedicated wellness sessions complete with a licensed therapist for members. All the while, despite the restrictions and hurdles the pandemic has thrown our way, SHM members keep meeting and collaborating through virtual chapter events, committee work, special interest groups, and our annual conference, SHM Converge. Thank you to the countless members who donated their time to SHM, so that SHM could support hospitalists and their patients.

Now, we are transitioning into a new phase of the pandemic. The medical miracles that are the COVID-19 vaccines have made that possible. Fully vaccinated, I no longer worry that every time someone sneezes, or when I care for patients with a fever, that I am playing a high stakes poker game with my life. Don’t get me wrong; as I write, the Delta variant has a hold on the nation, and I know it’s not over yet. But it does appear as if the medical war on COVID is shifting from national to regional (or even local) responses.

During this new phase, we must rebuild our personal and professional lives. If you haven’t read Retired Lieutenant General Mark Hertling’s perspective piece in the August issue of the Journal of Hospital Medicine, I strongly encourage you to do so. He shares profound lessons on transitioning from active combat that are directly applicable to hospitalists who have been “deployed” battling COVID-19.

SHM will continue to pivot to meet our members’ needs too. We are already gearing up for more in-person education and networking. Chapters are starting to meet in person, and SHM is happy to provide visiting faculty. I will visit members from Florida to Maine and places in between starting this fall! Our Board of Directors and other SHM leaders are also starting to meet with members in person. Our own Leadership Academy will take place at Amelia Island in Florida in October, where we can learn, network, and even decompress. We also can’t wait for SHM Converge 2022 in Nashville, where we hope to reunite with many of you after 2 years of virtual conferences.

Our response to the pandemic, a once in a century crisis where our own safety was at risk, where doing the right thing might mean death or harming loved ones, our response of running into the fire to save lives is truly inspiring. The power of care – for our patients, for our family and friends, and for our hospital medicine community and the community at large – is evident more now than ever.

There have always been good reasons to be proud of being a hospitalist: taking care of the acutely ill, helping hospitals improve, teaching young doctors, and watching my specialty grow by leaps and bounds, to name just a few. But I’ve never been prouder than I am now.

Dr. Howell is the CEO of the Society of Hospital Medicine.

I have been a proud hospitalist for more than 20 years, and yet I have never been prouder to be a hospitalist than now. The pandemic has been brutal, killing more than 600,000 Americans as of this writing. It has stretched the health care system, its doctors, nurses, and other providers to the limit. Yet we will get through it, we are getting through it, and hospitalists deserve a huge portion of the credit.

According to the CDC, there have been over 2.3 million COVID-19 hospitalizations. In my home state of Maryland, between two-thirds and three-quarters of hospitalized COVID patients are cared for on general medical floors, the domain of hospitalists. When hospitals needed COVID units, hospitalists stepped up to design and staff them. When our ICU colleagues needed support, especially in those early dark days, hospitalists stepped in. When our outpatient colleagues were called into the hospital, hospitalists were there to help them on board. When the House of Medicine was in chaos due to COVID-19, hospitalists ran towards that fire. Our previous 20+ years of collective experience made us the ideal specialty to manage the inpatient challenges over the last 18 months.

Need a new clinical schedule by Sunday? Check.

Need help with new clinical protocols? Check.

Need to help other colleagues? Check.

Need to reprogram the EMR? Check.

Need a new way to teach residents and students on the wards? Check.

Need a whole new unit – no, wait – a new hospital wing? No, scratch that – a whole new COVID hospital in a few weeks? Check. (I personally did that last one at the Baltimore Convention Center!)

For me and many hospitalists like me, it is as if the last 20 years were prep work for the pandemic.

Here at SHM, we know the pandemic is hard work – exhausting, even. SHM has been actively focused on supporting hospitalists during this crisis so that hospitalists can focus on patients. Early in the pandemic, SHM quickly pivoted to supply hospitalists with COVID-19 resources in their fight against the coronavirus. Numerous COVID-19 webinars, a COVID addendum to the State of Hospital Medicine Report, and a dedicated COVID issue of the Journal of Hospital Medicine were early and successful information dissemination strategies.

As the world – and hospitalists – dug in for a multi-year pandemic, SHM continued to advance the care of patients by opening our library of educational content for free to anyone. Our Public Policy Committee was active around both COVID-19- and hospitalist-related topics: immigration, telehealth, wellbeing, and financial impacts, to name a few.

As the pandemic slogged on, our Wellbeing Task Force came up with innovative support measures, including a check-in guide for hospitalists and fellow health care workers and dedicated wellness sessions complete with a licensed therapist for members. All the while, despite the restrictions and hurdles the pandemic has thrown our way, SHM members keep meeting and collaborating through virtual chapter events, committee work, special interest groups, and our annual conference, SHM Converge. Thank you to the countless members who donated their time to SHM, so that SHM could support hospitalists and their patients.

Now, we are transitioning into a new phase of the pandemic. The medical miracles that are the COVID-19 vaccines have made that possible. Fully vaccinated, I no longer worry that every time someone sneezes, or when I care for patients with a fever, that I am playing a high stakes poker game with my life. Don’t get me wrong; as I write, the Delta variant has a hold on the nation, and I know it’s not over yet. But it does appear as if the medical war on COVID is shifting from national to regional (or even local) responses.

During this new phase, we must rebuild our personal and professional lives. If you haven’t read Retired Lieutenant General Mark Hertling’s perspective piece in the August issue of the Journal of Hospital Medicine, I strongly encourage you to do so. He shares profound lessons on transitioning from active combat that are directly applicable to hospitalists who have been “deployed” battling COVID-19.

SHM will continue to pivot to meet our members’ needs too. We are already gearing up for more in-person education and networking. Chapters are starting to meet in person, and SHM is happy to provide visiting faculty. I will visit members from Florida to Maine and places in between starting this fall! Our Board of Directors and other SHM leaders are also starting to meet with members in person. Our own Leadership Academy will take place at Amelia Island in Florida in October, where we can learn, network, and even decompress. We also can’t wait for SHM Converge 2022 in Nashville, where we hope to reunite with many of you after 2 years of virtual conferences.

Our response to the pandemic, a once in a century crisis where our own safety was at risk, where doing the right thing might mean death or harming loved ones, our response of running into the fire to save lives is truly inspiring. The power of care – for our patients, for our family and friends, and for our hospital medicine community and the community at large – is evident more now than ever.

There have always been good reasons to be proud of being a hospitalist: taking care of the acutely ill, helping hospitals improve, teaching young doctors, and watching my specialty grow by leaps and bounds, to name just a few. But I’ve never been prouder than I am now.

Dr. Howell is the CEO of the Society of Hospital Medicine.

The American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) strongly recommend that all pregnant women be vaccinated against COVID-19.

Only about 16% of pregnant people have received one or more doses of a COVID-19 vaccine, according to the Centers for Disease Control and Prevention, despite evidence that COVID-19 infection puts pregnant people at an increased risk of severe complications and death.

That CDC report in June also found that vaccination during pregnancy was lowest among Hispanic (11.9%) and non-Hispanic Black women (6%) and women aged 18-24 years (5.5%) and highest among non-Hispanic Asian women (24.7%) and women aged 35-49 years (22.7%).

Linda Eckert, MD, professor of obstetrics and gynecology at University of Washington, Seattle, and a member of ACOG’s immunization expert work group, said in an interview that previously, ACOG has said that pregnant women should have the opportunity to be vaccinated, should they choose it.

Now the urgency has increased, she said: “This is a strong recommendation.”

The recommendation comes after mounting evidence demonstrating that COVID-19 vaccines are safe during pregnancy “from tens of thousands of reporting individuals over the last several months, as well as the current low vaccination rates and concerning increase in cases,” ACOG and SMFM said in the statement.

Both organizations said the timing of the advisory comes amid growing concern about the Delta variant.

CDC Director Rochelle Walensky, MD, has called the variant “one of the most infectious respiratory viruses we know of.”
 

No evidence of maternal/fetal harm

There is no evidence that COVID-19 vaccines could cause maternal or fetal harm, ACOG stated.

“ACOG encourages its members to enthusiastically recommend vaccination to their patients. This means emphasizing the known safety of the vaccines and the increased risk of severe complications associated with COVID-19 infection, including death, during pregnancy,” said J. Martin Tucker, MD, FACOG, president of ACOG. “It is clear that pregnant people need to feel confident in the decision to choose vaccination, and a strong recommendation from their obstetrician-gynecologist could make a meaningful difference for many pregnant people.”

Pregnant women are considered high risk because of concerns about the effect of COVID-19 during and after pregnancy, and on their offspring.

As this news organization has reported, research published in The BMJ found that pregnant women with COVID-19 may be at higher risk of admission to a hospital intensive care unit.

Preterm birth rates also were found to be higher among pregnant women with COVID-19 than among pregnant women without the disease.

Dr. Eckert said several of her patients have declined the vaccine. Among the reasons are that they don’t want to take any medications while pregnant or that they have heard that effects of the vaccines were not studied in pregnant women.

“Sometimes as I review with them the ongoing data coming in from pregnant individuals and newborns, [these patients] may change their minds and get the vaccine,” Dr. Eckert said.

In some cases, a pregnant patient’s family has pressured the patient not to get the vaccine.

The ACOG/SMFM advice notes that pregnant women who have decided to wait until after delivery to be vaccinated “may be inadvertently exposing themselves to an increased risk of severe illness or death.”

The recommendation extends to those who have already given birth.

“Those who have recently delivered and were not vaccinated during pregnancy are also strongly encouraged to get vaccinated as soon as possible,” the statement reads.

ACOG has developed talking points about the safety and efficacy of COVID-19 vaccines for pregnant patients.

Dr. Eckert disclosed no relevant financial relationships.

The American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) strongly recommend that all pregnant women be vaccinated against COVID-19.

Only about 16% of pregnant people have received one or more doses of a COVID-19 vaccine, according to the Centers for Disease Control and Prevention, despite evidence that COVID-19 infection puts pregnant people at an increased risk of severe complications and death.

That CDC report in June also found that vaccination during pregnancy was lowest among Hispanic (11.9%) and non-Hispanic Black women (6%) and women aged 18-24 years (5.5%) and highest among non-Hispanic Asian women (24.7%) and women aged 35-49 years (22.7%).

Linda Eckert, MD, professor of obstetrics and gynecology at University of Washington, Seattle, and a member of ACOG’s immunization expert work group, said in an interview that previously, ACOG has said that pregnant women should have the opportunity to be vaccinated, should they choose it.

Now the urgency has increased, she said: “This is a strong recommendation.”

The recommendation comes after mounting evidence demonstrating that COVID-19 vaccines are safe during pregnancy “from tens of thousands of reporting individuals over the last several months, as well as the current low vaccination rates and concerning increase in cases,” ACOG and SMFM said in the statement.

Both organizations said the timing of the advisory comes amid growing concern about the Delta variant.

CDC Director Rochelle Walensky, MD, has called the variant “one of the most infectious respiratory viruses we know of.”
 

No evidence of maternal/fetal harm

There is no evidence that COVID-19 vaccines could cause maternal or fetal harm, ACOG stated.

“ACOG encourages its members to enthusiastically recommend vaccination to their patients. This means emphasizing the known safety of the vaccines and the increased risk of severe complications associated with COVID-19 infection, including death, during pregnancy,” said J. Martin Tucker, MD, FACOG, president of ACOG. “It is clear that pregnant people need to feel confident in the decision to choose vaccination, and a strong recommendation from their obstetrician-gynecologist could make a meaningful difference for many pregnant people.”

Pregnant women are considered high risk because of concerns about the effect of COVID-19 during and after pregnancy, and on their offspring.

As this news organization has reported, research published in The BMJ found that pregnant women with COVID-19 may be at higher risk of admission to a hospital intensive care unit.

Preterm birth rates also were found to be higher among pregnant women with COVID-19 than among pregnant women without the disease.

Dr. Eckert said several of her patients have declined the vaccine. Among the reasons are that they don’t want to take any medications while pregnant or that they have heard that effects of the vaccines were not studied in pregnant women.

“Sometimes as I review with them the ongoing data coming in from pregnant individuals and newborns, [these patients] may change their minds and get the vaccine,” Dr. Eckert said.

In some cases, a pregnant patient’s family has pressured the patient not to get the vaccine.

The ACOG/SMFM advice notes that pregnant women who have decided to wait until after delivery to be vaccinated “may be inadvertently exposing themselves to an increased risk of severe illness or death.”

The recommendation extends to those who have already given birth.

“Those who have recently delivered and were not vaccinated during pregnancy are also strongly encouraged to get vaccinated as soon as possible,” the statement reads.

ACOG has developed talking points about the safety and efficacy of COVID-19 vaccines for pregnant patients.

Dr. Eckert disclosed no relevant financial relationships.

The American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) strongly recommend that all pregnant women be vaccinated against COVID-19.

Only about 16% of pregnant people have received one or more doses of a COVID-19 vaccine, according to the Centers for Disease Control and Prevention, despite evidence that COVID-19 infection puts pregnant people at an increased risk of severe complications and death.

That CDC report in June also found that vaccination during pregnancy was lowest among Hispanic (11.9%) and non-Hispanic Black women (6%) and women aged 18-24 years (5.5%) and highest among non-Hispanic Asian women (24.7%) and women aged 35-49 years (22.7%).

Linda Eckert, MD, professor of obstetrics and gynecology at University of Washington, Seattle, and a member of ACOG’s immunization expert work group, said in an interview that previously, ACOG has said that pregnant women should have the opportunity to be vaccinated, should they choose it.

Now the urgency has increased, she said: “This is a strong recommendation.”

The recommendation comes after mounting evidence demonstrating that COVID-19 vaccines are safe during pregnancy “from tens of thousands of reporting individuals over the last several months, as well as the current low vaccination rates and concerning increase in cases,” ACOG and SMFM said in the statement.

Both organizations said the timing of the advisory comes amid growing concern about the Delta variant.

CDC Director Rochelle Walensky, MD, has called the variant “one of the most infectious respiratory viruses we know of.”
 

No evidence of maternal/fetal harm

There is no evidence that COVID-19 vaccines could cause maternal or fetal harm, ACOG stated.

“ACOG encourages its members to enthusiastically recommend vaccination to their patients. This means emphasizing the known safety of the vaccines and the increased risk of severe complications associated with COVID-19 infection, including death, during pregnancy,” said J. Martin Tucker, MD, FACOG, president of ACOG. “It is clear that pregnant people need to feel confident in the decision to choose vaccination, and a strong recommendation from their obstetrician-gynecologist could make a meaningful difference for many pregnant people.”

Pregnant women are considered high risk because of concerns about the effect of COVID-19 during and after pregnancy, and on their offspring.

As this news organization has reported, research published in The BMJ found that pregnant women with COVID-19 may be at higher risk of admission to a hospital intensive care unit.

Preterm birth rates also were found to be higher among pregnant women with COVID-19 than among pregnant women without the disease.

Dr. Eckert said several of her patients have declined the vaccine. Among the reasons are that they don’t want to take any medications while pregnant or that they have heard that effects of the vaccines were not studied in pregnant women.

“Sometimes as I review with them the ongoing data coming in from pregnant individuals and newborns, [these patients] may change their minds and get the vaccine,” Dr. Eckert said.

In some cases, a pregnant patient’s family has pressured the patient not to get the vaccine.

The ACOG/SMFM advice notes that pregnant women who have decided to wait until after delivery to be vaccinated “may be inadvertently exposing themselves to an increased risk of severe illness or death.”

The recommendation extends to those who have already given birth.

“Those who have recently delivered and were not vaccinated during pregnancy are also strongly encouraged to get vaccinated as soon as possible,” the statement reads.

ACOG has developed talking points about the safety and efficacy of COVID-19 vaccines for pregnant patients.

Dr. Eckert disclosed no relevant financial relationships.

Like many colleagues, I have been working to change the minds and behaviors of acquaintances and patients who are opting to forgo a COVID vaccine. The large numbers of these unvaccinated Americans, combined with the surging Delta coronavirus variant, are endangering the health of us all.

When I spoke with the 22-year-old daughter of a family friend about what was holding her back, she told me that she would “never” get vaccinated. I shared my vaccination experience and told her that, except for a sore arm both times for a day, I felt no side effects. Likewise, I said, all of my adult family members are vaccinated, and everyone is fine. She was neither moved nor convinced.

Finally, I asked her whether she attended school (knowing that she was a college graduate), and she said “yes.” So I told her that all 50 states require children attending public schools to be vaccinated for diseases such as diphtheria, tetanus, polio, and the chickenpox – with certain religious, philosophical, and medical exemptions. Her response was simple: “I didn’t know that. Anyway, my parents were in charge.” Suddenly, her thinking shifted. “You’re right,” she said. She got a COVID shot the next day. Success for me.

When I asked another acquaintance whether he’d been vaccinated, he said he’d heard people were getting very sick from the vaccine – and was going to wait. Another gentleman I spoke with said that, at age 45, he was healthy. Besides, he added, he “doesn’t get sick.” When I asked another acquaintance about her vaccination status, her retort was that this was none of my business. So far, I’m batting about .300.

But as a physician, I believe that we – and other health care providers – must continue to encourage the people in our lives to care for themselves and others by getting vaccinated. One concrete step advised by the Centers for Disease Control and Prevention is to help people make an appointment for a shot. Some sites no longer require appointments, and New York City, for example, offers in-home vaccinations to all NYC residents.

Also, NYC Mayor Bill de Blasio announced Aug. 3 the “Key to NYC Pass,” which he called a “first-in-the-nation approach” to vaccination. Under this new policy, vaccine-eligible people aged 12 and older in New York City will need to prove with a vaccination card, an app, or an Excelsior Pass that they have received at least one dose of vaccine before participating in indoor venues such as restaurants, bars, gyms, and movie theaters within the city. Mayor de Blasio said the new initiative, which is still being finalized, will be phased in starting the week of Aug. 16. I see this as a major public health measure that will keep people healthy – and get them vaccinated.

The medical community should support this move by the city of New York and encourage people to follow CDC guidance on wearing face coverings in public settings, especially schools. New research shows that physicians continue to be among the most trusted sources of vaccine-related information.

Another strategy we might use is to point to the longtime practices of surgeons. We could ask: Why do surgeons wear face masks in the operating room? For years, these coverings have been used to protect patients from the nasal and oral bacteria generated by operating room staff. Likewise, we can tell those who remain on the fence that, by wearing face masks, we are protecting others from all variants, but specifically from Delta – which the CDC now says can be transmitted by people who are fully vaccinated.

Why did the CDC lift face mask guidance for fully vaccinated people in indoor spaces in May? It was clear to me and other colleagues back then that this was not a good idea. Despite that guidance, I continued to wear a mask in public places and advised anyone who would listen to do the same.

The development of vaccines in the 20th and 21st centuries has saved millions of lives. The World Health Organization reports that 4 million to 5 million lives a year are saved by immunizations. In addition, research shows that, before the emergence of SARS-CoV-2, vaccinations led to the eradication of smallpox and polio, and a 74% drop in measles-related deaths between 2004 and 2014.
 

Protecting the most vulnerable

With COVID cases surging, particularly in parts of the South and Midwest, I am concerned about children under age 12 who do not yet qualify for a vaccine. Certainly, unvaccinated parents could spread the virus to their young children, and unvaccinated children could transmit the illness to immediate and extended family. Now that the CDC has said that there is a risk of SARS-CoV-2 breakthrough infection among fully vaccinated people in areas with high community transmission, should we worry about unvaccinated young children with vaccinated parents? I recently spoke with James C. Fagin, MD, a board-certified pediatrician and immunologist, to get his views on this issue.

Dr. Fagin, who is retired, said he is in complete agreement with the Food and Drug Administration when it comes to approving medications for children. However, given the seriousness of the pandemic and the need to get our children back to in-person learning, he would like to see the approval process safely expedited. Large numbers of unvaccinated people increase the pool for the Delta variant and could increase the likelihood of a new variant that is more resistant to the vaccines, said Dr. Fagin, former chief of academic pediatrics at North Shore University Hospital and a former faculty member in the allergy/immunology division of Cohen Children’s Medical Center, both in New York.

Meanwhile, I agree with the American Academy of Pediatrics’ recommendations that children, teachers, and school staff and other adults in school settings should wear masks regardless of vaccination status. Kids adjust well to masks – as my grandchildren and their friends have.

The bottom line is that we need to get as many people as possible vaccinated as soon as possible, and while doing so, we must continue to wear face coverings in public spaces. As clinicians, we have a special responsibility to do all that we can to change minds – and behaviors.

Dr. London is a practicing psychiatrist who has been a newspaper columnist for 35 years, specializing in and writing about short-term therapy, including cognitive-behavioral therapy and guided imagery. He is author of “Find Freedom Fast” (New York: Kettlehole Publishing, 2019). He has no conflicts of interest.

Like many colleagues, I have been working to change the minds and behaviors of acquaintances and patients who are opting to forgo a COVID vaccine. The large numbers of these unvaccinated Americans, combined with the surging Delta coronavirus variant, are endangering the health of us all.

When I spoke with the 22-year-old daughter of a family friend about what was holding her back, she told me that she would “never” get vaccinated. I shared my vaccination experience and told her that, except for a sore arm both times for a day, I felt no side effects. Likewise, I said, all of my adult family members are vaccinated, and everyone is fine. She was neither moved nor convinced.

Finally, I asked her whether she attended school (knowing that she was a college graduate), and she said “yes.” So I told her that all 50 states require children attending public schools to be vaccinated for diseases such as diphtheria, tetanus, polio, and the chickenpox – with certain religious, philosophical, and medical exemptions. Her response was simple: “I didn’t know that. Anyway, my parents were in charge.” Suddenly, her thinking shifted. “You’re right,” she said. She got a COVID shot the next day. Success for me.

When I asked another acquaintance whether he’d been vaccinated, he said he’d heard people were getting very sick from the vaccine – and was going to wait. Another gentleman I spoke with said that, at age 45, he was healthy. Besides, he added, he “doesn’t get sick.” When I asked another acquaintance about her vaccination status, her retort was that this was none of my business. So far, I’m batting about .300.

But as a physician, I believe that we – and other health care providers – must continue to encourage the people in our lives to care for themselves and others by getting vaccinated. One concrete step advised by the Centers for Disease Control and Prevention is to help people make an appointment for a shot. Some sites no longer require appointments, and New York City, for example, offers in-home vaccinations to all NYC residents.

Also, NYC Mayor Bill de Blasio announced Aug. 3 the “Key to NYC Pass,” which he called a “first-in-the-nation approach” to vaccination. Under this new policy, vaccine-eligible people aged 12 and older in New York City will need to prove with a vaccination card, an app, or an Excelsior Pass that they have received at least one dose of vaccine before participating in indoor venues such as restaurants, bars, gyms, and movie theaters within the city. Mayor de Blasio said the new initiative, which is still being finalized, will be phased in starting the week of Aug. 16. I see this as a major public health measure that will keep people healthy – and get them vaccinated.

The medical community should support this move by the city of New York and encourage people to follow CDC guidance on wearing face coverings in public settings, especially schools. New research shows that physicians continue to be among the most trusted sources of vaccine-related information.

Another strategy we might use is to point to the longtime practices of surgeons. We could ask: Why do surgeons wear face masks in the operating room? For years, these coverings have been used to protect patients from the nasal and oral bacteria generated by operating room staff. Likewise, we can tell those who remain on the fence that, by wearing face masks, we are protecting others from all variants, but specifically from Delta – which the CDC now says can be transmitted by people who are fully vaccinated.

Why did the CDC lift face mask guidance for fully vaccinated people in indoor spaces in May? It was clear to me and other colleagues back then that this was not a good idea. Despite that guidance, I continued to wear a mask in public places and advised anyone who would listen to do the same.

The development of vaccines in the 20th and 21st centuries has saved millions of lives. The World Health Organization reports that 4 million to 5 million lives a year are saved by immunizations. In addition, research shows that, before the emergence of SARS-CoV-2, vaccinations led to the eradication of smallpox and polio, and a 74% drop in measles-related deaths between 2004 and 2014.
 

Protecting the most vulnerable

With COVID cases surging, particularly in parts of the South and Midwest, I am concerned about children under age 12 who do not yet qualify for a vaccine. Certainly, unvaccinated parents could spread the virus to their young children, and unvaccinated children could transmit the illness to immediate and extended family. Now that the CDC has said that there is a risk of SARS-CoV-2 breakthrough infection among fully vaccinated people in areas with high community transmission, should we worry about unvaccinated young children with vaccinated parents? I recently spoke with James C. Fagin, MD, a board-certified pediatrician and immunologist, to get his views on this issue.

Dr. Fagin, who is retired, said he is in complete agreement with the Food and Drug Administration when it comes to approving medications for children. However, given the seriousness of the pandemic and the need to get our children back to in-person learning, he would like to see the approval process safely expedited. Large numbers of unvaccinated people increase the pool for the Delta variant and could increase the likelihood of a new variant that is more resistant to the vaccines, said Dr. Fagin, former chief of academic pediatrics at North Shore University Hospital and a former faculty member in the allergy/immunology division of Cohen Children’s Medical Center, both in New York.

Meanwhile, I agree with the American Academy of Pediatrics’ recommendations that children, teachers, and school staff and other adults in school settings should wear masks regardless of vaccination status. Kids adjust well to masks – as my grandchildren and their friends have.

The bottom line is that we need to get as many people as possible vaccinated as soon as possible, and while doing so, we must continue to wear face coverings in public spaces. As clinicians, we have a special responsibility to do all that we can to change minds – and behaviors.

Dr. London is a practicing psychiatrist who has been a newspaper columnist for 35 years, specializing in and writing about short-term therapy, including cognitive-behavioral therapy and guided imagery. He is author of “Find Freedom Fast” (New York: Kettlehole Publishing, 2019). He has no conflicts of interest.

Like many colleagues, I have been working to change the minds and behaviors of acquaintances and patients who are opting to forgo a COVID vaccine. The large numbers of these unvaccinated Americans, combined with the surging Delta coronavirus variant, are endangering the health of us all.

When I spoke with the 22-year-old daughter of a family friend about what was holding her back, she told me that she would “never” get vaccinated. I shared my vaccination experience and told her that, except for a sore arm both times for a day, I felt no side effects. Likewise, I said, all of my adult family members are vaccinated, and everyone is fine. She was neither moved nor convinced.

Finally, I asked her whether she attended school (knowing that she was a college graduate), and she said “yes.” So I told her that all 50 states require children attending public schools to be vaccinated for diseases such as diphtheria, tetanus, polio, and the chickenpox – with certain religious, philosophical, and medical exemptions. Her response was simple: “I didn’t know that. Anyway, my parents were in charge.” Suddenly, her thinking shifted. “You’re right,” she said. She got a COVID shot the next day. Success for me.

When I asked another acquaintance whether he’d been vaccinated, he said he’d heard people were getting very sick from the vaccine – and was going to wait. Another gentleman I spoke with said that, at age 45, he was healthy. Besides, he added, he “doesn’t get sick.” When I asked another acquaintance about her vaccination status, her retort was that this was none of my business. So far, I’m batting about .300.

But as a physician, I believe that we – and other health care providers – must continue to encourage the people in our lives to care for themselves and others by getting vaccinated. One concrete step advised by the Centers for Disease Control and Prevention is to help people make an appointment for a shot. Some sites no longer require appointments, and New York City, for example, offers in-home vaccinations to all NYC residents.

Also, NYC Mayor Bill de Blasio announced Aug. 3 the “Key to NYC Pass,” which he called a “first-in-the-nation approach” to vaccination. Under this new policy, vaccine-eligible people aged 12 and older in New York City will need to prove with a vaccination card, an app, or an Excelsior Pass that they have received at least one dose of vaccine before participating in indoor venues such as restaurants, bars, gyms, and movie theaters within the city. Mayor de Blasio said the new initiative, which is still being finalized, will be phased in starting the week of Aug. 16. I see this as a major public health measure that will keep people healthy – and get them vaccinated.

The medical community should support this move by the city of New York and encourage people to follow CDC guidance on wearing face coverings in public settings, especially schools. New research shows that physicians continue to be among the most trusted sources of vaccine-related information.

Another strategy we might use is to point to the longtime practices of surgeons. We could ask: Why do surgeons wear face masks in the operating room? For years, these coverings have been used to protect patients from the nasal and oral bacteria generated by operating room staff. Likewise, we can tell those who remain on the fence that, by wearing face masks, we are protecting others from all variants, but specifically from Delta – which the CDC now says can be transmitted by people who are fully vaccinated.

Why did the CDC lift face mask guidance for fully vaccinated people in indoor spaces in May? It was clear to me and other colleagues back then that this was not a good idea. Despite that guidance, I continued to wear a mask in public places and advised anyone who would listen to do the same.

The development of vaccines in the 20th and 21st centuries has saved millions of lives. The World Health Organization reports that 4 million to 5 million lives a year are saved by immunizations. In addition, research shows that, before the emergence of SARS-CoV-2, vaccinations led to the eradication of smallpox and polio, and a 74% drop in measles-related deaths between 2004 and 2014.
 

Protecting the most vulnerable

With COVID cases surging, particularly in parts of the South and Midwest, I am concerned about children under age 12 who do not yet qualify for a vaccine. Certainly, unvaccinated parents could spread the virus to their young children, and unvaccinated children could transmit the illness to immediate and extended family. Now that the CDC has said that there is a risk of SARS-CoV-2 breakthrough infection among fully vaccinated people in areas with high community transmission, should we worry about unvaccinated young children with vaccinated parents? I recently spoke with James C. Fagin, MD, a board-certified pediatrician and immunologist, to get his views on this issue.

Dr. Fagin, who is retired, said he is in complete agreement with the Food and Drug Administration when it comes to approving medications for children. However, given the seriousness of the pandemic and the need to get our children back to in-person learning, he would like to see the approval process safely expedited. Large numbers of unvaccinated people increase the pool for the Delta variant and could increase the likelihood of a new variant that is more resistant to the vaccines, said Dr. Fagin, former chief of academic pediatrics at North Shore University Hospital and a former faculty member in the allergy/immunology division of Cohen Children’s Medical Center, both in New York.

Meanwhile, I agree with the American Academy of Pediatrics’ recommendations that children, teachers, and school staff and other adults in school settings should wear masks regardless of vaccination status. Kids adjust well to masks – as my grandchildren and their friends have.

The bottom line is that we need to get as many people as possible vaccinated as soon as possible, and while doing so, we must continue to wear face coverings in public spaces. As clinicians, we have a special responsibility to do all that we can to change minds – and behaviors.

Dr. London is a practicing psychiatrist who has been a newspaper columnist for 35 years, specializing in and writing about short-term therapy, including cognitive-behavioral therapy and guided imagery. He is author of “Find Freedom Fast” (New York: Kettlehole Publishing, 2019). He has no conflicts of interest.

Relaxation of nonpharmaceutical interventions once vaccination of the population has reached a tipping point short of herd immunity can increase the probability of the emergence of a resistant strain that natural selection then favors, according to new findings of a modeling study published online on July 30, 2021, in Scientific Reports.

Although vaccination is the best strategy for controlling viral spread, changes in our behavior and mindset will be increasingly required to stay ahead of vaccine-resistant strains, according to the authors of the report.

“We have become accustomed to thinking of the pandemic from the point of view of epidemiology, and advised to reduce transmission and the number of people getting sick and the death rate. As the pandemic spreads across years, there will be a new dimension to our thinking, both for policymakers and the public. And that’s the evolutionary perspective,” coauthor Fyodor Kondrashov, PhD, an evolutionary biologist at the Institute of Science and Technology, Klosterneuburg, Austria, said at a press briefing on July 299.

The coming “change of mentality” that Dr. Kondrashov foresees should reassure people that masking and social distancing even after being vaccinated aren’t futile. “It decreases the possibility that a vaccine-resistant strain is running around. We’re not just trying to prevent the spread, but the evolution of novel variants, which are so rare at this point that we haven’t yet identified them,” he said.

The study focused on evolution generically, rather than on specific variants. “We took the classical model used to study epidemiology of pandemics, the SIR [susceptible, infected, recovered] model, and we modified it to study the dynamics of rare mutations associated with emergence of a vaccine-resistant strain,” Simon A. Rella, the lead author of the study and a PhD student at the Institute of Science and Technology, explained at the briefing.

The researchers simulated the probability that a vaccine-resistant strain will emerge in a population of 10,000,000 individuals over 3 years, with vaccinations beginning after the first year. For eight scenarios, rates of infection, recovery, death, vaccination, and mutation and the percentage of individuals with resistant viral strains were factors in the model.

The model also simulated waves of low and high transmission, similar to the effects of large-scale interventions such as lockdowns.
 

Three factors

The study showed that a trio of factors increases the probability of a vaccine-resistant strain taking hold: slow rates of vaccination, high number of infected individuals, and faster mutation rate

These factors, Mr. Rella said, are obvious to some degree. “Every infected individual is like a mini-bioreactor, increasing the risk that mutations will appear that will endow the virus with the property of avoiding the immune system primed by a vaccine.”

Not as obvious, Mr. Rella added, is that, when most people are vaccinated, a vaccine-resistant strain has an advantage over the original strain and spreads faster.

But we can stop it, he said. “Our model shows that if at the time a vaccine campaign is close to finishing and nonpharmacological interventions are maintained, then there’s a chance to completely remove the vaccine-resistant mutations from the virus population.”

In scenarios in which a resistant strain became established, resistance initially emerged after about 60% of the population had been vaccinated. That makes nonpharmaceutical interventions such as masking and social distancing vitally important. Just under 50% of the U.S. population over the age of 12 has been fully vaccinated, according to the Centers for Disease Control and Prevention.

“Our results suggest that policymakers and individuals should consider maintaining nonpharmaceutical interventions and transmission-reducing behaviors throughout the entire vaccination period,” the investigators concluded.
 

A ‘powerful force’

“We hope for the best, that vaccine resistance has not developed, but caution that evolution is a very powerful force, and maintaining some precautions during vaccination may help to control that evolution,” said Dr. Kondrashov.

The investigators are relying on epidemiologists to determine which measures are most effective.

“It’s necessary to vaccinate as many people as fast as possible and as globally as possible and to maintain some level of nonpharmaceutical intervention to ensure rare variants have a chance to be suppressed instead of spread,” concluded Dr. Kondrashov.

He’s pessimistic because many countries are still having difficulty accessing vaccines, and vaccine efficacy wanes slightly over time. The authors warned that “the emergence of a partially or fully vaccine-resistant strain and its eventual establishment appears inevitable.”

The worst-case scenario is familiar to population biologists: rounds of “vaccine development playing catch up in the evolutionary arms race against novel strains,” the authors wrote.

Limitations of the study are that some parameters of the rate of evolution for vaccine-resistant strains aren’t known, and in creating the model, consideration was not given to effects of increased testing, rigorous contact tracing, rates of viral genome sequencing, and travel restrictions.

Rather, the model illustrates general principals by which vaccine resistance can evolve, Dr. Kondrashov said.

A version of this article first appeared on Medscape.com.

Relaxation of nonpharmaceutical interventions once vaccination of the population has reached a tipping point short of herd immunity can increase the probability of the emergence of a resistant strain that natural selection then favors, according to new findings of a modeling study published online on July 30, 2021, in Scientific Reports.

Although vaccination is the best strategy for controlling viral spread, changes in our behavior and mindset will be increasingly required to stay ahead of vaccine-resistant strains, according to the authors of the report.

“We have become accustomed to thinking of the pandemic from the point of view of epidemiology, and advised to reduce transmission and the number of people getting sick and the death rate. As the pandemic spreads across years, there will be a new dimension to our thinking, both for policymakers and the public. And that’s the evolutionary perspective,” coauthor Fyodor Kondrashov, PhD, an evolutionary biologist at the Institute of Science and Technology, Klosterneuburg, Austria, said at a press briefing on July 299.

The coming “change of mentality” that Dr. Kondrashov foresees should reassure people that masking and social distancing even after being vaccinated aren’t futile. “It decreases the possibility that a vaccine-resistant strain is running around. We’re not just trying to prevent the spread, but the evolution of novel variants, which are so rare at this point that we haven’t yet identified them,” he said.

The study focused on evolution generically, rather than on specific variants. “We took the classical model used to study epidemiology of pandemics, the SIR [susceptible, infected, recovered] model, and we modified it to study the dynamics of rare mutations associated with emergence of a vaccine-resistant strain,” Simon A. Rella, the lead author of the study and a PhD student at the Institute of Science and Technology, explained at the briefing.

The researchers simulated the probability that a vaccine-resistant strain will emerge in a population of 10,000,000 individuals over 3 years, with vaccinations beginning after the first year. For eight scenarios, rates of infection, recovery, death, vaccination, and mutation and the percentage of individuals with resistant viral strains were factors in the model.

The model also simulated waves of low and high transmission, similar to the effects of large-scale interventions such as lockdowns.
 

Three factors

The study showed that a trio of factors increases the probability of a vaccine-resistant strain taking hold: slow rates of vaccination, high number of infected individuals, and faster mutation rate

These factors, Mr. Rella said, are obvious to some degree. “Every infected individual is like a mini-bioreactor, increasing the risk that mutations will appear that will endow the virus with the property of avoiding the immune system primed by a vaccine.”

Not as obvious, Mr. Rella added, is that, when most people are vaccinated, a vaccine-resistant strain has an advantage over the original strain and spreads faster.

But we can stop it, he said. “Our model shows that if at the time a vaccine campaign is close to finishing and nonpharmacological interventions are maintained, then there’s a chance to completely remove the vaccine-resistant mutations from the virus population.”

In scenarios in which a resistant strain became established, resistance initially emerged after about 60% of the population had been vaccinated. That makes nonpharmaceutical interventions such as masking and social distancing vitally important. Just under 50% of the U.S. population over the age of 12 has been fully vaccinated, according to the Centers for Disease Control and Prevention.

“Our results suggest that policymakers and individuals should consider maintaining nonpharmaceutical interventions and transmission-reducing behaviors throughout the entire vaccination period,” the investigators concluded.
 

A ‘powerful force’

“We hope for the best, that vaccine resistance has not developed, but caution that evolution is a very powerful force, and maintaining some precautions during vaccination may help to control that evolution,” said Dr. Kondrashov.

The investigators are relying on epidemiologists to determine which measures are most effective.

“It’s necessary to vaccinate as many people as fast as possible and as globally as possible and to maintain some level of nonpharmaceutical intervention to ensure rare variants have a chance to be suppressed instead of spread,” concluded Dr. Kondrashov.

He’s pessimistic because many countries are still having difficulty accessing vaccines, and vaccine efficacy wanes slightly over time. The authors warned that “the emergence of a partially or fully vaccine-resistant strain and its eventual establishment appears inevitable.”

The worst-case scenario is familiar to population biologists: rounds of “vaccine development playing catch up in the evolutionary arms race against novel strains,” the authors wrote.

Limitations of the study are that some parameters of the rate of evolution for vaccine-resistant strains aren’t known, and in creating the model, consideration was not given to effects of increased testing, rigorous contact tracing, rates of viral genome sequencing, and travel restrictions.

Rather, the model illustrates general principals by which vaccine resistance can evolve, Dr. Kondrashov said.

A version of this article first appeared on Medscape.com.

Relaxation of nonpharmaceutical interventions once vaccination of the population has reached a tipping point short of herd immunity can increase the probability of the emergence of a resistant strain that natural selection then favors, according to new findings of a modeling study published online on July 30, 2021, in Scientific Reports.

Although vaccination is the best strategy for controlling viral spread, changes in our behavior and mindset will be increasingly required to stay ahead of vaccine-resistant strains, according to the authors of the report.

“We have become accustomed to thinking of the pandemic from the point of view of epidemiology, and advised to reduce transmission and the number of people getting sick and the death rate. As the pandemic spreads across years, there will be a new dimension to our thinking, both for policymakers and the public. And that’s the evolutionary perspective,” coauthor Fyodor Kondrashov, PhD, an evolutionary biologist at the Institute of Science and Technology, Klosterneuburg, Austria, said at a press briefing on July 299.

The coming “change of mentality” that Dr. Kondrashov foresees should reassure people that masking and social distancing even after being vaccinated aren’t futile. “It decreases the possibility that a vaccine-resistant strain is running around. We’re not just trying to prevent the spread, but the evolution of novel variants, which are so rare at this point that we haven’t yet identified them,” he said.

The study focused on evolution generically, rather than on specific variants. “We took the classical model used to study epidemiology of pandemics, the SIR [susceptible, infected, recovered] model, and we modified it to study the dynamics of rare mutations associated with emergence of a vaccine-resistant strain,” Simon A. Rella, the lead author of the study and a PhD student at the Institute of Science and Technology, explained at the briefing.

The researchers simulated the probability that a vaccine-resistant strain will emerge in a population of 10,000,000 individuals over 3 years, with vaccinations beginning after the first year. For eight scenarios, rates of infection, recovery, death, vaccination, and mutation and the percentage of individuals with resistant viral strains were factors in the model.

The model also simulated waves of low and high transmission, similar to the effects of large-scale interventions such as lockdowns.
 

Three factors

The study showed that a trio of factors increases the probability of a vaccine-resistant strain taking hold: slow rates of vaccination, high number of infected individuals, and faster mutation rate

These factors, Mr. Rella said, are obvious to some degree. “Every infected individual is like a mini-bioreactor, increasing the risk that mutations will appear that will endow the virus with the property of avoiding the immune system primed by a vaccine.”

Not as obvious, Mr. Rella added, is that, when most people are vaccinated, a vaccine-resistant strain has an advantage over the original strain and spreads faster.

But we can stop it, he said. “Our model shows that if at the time a vaccine campaign is close to finishing and nonpharmacological interventions are maintained, then there’s a chance to completely remove the vaccine-resistant mutations from the virus population.”

In scenarios in which a resistant strain became established, resistance initially emerged after about 60% of the population had been vaccinated. That makes nonpharmaceutical interventions such as masking and social distancing vitally important. Just under 50% of the U.S. population over the age of 12 has been fully vaccinated, according to the Centers for Disease Control and Prevention.

“Our results suggest that policymakers and individuals should consider maintaining nonpharmaceutical interventions and transmission-reducing behaviors throughout the entire vaccination period,” the investigators concluded.
 

A ‘powerful force’

“We hope for the best, that vaccine resistance has not developed, but caution that evolution is a very powerful force, and maintaining some precautions during vaccination may help to control that evolution,” said Dr. Kondrashov.

The investigators are relying on epidemiologists to determine which measures are most effective.

“It’s necessary to vaccinate as many people as fast as possible and as globally as possible and to maintain some level of nonpharmaceutical intervention to ensure rare variants have a chance to be suppressed instead of spread,” concluded Dr. Kondrashov.

He’s pessimistic because many countries are still having difficulty accessing vaccines, and vaccine efficacy wanes slightly over time. The authors warned that “the emergence of a partially or fully vaccine-resistant strain and its eventual establishment appears inevitable.”

The worst-case scenario is familiar to population biologists: rounds of “vaccine development playing catch up in the evolutionary arms race against novel strains,” the authors wrote.

Limitations of the study are that some parameters of the rate of evolution for vaccine-resistant strains aren’t known, and in creating the model, consideration was not given to effects of increased testing, rigorous contact tracing, rates of viral genome sequencing, and travel restrictions.

Rather, the model illustrates general principals by which vaccine resistance can evolve, Dr. Kondrashov said.

A version of this article first appeared on Medscape.com.

In announcing new guidance on July 27, the CDC said vaccinated people should wear face masks in indoor public places with “high” or “substantial” community transmission rates of COVID-19.

Data from the CDC shows that designation covers 69.3% of all counties in the United States – 52.2% (1,680 counties) with high community transmission rates and 17.1% (551 counties) with substantial rates.

A county has “high transmission” if it reports 100 or more weekly cases per 100,000 residents or a 10% or higher test positivity rate in the last 7 days, the CDC said. “Substantial transmission” means a county reports 50-99 weekly cases per 100,000 residents or has a positivity rate between 8% and 9.9% in the last 7 days.

About 23% of U.S. counties had moderate rates of community transmission, and 7.67% had low rates.

To find out the transmission rate in your county, go to the CDC COVID data tracker.
 

Smithsonian requiring masks again

The Smithsonian now requires all visitors over age 2, regardless of vaccination status, to wear face masks indoors and in all museum spaces.

The Smithsonian said in a news release that fully vaccinated visitors won’t have to wear masks at the National Zoo or outdoor gardens for museums.

The new rule goes into effect Aug. 6. It reverses a rule that said fully vaccinated visitors didn’t have to wear masks indoors beginning June 28.

Indoor face masks will be required throughout the District of Columbia beginning July 31., D.C. Mayor Muriel Bowser.
 

House Republicans protest face mask policy

About 40 maskless Republican members of the U.S. House of Representatives filed onto the Senate floor on July 29 to protest a new rule requiring House members to wear face masks, the Hill reported.

Congress’s attending doctor said in a memo that the 435 members of the House, plus workers, must wear masks indoors, but not the 100 members of the Senate. The Senate is a smaller body and has had better mask compliance than the House.

Rep. Ronny Jackson (R-Tex.), told the Hill that Republicans wanted to show “what it was like on the floor of the Senate versus the floor of the House. Obviously, it’s vastly different.”

Among the group of Republicans who filed onto the Senate floor were Rep. Lauren Boebert of Colorado, Rep. Matt Gaetz and Rep. Byron Donalds of Florida, Rep. Marjorie Taylor Greene of Georgia, Rep. Chip Roy and Rep. Louie Gohmert of Texas, Rep. Madison Cawthorn of North Carolina, Rep. Warren Davidson of Ohio, and Rep. Andy Biggs of Arizona.

A version of this article first appeared on WebMD.com.

In announcing new guidance on July 27, the CDC said vaccinated people should wear face masks in indoor public places with “high” or “substantial” community transmission rates of COVID-19.

Data from the CDC shows that designation covers 69.3% of all counties in the United States – 52.2% (1,680 counties) with high community transmission rates and 17.1% (551 counties) with substantial rates.

A county has “high transmission” if it reports 100 or more weekly cases per 100,000 residents or a 10% or higher test positivity rate in the last 7 days, the CDC said. “Substantial transmission” means a county reports 50-99 weekly cases per 100,000 residents or has a positivity rate between 8% and 9.9% in the last 7 days.

About 23% of U.S. counties had moderate rates of community transmission, and 7.67% had low rates.

To find out the transmission rate in your county, go to the CDC COVID data tracker.
 

Smithsonian requiring masks again

The Smithsonian now requires all visitors over age 2, regardless of vaccination status, to wear face masks indoors and in all museum spaces.

The Smithsonian said in a news release that fully vaccinated visitors won’t have to wear masks at the National Zoo or outdoor gardens for museums.

The new rule goes into effect Aug. 6. It reverses a rule that said fully vaccinated visitors didn’t have to wear masks indoors beginning June 28.

Indoor face masks will be required throughout the District of Columbia beginning July 31., D.C. Mayor Muriel Bowser.
 

House Republicans protest face mask policy

About 40 maskless Republican members of the U.S. House of Representatives filed onto the Senate floor on July 29 to protest a new rule requiring House members to wear face masks, the Hill reported.

Congress’s attending doctor said in a memo that the 435 members of the House, plus workers, must wear masks indoors, but not the 100 members of the Senate. The Senate is a smaller body and has had better mask compliance than the House.

Rep. Ronny Jackson (R-Tex.), told the Hill that Republicans wanted to show “what it was like on the floor of the Senate versus the floor of the House. Obviously, it’s vastly different.”

Among the group of Republicans who filed onto the Senate floor were Rep. Lauren Boebert of Colorado, Rep. Matt Gaetz and Rep. Byron Donalds of Florida, Rep. Marjorie Taylor Greene of Georgia, Rep. Chip Roy and Rep. Louie Gohmert of Texas, Rep. Madison Cawthorn of North Carolina, Rep. Warren Davidson of Ohio, and Rep. Andy Biggs of Arizona.

A version of this article first appeared on WebMD.com.

In announcing new guidance on July 27, the CDC said vaccinated people should wear face masks in indoor public places with “high” or “substantial” community transmission rates of COVID-19.

Data from the CDC shows that designation covers 69.3% of all counties in the United States – 52.2% (1,680 counties) with high community transmission rates and 17.1% (551 counties) with substantial rates.

A county has “high transmission” if it reports 100 or more weekly cases per 100,000 residents or a 10% or higher test positivity rate in the last 7 days, the CDC said. “Substantial transmission” means a county reports 50-99 weekly cases per 100,000 residents or has a positivity rate between 8% and 9.9% in the last 7 days.

About 23% of U.S. counties had moderate rates of community transmission, and 7.67% had low rates.

To find out the transmission rate in your county, go to the CDC COVID data tracker.
 

Smithsonian requiring masks again

The Smithsonian now requires all visitors over age 2, regardless of vaccination status, to wear face masks indoors and in all museum spaces.

The Smithsonian said in a news release that fully vaccinated visitors won’t have to wear masks at the National Zoo or outdoor gardens for museums.

The new rule goes into effect Aug. 6. It reverses a rule that said fully vaccinated visitors didn’t have to wear masks indoors beginning June 28.

Indoor face masks will be required throughout the District of Columbia beginning July 31., D.C. Mayor Muriel Bowser.
 

House Republicans protest face mask policy

About 40 maskless Republican members of the U.S. House of Representatives filed onto the Senate floor on July 29 to protest a new rule requiring House members to wear face masks, the Hill reported.

Congress’s attending doctor said in a memo that the 435 members of the House, plus workers, must wear masks indoors, but not the 100 members of the Senate. The Senate is a smaller body and has had better mask compliance than the House.

Rep. Ronny Jackson (R-Tex.), told the Hill that Republicans wanted to show “what it was like on the floor of the Senate versus the floor of the House. Obviously, it’s vastly different.”

Among the group of Republicans who filed onto the Senate floor were Rep. Lauren Boebert of Colorado, Rep. Matt Gaetz and Rep. Byron Donalds of Florida, Rep. Marjorie Taylor Greene of Georgia, Rep. Chip Roy and Rep. Louie Gohmert of Texas, Rep. Madison Cawthorn of North Carolina, Rep. Warren Davidson of Ohio, and Rep. Andy Biggs of Arizona.

A version of this article first appeared on WebMD.com.