Category: From California Healthline.org

One tray of COVID-19 vaccine from pharmaceutical giant Pfizer contains 975 doses — way too many for a rural hospital in Arkansas.

But with the logistical gymnastics required to safely get the Pfizer vaccine to rural health care workers, splitting the trays into smaller shipments has its own dangers. Once out of the freezer that keeps it at 94 degrees below zero, the vaccine lasts only five days and must be refrigerated in transit.

In Arkansas — where over 40% of its counties are rural and COVID infections are climbing — solving this distribution puzzle is urgently critical, said Dr. Jennifer Dillaha, the state’s epidemiologist.

“If their providers come down with COVID-19,” Dillaha said, “there’s no one there to take care of the patients.”

Such quandaries resonate with officials in Georgia, Kentucky, Utah, Indiana, Wisconsin and Colorado. The first push of the nation’s mass COVID vaccination effort has been chaotic, marked by a lack of guidance and miscommunication from the federal level.

With Washington punting most vaccination decisions, each state and county is left to weigh where to send vaccines first and which of two vaccines authorized by the Food and Drug Administration for emergency use makes the most sense for each nursing home, hospital, local health department and even school. And after warning for months that they lacked the resources to distribute vaccines, state officials are only now set to receive a major bump in funding — $8.75 billion in Congress’ latest relief bill, which lawmakers are likely to pass this week.

The feat facing public health officials has “absolutely no comparison” in recent history, said Claire Hannan, executive director of the Association of Immunization Managers.

Officials who thought the H1N1 swine flu shot in 2009 was a logistical nightmare say it now looks simple in comparison. “It was a flu vaccine. It was one dose. It came at refrigerator-stable temperatures,” Hannan said. “It was nothing like this.”

Within just a few days, the logistical barriers of the vaccine made by Pfizer and BioNTech were laid bare. Many officials now hang their hopes on Moderna, whose vaccine comes in containers of 100 doses, doesn’t require deep freezing and is good for 30 days from the time it’s shipped.

The federal government had divvied up nearly 8 million doses of Pfizer and Moderna’s vaccines to distribute this week, on top of roughly 3 million Pfizer shots that were sent last week, said Army Gen. Gustave Perna, chief operating officer of the Trump administration’s Operation Warp Speed effort.

Perna said he took “personal responsibility” for overstating how many Pfizer doses states would receive.

Federal delays have led to confusion, Dillaha said: “Sometimes we don’t have information from CDC or Operation Warp Speed until right before a decision needs to be made.”

Officials in other states painted a mixed picture of the rollout.

Georgia’s Coastal Health District, which oversees public health for eight counties and has offices in Savannah and Brunswick, spent more than $27,000 on two ultra-cold freezers for the Pfizer vaccine, which it’s treating “like gold,” said Dr. Lawton Davis, its health director. Health care workers are being asked to travel, some up to 40 minutes, to get their vaccinations, because shipping them would risk wasting doses, he said. Vaccination uptake has been lower than Davis would like to see. “It’s sort of a jigsaw puzzle and balancing act,” he said. “We’re kind of learning as we go.”

In Utah, sites to vaccinate teachers and first responders starting in January had no capability to store the Pfizer vaccine, although officials are trying to secure some ultra-cold storage, a state department of health spokesperson said. Very few of Kentucky’s local health offices could store the Pfizer shots, because of refrigeration requirements and the size of shipments, said Sara Jo Best, public health director of the Lincoln Trail District. Indiana’s state health department had to identify alternative cold storage options for 17 hospitals following changes in guidance for the vaccine thermal shippers.

And in New Hampshire, where the National Guard will help administer vaccines, officials last week were still finalizing details for 13 community-based sites where first responders and health care workers are due to get vaccinated later this month. Jake Leon, a state Health and Human Services spokesperson, said that while the sites will be able to administer both companies’ vaccines, most likely they’ll get Moderna’s because of its easier transport. Even as the earliest vaccines are injected, much remains up in the air.

“It’s day to day and even then hour by hour or minute by minute — what we know and how we plan for it,” Leon said Friday. “We’re building the plane while flying it.”

In all, the Trump administration has bought 900 million COVID vaccine doses from six companies, but most of the vaccines are still in clinical studies. Even the front-runners whose shots have received FDA emergency authorization— Pfizer and BioNTech on Dec. 11, Moderna on Dec. 18 — will require months to manufacture at that scale. The Trump administration plans to distribute 20 million vaccine doses to states by early January, Perna said Saturday.

By spring, officials hope to stage broader vaccine deployment beyond top-priority populations of health care workers, nursing home residents and staff, as well as first responders.

During the effort to vaccinate Americans against H1N1, Dillaha said, health departments set up mass vaccination clinics in their counties and delivered doses to schools. But hospitals are taking charge of parts of the initial COVID immunization campaign, both because health care workers are at highest risk of illness or death from COVID-19, and to pick up the slack from health departments overwhelmed by case investigations and contact tracing from an unending stream of new infections.

Best said her workforce is struggling to keep up with COVID infections alone, much less flu season and upcoming COVID vaccinations. Public health department personnel in Kentucky shrank by 49% from 2009 to 2019, according to state data she supplied. Across the country, 38,000 state and local health positions have disappeared since the 2008 recession. Per capita spending for local health departments has dropped by 18% since 2010.

Nationally, Pfizer and Moderna have signed contracts with the federal government to each provide 100 million vaccine doses by the end of March; Moderna is set to deliver a second tranche of 100 million doses by June. States were playing it safe last week, directing Pfizer vials mainly to facilities with ultra-cold freezers, Hannan said.

“A lot of that vaccine is destined for institutional facilities,” Sean Dickson, director of health policy for West Health Policy Center, said of the Pfizer shots. The center, with the University of Pittsburgh School of Pharmacy, found that 35% of counties have two or fewer facilities to administer COVID vaccines.

The analysis found tremendous variation in how far people would need to drive for the vaccine. Residents of North Dakota, South Dakota, Montana, Wyoming, Nebraska and Kansas face the longest drives, with more than 10% living more than 10 miles from the closest facility that could administer a shot.

Counties with long driving distances between sites and a low number of sites overall “are going to be the hardest ones to reach,” said Inmaculada Hernandez, an assistant professor at the University of Pittsburgh School of Pharmacy and lead author of the analysis.

Certain vaccines could be better suited for such places, including Johnson & Johnson’s potential offering, which is a single shot, and health departments could distribute in rural areas through mobile units, she said. The company is expected to apply for FDA emergency authorization in February, Operation Warp Speed chief scientific adviser Moncef Slaoui said this month.

Until then, Pfizer and Moderna are the companies supplying doses for the country, and they’re not considered equal even though each is more than 90% effective at reducing disease.

In Wisconsin, the Moderna vaccine “gives us many more options” and “allows for us to get doses to those smaller clinics, more-rural clinics, in a way that reduces the number of logistics” needed for ultra-cold storage, Dr. Stephanie Schauer, the state’s immunization program manager, told reporters Wednesday.

Alan Morgan, head of the National Rural Health Association, echoed that the Moderna vaccine is being looked to as a “rural solution.” But he said states including Kansas have shown that a Pfizer rural rollout can be done.

“It’s where these states put a priority — either they prioritize rural or they don’t,” he said. “It’s a cautionary tale of what we may see this spring, of rural populations perhaps being second-tier when it comes to vaccination.”

Virginia, too, has a plan for getting the Pfizer vaccine to far-flung places. It’s shipping the vaccines to 18 health facilities with ultra-cold freezers across the state. The hubs are distributed widely enough so vaccinators can bring shots from there to health workers even in thinly populated areas before they spoil, said Brookie Crawford, spokesperson for the Virginia Department of Health’s central region.

Washington, on the other hand, allows hospitals without ultra-cold freezers to temporarily store Pfizer vaccines in the thermal boxes they arrive in, said Franji Mayes, spokesperson for the state’s health department. That means a box needs to be used quickly, before doses expire. “We are also working on a policy that will allow hospitals who don’t expect to vaccinate 975 people to transfer extra vaccine to other enrolled facilities,” she said. “This will reduce wasted vaccine.”

This story is from a reporting partnership that includes WABE, NPR and KHN. It can be republished for free.

Vice President Mike Pence was the clear celebrity draw at a Nov. 20 campaign event for Georgia’s two incumbent U.S. senators, Kelly Loeffler and David Perdue. Both Republicans are fighting to keep their seats against two Democratic challengers in the runoff election set for Jan. 5.

People were so eager to see Pence at the rally in Canton, Georgia, that parking spots were scarce and a long line of cars snaked through the parking lot of a community college. Some drivers jumped the curb and parked in the grass.

Hundreds of people, many unmasked, were given temperature checks before boarding large coach buses for a short ride to the rally site. The venue was a large, open space outside the conference center, but few attendees maintained physical distance

The runoff in Georgia was triggered when no candidate in either Senate race won more than 50% of the vote in the general election on Nov. 3.

In the midst of the coronavirus pandemic and with the fate of the Affordable Care Act in question, Republicans hope the two incumbents will win reelection, thus preserving their party’s 50-48 control of the Senate.

But if the two challengers, Raphael Warnock and Jon Ossoff, win their runoffs, Democrats will gain narrow control of the Senate, with Vice President-elect Kamala Harris serving as the designated tie-breaker.

Yana De Moraes came to the rally from another Atlanta suburb, Buford. She is uninsured and, after a recent hospital stay, said the high cost of medical care was weighing on her mind.

“We would like our health care costs lowered, so it could be more affordable,” she said, with a rueful laugh. “So you don’t get another heart attack while you’re getting a bill!”

De Moraes added she’d also like to see better price controls on prescription drugs to stop pharmaceutical companies from “robbing American people.”

Others on their way to the rally said they were looking for any kind of change, ideally one that minimizes government involvement in health care.

Barry Brown made the 40-mile drive from his home in Atlanta for the rally. He’s retired but too young to qualify for Medicare, so he has ACA insurance, which he affords with the help of a federal subsidy.

“It sort of works. It’s better than nothing,” Brown said. “I would like to see an improved health care situation. I don’t know what that will be, so maybe they’ll mention that today. I’m hoping so.”

But at the rally, Loeffler only briefly mentioned her health care plan, which focuses on reducing drug prices and giving people access to insurance options that cost less but offer fewer benefits.

When it was his turn to speak, Perdue didn’t talk much about health care either, though he did take a shot at Obamacare, which he’s voted multiple times to overturn.

“Remember a little thing called the Affordable Care Act? You think that was done bipartisan?” Perdue asked the crowd. “No! It was done with a supermajority! Can you imagine what they’re gonna do if they get control of the Senate?”

As the two Republicans have campaigned throughout the state, they have consistently stoked fears about what Democrats will do, and health care policy has not led their messaging.

Their Democratic challengers, however, have been all over health care in their own speeches.

Warnock opened his runoff campaign to unseat Loeffler with a modestly attended Nov. 12 event devoted to health care. That’s also been a focus for Ossoff in his bid to win Perdue’s seat.

“This is why these Senate runoffs are so vital,” Ossoff explained at a small, physically distanced event in the shadow of the Georgia Capitol building in Atlanta on Nov. 10.

Ossoff and Warnock support adding a public insurance option to the Affordable Care Act. They also have emphasized the role Democrats will play in resurrecting key parts of the law if the U.S. Supreme Court decides to overturn it. The justices are set to make a ruling next year.

“If the Supreme Court strikes down the Affordable Care Act, it will be up to Congress to decide how to legislate such that preexisting conditions remain covered,” Ossoff said.

Voters like Janel Green, a Democrat, connect with that message. She’s from the nearby suburb of Decatur and is fighting breast cancer — for the second time. Green wondered whether her private health insurance might try to deny her coverage if the protections in the ACA disappear.

“I have to worry about whether or not next year in open enrollment that I won’t be discriminated against, that I won’t have limits that would then potentially end my life,” she said.

More than one-quarter of Georgians have preexisting conditions that could make it hard to get coverage if the ACA is struck down, according to an analysis by KFF. (KHN is an editorially independent program of KFF.)

That possibility also drove Atlanta resident Herschel Jones to support the runoff. On a recent weekday morning, he dropped by an Ossoff campaign office to pick up a yard sign.

Jones, who has diabetes, is insured through the Veterans Health Administration. He said everyone deserves access to health care.

“It’s a main issue, because the Affordable Care Act benefits all those individuals who might have preexisting conditions,” Jones said.

One likely reason Ossoff and Warnock are running so much harder on health care than Perdue and Loeffler is because that strategy paid off for Democrats in the general election, said Ken Thorpe, a health policy professor at Emory University.

President-elect Joe Biden can thank independent voters for his win in Georgia, Thorpe said, and they were drawn to him because of his promise to uphold Obamacare.

“The threat of potentially losing health insurance in the midst of this pandemic turned out to be probably the major defining issue in the election,” Thorpe said.

Polling in the days leading up to the Nov. 3 election showed Democrats were motivated on the issues of health care and the coronavirus pandemic.

For Democrats to win Georgia’s Senate seats, Thorpe said, they’ll need to stay focused on those issues. That emphasis could help them attract additional moderate voters, as well as entice those in the party base to cast ballots a second time.

“The health care issue is the probably main motivating factor that’s gonna get Democrats and independents to the polls,” he said.

Still, no Democrat has ever won a statewide runoff race in Georgia. That means that even with a strong health care message, it’ll be tough for Ossoff and Warnock to break that trend and unseat the Republicans, Thorpe said.

This story is from a reporting partnership that includes WABE, NPR and KHN, an editorially independent program of KFF.

Most Americans tell pollsters they’re worried about being able to afford an unexpected medical bill.

Late Monday, Congress passed a bill to allay some of those fears. The measure is included in a nearly 5,600-page package providing coronavirus economic relief and government funding for the rest of the fiscal year.

Specifically, the legislation addresses those charges that result from a long-running practice in which out-of-network medical providers — from doctors to air ambulance companies — send insured Americans “surprise bills,” sometimes for tens of thousands of dollars.

The legislation itself was a bit of a surprise, coming after two years of debate that featured high-stakes lobbying by all who stood to gain or lose: hospitals, insurers, patient advocacy groups, physicians, air ambulance companies and private equity firms, which own a growing number of doctor practices. A similar effort failed at the last minute a year ago after intense pressure from a range of interests, including those private equity groups.

This time around, no group got everything it wanted. Lawmakers compromised — mainly over how to determine how much providers will ultimately be paid for their services.

“No law is perfect,” said Zack Cooper, an associate professor of public health and economics at Yale who studies health care pricing. “But it fundamentally protects patients from being balance-billed,” he said, referring to out-of-network medical providers billing patients for amounts their insurer did not cover. “That’s a remarkable achievement.”

The bottom line: Patients may still be surprised by the high cost of health care overall. But they will now be protected against unexpected bills from out-of-network providers.

Here’s a rundown on what this legislation means for consumers:

Fewer Surprise Bills

Starting in 2022, when the law goes into effect, consumers won’t get balance bills when they seek emergency care, when they are transported by an air ambulance, or when they receive nonemergency care at an in-network hospital but are unknowingly treated by an out-of-network physician or laboratory.

Patients will pay only the deductibles and copayment amounts that they would under the in-network terms of their insurance plans.

Medical providers won’t be allowed to hold patients responsible for the difference between those amounts and the higher fees they might like to charge. Instead, those providers will have to work out with insurers acceptable payments. For the uninsured, for whom everything is out of network, the bill requires the secretary of Health and Human Services to create a provider-patient bill dispute resolution process.

The measure takes aim at situations in which patients have little choice about whether they are in network, including emergencies. A recent survey found 18% of emergency room visits, on average, resulted in at least one surprise bill. (A growing number of emergency rooms are staffed by private equity-owned agencies that sign few in-network agreements.)

The legislative agreement also applies to nonemergency care provided at in-network facilities, where patients receive care and services from out-of-network providers, such as anesthesiologists and laboratories.

Also included in the bar on balance billing is air ambulance transportation, which is among the most expensive medical services, often costing tens of thousands of dollars.

Still, the bill does not extend its consumer protections to the far more commonly used ground ambulance services. But it does call for an advisory committee to recommend how to take this step.

An Option for Consumers to Agree to Balance Billing

In some cases, physicians can balance-bill their patients, but they must get consent in advance.

This part of the bill is aimed at patients who want to see an out-of-network physician, perhaps a surgeon or obstetrician recommended by a friend.

In those cases, physicians must provide a cost estimate and get patient consent at least 72 hours before treatment. For shorter-turnaround situations, the bill requires that patients receive the consent information the day the appointment is made.

In a sense, though, this provision allows consumers to forfeit protection.

Health providers “have to give you a good-faith cost estimate. If you sign that, then you can be billed whatever that physician wants to bill you,” said Jack Hoadley, research professor emeritus in the Health Policy Institute at Georgetown University.

The legislation allows this only in nonemergency circumstances and bars many types of physicians from the practice. Anesthesiologists, for example, can’t seek consent to balance-bill for their services, nor can radiologists, pathologists, neonatologists, assistant surgeons or laboratories.

Payment Will Be Sorted Out in Negotiations

While lawmakers agreed that patients will be held harmless, the real fight was over how to decide what amounts providers would be paid by insurers.

Some groups — including hospitals and physicians — opposed any kind of benchmark or standard to which all bills would be held. On the other side, insurers, employers and consumer groups argued for a benchmark, warning that, without one, providers would angle for much higher payments.

The legislation carves out some middle ground.

It gives insurers and providers 30 days to try to negotiate payment of out-of-network bills. If that fails, the claims would go through an independent dispute resolution process with an arbitrator, who would have the final say.

The bill does not specify a benchmark, but it bars physicians and hospitals from using their “billed charges” during arbitration. Such charges are generally far higher than negotiated rates and bear little or no relation to the actual cost of providing the care.

That was considered a win for insurers, employers and consumer advocates, who argued that allowing billed charges would mean higher prices — potentially driving up premiums — in cases sent to arbitration.

Billed charges “are totally made up” by providers, said Cooper, at Yale. “So, the big deal is that arbitrators are not considering charges.”

But hospitals and doctors won a limit they sought, too.

In last-minute changes over the weekend, they succeeded in barring consideration of Medicare or Medicaid prices during arbitration. Those government payments are often far lower than the negotiated rates paid by insurers and self-insured employers.

Instead, the bill says negotiators can consider the median in-network prices paid by each insurer for the services in dispute. Other factors, too, can come into play, including whether the medical provider tried to join the insurers’ network, and how sick the patient was compared with others. It also allows consideration of network rates a provider may have agreed to during the previous four years, which might help some high-priced services, such as air ambulances, remain costly even in arbitration.

Overall, the legislation “did include some wins for provider groups,” said Loren Adler, associate director at the USC-Brookings Schaeffer Initiative for Health Policy.

Even so, he expects the legislation will help insurers contain some prices and provide “some downward pressure on premiums, even if relatively minor at the end of the day.”

State Laws May Change

More than 30 states have enacted some type of surprise billing protections, but only 17 are considered comprehensive, according to the Commonwealth Fund.

Comprehensive states — California, New York and New Mexico, for example — extend protections to cover nonemergency situations at in-network hospitals, but that isn’t the case in less comprehensive states, the fund noted.

And state laws have another limitation: They apply only to certain types of insurance, and often do not cover Americans who get their health insurance through self-insured employers, which tend to be midsize to large companies because they fall under federal rules.

But the new federal rules will cover most types of insurance plans, including those offered by self-insured employers.

“States can’t fully deal with these situations, but this covers it,” said Hoadley, at Georgetown.

Still, some provisions in state law, such as how to determine a payment, differ from the federal law. In such cases, the federal law defers to states.

Statehouse lawmakers may eventually alter their legislation or adopt new proposals to avoid confusion, said policy experts. If they don’t, they could be left with rules that affect people differently depending on whether their insurance comes through a large self-insured employer or directly from an insurance plan subject to state law. “I would be surprised if, over time, states don’t just glom onto the federal law,” said Adler.

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SACRAMENTO — Nearly six months since Gov. Gavin Newsom promised to target businesses that are flagrantly violating public health orders to control the spread of COVID-19, California regulators have issued just 424 citations and suspended two business licenses as of Monday, according to data from 10 state regulatory and law enforcement agencies.

Instead of strictly penalizing businesses for violations, the Democratic governor and businessman with a portfolio of wineries, bars and restaurants under the brand name PlumpJack, has relied on educating owners about infectious disease mandates. State agencies have contacted establishments primarily by email, sending them 1.3 million messages since July 1 to urge them to comply with state and local public health rules.

Enforcement at bars and restaurants where alcohol is served, identified by the Centers for Disease Control and Prevention as among the highest-risk environments for COVID transmission, has been limited, data shows. The state Department of Alcoholic Beverage Control, which can issue criminal misdemeanor citations, fine businesses and revoke liquor licenses, has issued just 45 citations against bars and 119 against restaurants since July. No fines have been issued or licenses revoked for the 94,000 businesses it regulates.

By comparison, the state of New York — with half the population of California and far fewer eating and drinking establishments — has issued 1,867 fines against bars and restaurants and temporarily suspended 279 business liquor licenses from June 18 to Dec. 8.

“The reality is it’s not enough to send an email and say ‘Wear a mask,’” said Dr. Kirsten Bibbins-Domingo, a professor of epidemiology and biostatistics at the University of California-San Francisco. “We see workplace violations that we know are major sources of transmission. We have to be willing to enforce or there’s no point in doing these things.”

Like much of the country, both California and New York, the nation’s two most populous Democratic-led states, have put primary responsibility for enforcing public health mandates on cities and counties. Newsom and New York Gov. Andrew Cuomo have bolstered local enforcement efforts by forming statewide task forces to go after businesses that repeatedly violate or ignore public health rules, such as mask mandates and business closures.

But California has been less aggressive than New York in targeting and penalizing bad actors. Newsom and state agencies have instead relied on tough talk and persuasion, emphasizing “personal responsibility,” informing businesses about their responsibilities — and giving them plenty of time to comply.

“I’m not coming out with a fist. We want to come out with an open heart,” Newsom said July 1. “We have, I think, a responsibility at the same time to go after people that are thumbing their nose, that are particularly being aggressive and reticent to do anything.”

The state’s lenient enforcement policy has put enormous responsibility and pressure on cities and counties struggling to gain compliance with COVID measures. Local government leaders are preparing for deep budget cuts and can’t find resources to undertake a coherent enforcement strategy of their own. Many are also fighting intense political battles over mask mandates, curfews and other COVID safety measures.

As a result, some counties enforce the rules and some don’t. And because the state hasn’t stepped in to assist with adequate enforcement, some local officials say, businesses are often free to ignore the rules, allowing the virus to run rampant.

“It would be nice to have some air support from the governor,” said Nevada City Councilman Doug Fleming, who backs the city’s new ordinance imposing fines for violating the state mask mandate. “He’s kind of forcing local jurisdictions to enforce his rules without any air support.”

California is experiencing a COVID surge as never before, setting records almost daily for infections and deaths. Hospitals across the state are running dangerously low on intensive care beds, with the state reporting 2.5% ICU capacity as of Monday.

Most of California is under a mandatory stay-at-home order, which prohibits indoor and outdoor dining and requires closure of a wide swath of businesses, from barbershops to wineries. Retail operations are limited to 20% capacity and churches must hold services outside.

Yet across the state, many people continue to flout the rules, keeping businesses open and refusing to wear masks in public. Pastors Jim and Cyndi Franklin, for instance, continue to hold indoor Sunday sermons at the Cornerstone Church in Fresno. Bars in Los Angeles County were packed with maskless football fans on a recent Sunday. And the owners of Calla Lily Crepes in Nevada City have repeatedly refused to close or require masks despite more than 20 warnings and attempts by Nevada County to gain compliance.

As ICUs run out of capacity, this Huntington Beach, CA scene was posted by a resident noting that today’s Green Bay/ Detroit game can be seen on overhead TVs. pic.twitter.com/Dcr3IlOOaS

— Margot Roosevelt (@margotroosevelt) December 14, 2020

“We are free thinkers. I hope I’m not stepping out too far by saying we strongly question the masks, but we do,” said Rebecca Sweet Engstrom, who owns the restaurant with her husband, Darren Engstrom. “We feel that it should be people’s choice.”

Newsom in July threatened to withhold money from cities and counties that refuse to enforce public health orders. To date, the state has withheld federal funding from two cities in the Central Valley, Atwater and Coalinga, for allowing businesses to remain open in defiance of state and local health orders.

The governor has also directed 10 state agencies to police egregious violators of state and local health orders, primarily businesses, to protect workers and the public. State enforcement officials have issued few harsh penalties, they argue, because most businesses are complying — and the state doesn’t want to be punitive.

In interviews, regulators described long hours of back-breaking work to inform business owners about the rapidly changing COVID restrictions and enforcement rules.

“We’re not trying to get into an adversarial situation here,” said Erika Monterroza, chief spokesperson for the state Department of Industrial Relations, which oversees Cal/OSHA, the agency responsible for regulating workplace safety and employer public health mandates.

Cal/OSHA issued 219 COVID-related citations to 90 employers from Aug. 25 to Dec. 14, accompanied by about $2.2 million in proposed fines, according to department data. The penalties ranged from $475 on Sept. 30 against a Taco Bell in Anaheim for failing to require employees to maintain 6 feet of physical distance, to $108,000 on Oct. 29 against Apple Bistro in Placerville for not requiring masks indoors and for not providing adequate physical distance between employees and guests. The department is investigating about 1,700 other cases.

The state Board of Barbering and Cosmetology, which regulates about 54,000 salons and barbershops, has levied just two citations and suspended two licenses, both held by Primo’s Barbershop in Vacaville, which has “very adamantly” opposed state health orders, said Matt Woodcheke, a spokesperson for the state Department of Consumer Affairs, which oversees the board.

No citations have been issued for COVID-related public health violations by California’s 280 state parks, nor by the California Highway Patrol.

Regulators said they have felt tremendous angst trying to get businesses to follow rapidly changing rules, but they aim for voluntary compliance and don’t want to cause businesses to go under.

“This is extremely difficult and we don’t want to do it,” said Luke Blehm, an acting supervising agent in charge for the state Department of Alcoholic Beverage Control. “We are all compassionate and empathetic and it’s a very hard thing to tell somebody that they’ve got to close and they may lose everything because of these rules they have to comply with.”

The state Department of Public Health, which is not one of the 10 task force agencies but assists them, has not issued fines or citations for health order violations, even though it is the primary agency responsible for issuing statewide mandates, according to spokesperson Corey Egel.

In New York, by contrast, Cuomo has leaned on political leaders and law enforcement agencies to aggressively police violations of COVID public health rules and has publicly admonished sheriffs who refuse to enforce violations. He ordered a statewide crackdown on bars and restaurants as cases surged this summer after contact-tracing data indicated drinking and dining were a major source of community spread, said Cuomo spokesperson Jack Sterne.

In hard-hit counties and towns where political leadership rebuffed enforcement, the Cuomo administration deployed COVID strike teams composed of state inspectors — in some cases, retrained Department of Motor Vehicles employees — to police business violations of public health rules. Cuomo argues it has made a difference.

“Compliance on bars has increased dramatically from when we started,” he said in September, “because if you know someone is going to check, if you know there’s monitoring, people tend to increase compliance.”

In California, some counties are enforcing COVID restrictions. San Diego County is dedicating six sheriff’s deputies to the cause and fines repeat violators up to $1,000.

“We’re supportive of enforcement here,” said San Diego County Sheriff’s Lt. Ricardo Lopez. “COVID-19 is exploding and our view is, let’s get this over with as fast as possible.”

But elsewhere, county health officers pushing for stricter enforcement face intense political opposition from their bosses and law enforcement agencies. Sacramento County, for example, dropped its plan to impose fines this month after confronting resistance from businesses. Sacramento County Sheriff Scott Jones also has refused to enforce mask and other public health mandates.

Dr. Georges Benjamin, executive director of the American Public Health Association, said the state, ideally, should develop a consistent statewide enforcement system that starts with warnings and a strong public messaging campaign, then moves to graduated fines if noncompliance continues.

Until that happens, local leaders say, the patchwork of rules and enforcement strategies is causing confusion and chaos.

“People are continuing to disobey,” said Dr. Olivia Kasirye, Sacramento County’s health officer. “Some people are outright angry with us, asking why aren’t we doing something, but all we can do is refer problems to the state enforcement agencies.”

It was a down-in-the-mud presidential campaign, but the dirtiest part comes on Inauguration Day.

As Joe Biden lifts his right hand to take the oath of office at noon on Jan. 20 at the Capitol, a team of specially trained cleaners will be lifting their hands to disinfect the White House.

The executive mansion will get a deep clean after two COVID-19 outbreaks this fall led to President Donald Trump and members of his staff and family becoming infected.

The departure of one president and the arrival of another is always a fast but highly synchronized behind-the-scenes ballet by White House staff members and moving crews.

But this year is different. The shift means more than rearranging the Oval Office and putting new clothes in bedroom closets: It means a top-to-bottom disinfection amid a pandemic. Biden, who at 78 is taking office as the oldest president in U.S. history, is at high risk of complications from the virus.

So, the General Services Administration will oversee a thorough cleaning and disinfection of every doorknob, toilet handle, light switch, stair railing, telephone, elevator button, computer keyboard and other objects inside the 55,000-square-foot mansion at 1600 Pennsylvania Ave.

But can such a large building get fully clean in just five or six hours?

Experts say that should not be a problem with a large enough team and preparation time.

K. Mark Wiencek, lead microbiologist for South Carolina-based Contec Inc., which sells cleaning supplies to hospitals, said GSA cleaners should focus on the rooms last occupied by the Trump staff, since the virus can’t survive long on surfaces. Cleaning crews, he added, should wear masks and gloves to protect themselves and not introduce any germs.

He recommended replacing the air filters and using fogging and spraying disinfectant to kill viruses.

The GSA said it is already cleaning the White House East Wing and West Wing offices daily with disinfectant.

GSA officials said they expect no difficulties in making the transition and pledged that all furniture and surfaces would be cleaned. “GSA will thoroughly clean and disinfect the building spaces between the administrations and ensure that everything is up to standard,” a spokesperson said in a statement.

It’s vital that cleaners leave the cleaning chemicals on surfaces a full 10 minutes before wiping them down, said O.P. Almaraz, a disaster relief expert in West Covina, California, and president of Allied Restoration, which has cleaned dozens of businesses after suspected COVID cases.

“With a large enough crew, a professional disinfection company could apply disinfectants to the entire White House in six hours,” he said. It’s important, he explained, that the crew pay “special attention to points that may be touched often, like tabletops, door handles and light switches.”

As long as cleaners have an organized plan for each room, Almaraz doesn’t see them having trouble getting done before the Bidens move in at the end of the day.

Sheldon Yellen, CEO of Michigan-based Belfor Property Restoration, said cleaning crews need to be rehearsed and in fully ventilated suits to clean the White House in one afternoon.

“It’s a level 3 clean,” he said, noting the building needs the most intensive service because of confirmed COVID cases. That means disposing of anything that doesn’t have to stay for the Bidens, including pillows and bedsheets. He said books need to be wiped down, not just on the binding but all sides. He recommended cleaning the ductwork and ventilation systems as well.

Jack Shevel, co-founder of San Diego disinfection company Zappogen, said that because COVID-19 spreads by airborne transmission, it is best to disinfect using an electrostatic sprayer or fogger filled with a disinfectant designed to kill airborne pathogens. That covers a large area more easily than just wiping surfaces.

“To truly disinfect all those rooms quickly and thoroughly, they should be sprayed with a fine micron mist that can reach all crevices and surfaces evenly,” he said.

Still, the White House cleaners must be careful to remove paintings, antiques and other valuable items before spraying with disinfectant, said Ernesto Abel-Santos, professor of biochemistry at the University of Nevada-Las Vegas. Those items should be cleaned by hand.

Abel-Santos said a simple alcohol-based disinfectant should be enough to kill the COVID virus. Although the virus can be detected on some surfaces for days, it typically degrades within hours. People are much more likely to be infected by droplets expelled when someone coughs, sneezes or talks.

During the turnover, cleaners should focus on the most commonly used areas of the building, he said, such as the Oval Office and bedrooms. “The rest can get deep-cleaned as needed,” he added.

Even more important than cleaning, however, is asking the new president and his family and staff to physically distance, wear their masks and wash their hands, according to Abel-Santos.

“You don’t realize how many times in a day you touch your face with your hands,” he said. “If you touch a surface and then touch your face, it increases the probability of contagion.”

This story also ran on Daily Beast. It can be republished for free.

Administrators at Howard University Hospital in Washington, D.C., were thrilled to be among the city’s first hospitals to get a COVID-19 vaccine, but they knew it could be a tough sell to get staffers to take the shot.

They were right.

The hospital, located on the campus of one the nation’s oldest historically Black colleges, received 725 doses of the vaccine made by Pfizer and BioNTech on Dec. 14 and expects 1,000 more vaccine doses this week to immunize its workers.

Yet, as of Friday afternoon, about 600 employees had signed up for the shots, touted as about 95% effective in preventing the deadly disease. Howard has about 1,900 employees, not counting hundreds of independent contractors it also hoped to vaccinate.

“There is a high level of mistrust and I get it,” said Anita Jenkins, the hospital’s chief executive officer who received the shot Tuesday in hopes of inspiring her staff to follow her lead. “People are genuinely afraid of the vaccine.”

Studies showed few serious side effects in more than 40,000 people before the vaccine was authorized for emergency use in the U.S. A few people worldwide have had allergic reactions in the past week.

In late November, a hospital survey of 350 workers found 70% either did not want to take a COVID vaccine or did not want it as soon as it became available.

So, officials are not dismayed at the turnout so far, saying it shows their educational campaign is beginning to work.

“This is a significant win,” said Jenkins, who added she was happy to “take one for the team” when she and other health care personnel got the first shots. About 380 Howard employees or affiliated staff had been vaccinated by Friday afternoon.

Although hesitancy toward the vaccine is a challenge nationally, it’s a significant problem among Black adults because of their generations-long distrust of the medical community and racial inequities in health care.

When Jenkins posted a picture of herself getting vaccinated on her Facebook page, she received many thumbs up but also pointed criticism. “One called me a sellout and asked why I would do that to my people,” she said.

Before being vaccinated, Jenkins said, she read about the clinical trials and was glad to learn the first vaccines in development were unlike some that use weakened or inactivated viruses to stimulate the body’s immune defense. The COVID vaccine by Pfizer and BioNTech does not contain the actual virus.

And one factor driving her to take the shot was that some employees said they would be more willing to do it if she did.

The hesitancy among her staff members has its roots in the Tuskegee syphilis experiment, said Jenkins, who started at Howard in February.

The 40-year study, which was run by the U.S. Public Health Service until 1972, followed 600 Black men infected with syphilis in rural Alabama over the course of their lives. The researchers refused to tell patients their diagnosis or treat them for the debilitating disease. Many men died of the disease and several wives contracted it.

Jenkins said she was not surprised that many Howard employees — including doctors — are questioning whether to take a vaccine, even though Black patients are twice as likely to die of COVID-19.

While African Americans make up 45% of the population in the District of Columbia, they account for 74% of the 734 COVID deaths. Nationally, Blacks are nearly four times more likely to be hospitalized due to COVID compared with whites and nearly three times more likely to die.

Howard, which has treated hundreds of COVID patients, was one of six hospitals in the city to get the first batch of nearly 7,000 doses of the Pfizer vaccine Monday. About one-third of those doses were administered by Friday morning, said Justin Palmer, a vice president of the District of Columbia Hospital Association.

Federal officials Friday authorized a second vaccine, made by Moderna, for emergency use. That vaccine is expected to be distributed starting this week.

The political bickering over the COVID response has also hurt efforts to instill confidence in the vaccine, Jenkins said.

Other than a sore arm, Jenkins said, she’s had no side effects from the vaccine, which can also commonly cause fatigue and headache. “Today I am walking the halls,” she explained, “and I got the shot two days ago.”

Part of the challenge for Jenkins and other hospital officials will be persuading employees not just to take a vaccine now but to return for the booster shot three weeks later. One dose offers only partial protection.

Jenkins said the hospital plans to make reminder calls to get people to follow up. She said efforts to increase participation at the hospital will also continue.

“It was important for me to be a standard-bearer to show the team I am in there with them,” she said.

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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HELENA, Mont. — Incoming Montana Gov. Greg Gianforte signaled he won’t continue a statewide mask mandate in place since July, though he said he plans to wear a mask himself and get vaccinated against COVID-19.

If Gianforte, a Republican, reverses outgoing Democratic Gov. Steve Bullock’s mask order, Montana will be just the second state after Mississippi to lift its mandate. Thirty-eight states now have statewide mandates.

“I trust Montanans with their health and the health of their loved ones,” Gianforte said in a recent interview with KHN. “The state has a role in clearly communicating the risks of who is most vulnerable, what the potential consequences are, but then I do trust Montanans to make the right decisions for themselves and their family.”

The Centers for Disease Control and Prevention says masks help prevent transmission of COVID-19. At least one study has found that states with mask requirements have had slower COVID growth rates compared with those without mandates.

“We’re going to encourage people to wear masks,” Gianforte said. “I’m personally going to lead by example, wearing a mask in the Capitol.”

Montana is the only state where control of the governor’s office is changing parties as a result of November’s election. Also, among the 11 governors being sworn in this January, Gianforte will be the only one new to managing his state’s response to the pandemic.

Nine of the others are incumbents starting second terms. The 10th, Spencer Cox, is Utah’s lieutenant governor in the current administration and has played a central role in his state’s COVID response.

Montana alone will have wholly new leadership next year as states try to keep hospitals from overflowing amid the surging virus, while adjusting to a new presidential administration and executing vaccine distribution plans.

Gianforte doesn’t plan to scrap everything the outgoing administration has done to fight the pandemic. For example, he said he and Bullock are “on the same page” when it comes to prioritizing distribution of the vaccine to health care workers and vulnerable residents.

Gianforte also said he plans to take the vaccine when it’s his turn.

“When my name comes up on the list, I will raise my hand and I am going to get vaccinated,” Gianforte said. “It’s very important that I lead by example because I think this vaccine is a critical part of us getting back to normal.”

Gianforte, a businessman who sold his software company, RightNow Technologies, to Oracle for $1.8 billion in 2011, has long coveted Montana’s governor’s office, spending nearly $12 million of his personal fortune over four years and two campaigns to win the seat.

He ran against Bullock and lost in 2016, then won Montana’s congressional seat in a 2017 special election infamous for Gianforte’s misdemeanor assault against a reporter trying to ask him questions.

Gianforte won a second term in Congress in 2018 and defeated Bullock’s lieutenant governor, Mike Cooney, by more than 12 percentage points in November’s election.

Gianforte will be the first Republican in the governor’s office in 16 years. Republican lawmakers, who control the Montana Legislature, cheered Gianforte’s election and have high expectations for the session that begins the day of his inauguration.

Republican lawmakers will likely seek budget cuts after unsuccessfully asking Bullock to preemptively cut state spending during the pandemic. Bullock has said the state is in good financial shape and that any decision to cut spending would be made for ideological reasons, not out of necessity.

Gianforte has declined to indicate whether he plans to support spending cuts, saying his incoming team is still reviewing Bullock’s proposed two-year budget. That budget proposal includes spending increases to Medicaid, support for children and families, senior and long-term care and treatment for addiction and mental disorders.

John Doran, vice president of external affairs for Blue Cross and Blue Shield of Montana, said he hopes lawmakers spare health services used by at-risk residents if they plan to reduce spending to balance the budget.

“These are critical services and the need for them has only increased since the start of the pandemic,” Doran said.

The structure of Montana’s Medicaid expansion program could emerge as one of the more contentious health issues this session. The federal and state health insurance program for people with low incomes or disabilities extended eligibility to Montana adults who make 138% of the federal poverty level in 2015, and it now enrolls more than 90,000 low-income adults.

At least a half-dozen bill requests have been made by Republican lawmakers ahead of the session to revise the Medicaid expansion program, alarming some health care industry officials. Rich Rasmussen, president and CEO of the Montana Hospital Association, said Medicaid expansion has helped small, rural hospitals maintain financial stability, particularly during the COVID crisis.

“We will adamantly oppose any effort to dismantle the program,” Rasmussen said. “We will share with lawmakers how devastating it will be to employers.”

Gianforte said he supports continuing Medicaid expansion but would be willing to revise the program to increase safeguards against fraud. There hasn’t been evidence of widespread fraud in the state’s Medicaid expansion program.

“If we let people sign up for it who are not qualified, the benefits may not be there for the people who really need it,” he said. “So I am open to additional accountability components.”

Gianforte also is expected to be drawn into a legislative debate about changing or limiting the powers of county public health officials. Local conservative leaders and business owners complain that many health officials have overstepped their authority during the pandemic, while at least seven local health leaders have left their positions amid complaints about a lack of support by some county leaders and law enforcement officials in enforcing directives.

Republican Rep. David Bedey is proposing a measure that would require county commissioners to ratify any decisions made by a local public health officer or panel. He said his proposal isn’t meant to take power away from public health officials, but rather to shift the accountability of such decisions to elected officials.

“I do not wish to punish public health officials,” Bedey said. I think they need political cover to do their jobs.”

Bedey’s proposal is one of a handful of bill requests seeking changes in the powers of local health officials. Some health industry officials and lobbyists worry about any infringement on the ability to respond to a public health emergency.

“Local governments are best equipped to make decisions about the health of their communities,” said Amanda Cahill, the Montana government relations director for the American Heart Association and American Stroke Association. “Public health safeguards are more important than ever, and we hope that the ability of local decision-makers to take protective action remains intact.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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A year ago, while many Americans were finishing their holiday shopping and finalizing travel plans, doctors in Wuhan, China, were battling a mysterious outbreak of pneumonia with no known cause.

Chinese doctors began to fear they were witnessing the return of severe acute respiratory syndrome, or SARS, a coronavirus that emerged in China in late 2002 and spread to 8,000 people worldwide, killing almost 800.

The disease never gained a foothold in the U.S. and disappeared by 2004.

Although the disease hasn’t been seen in 16 years, SARS cast a long shadow that colored how many nations — and U.S. scientists — reacted to its far more dangerous cousin, the novel coronavirus that causes COVID-19.

When Chinese officials revealed that their pneumonia outbreak was caused by another new coronavirus, Asian countries hit hard by SARS knew what they had to do, said Dr. Amesh Adalja, a senior scholar at the Johns Hopkins Center for Health Security. Taiwan and South Korea had already learned the importance of a rapid response that included widespread testing, contact tracing and isolating infected people.

The U.S., by contrast, learned all the wrong lessons.

This country’s 20-year run of good luck with emerging pathogens —including not just SARS, but also the relatively mild H1N1 pandemic, Middle East respiratory syndrome, Ebola, Zika virus and two strains of bird flu — gave us a “false sense of security,” Adalja said.

KHN’s in-depth examination of the year-long pandemic shows that many leading infectious disease specialists underestimated the fast-moving outbreak in its first weeks and months, assuming that the United States would again emerge largely unscathed. American hubris prevented the country from reacting as quickly and effectively as Asian nations, Adalja said.

During the first two decades of this century, “there were a lot of fire alarms with no fire, so people tended to ignore this one,” said Lawrence Gostin, director of Georgetown’s O’Neill Institute for National and Global Health Law, who acknowledges he underestimated the virus in its first few weeks.

In a Jan. 24 story, Dr. William Schaffner told KHN the real danger to Americans was the common flu, which can kill up to 61,000 Americans a year.

“Coronavirus will be a blip on the horizon in comparison,” said Schaffner, a professor of preventive medicine and health policy at Vanderbilt University Medical Center. “The risk is trivial.”

The same day, The Washington Post published a column by Dr. Howard Markel, who questioned China’s lockdown of millions of people. “It’s possible that this coronavirus may not be highly contagious, and it may not be all that deadly,” wrote Markel, director of the Center for the History of Medicine at the University of Michigan.

JAMA, one of the most prestigious medical journals in the world, published a podcast Feb. 18 titled, “The 2020 Influenza Epidemic — More Serious Than Coronavirus in the US.” A week later, JAMA published a large infographic illustrating the dangers of flu and minimizing the risks from the novel virus.

Dr. Paul Offit, who led development of a rotavirus vaccine, predicted that the coronavirus, like most respiratory bugs, would fade in the summer.

“I can’t imagine, frankly, that it would cause even one-tenth of the damage that influenza causes every year in the United States,” Offit told Christiane Amanpour in a March 2 appearance on PBS.

President Donald Trump picked up on many of these remarks, predicting that the coronavirus would disappear by April and that it was no worse than the flu. Trump later said the country was “rounding the turn” on the pandemic, even as the number of deaths exploded to record levels.

Caitlin Rivers, an epidemiologist and assistant professor at the Johns Hopkins Bloomberg School of Public Health, worried — and tweeted — about the novel coronavirus from the beginning. But she said public health officials try to balance those fears with the reality that most small outbreaks in other countries typically don’t become global threats.

New sitrep out from Wuhan pneumonia outbreak. 59 cases between 12/12 and 12/29. SARS ruled out, but no other etiology identified. Still no evidence of H2H. https://t.co/b8ZdEGIzyJ

— Caitlin Rivers, PhD (@cmyeaton) January 5, 2020

“If you cry wolf too often, people will never pay attention,” said epidemiologist Mark Wilson, an emeritus professor at the University of Michigan School of Public Health.

Experts were hesitant to predict the novel coronavirus was the big pandemic they had long anticipated “for fear of seeming alarmist,” said Dr. Céline Gounder, an infectious disease specialist advising President-elect Joe Biden.

Many experts fell victim to wishful thinking or denial, said Dr. Nicole Lurie, who served as assistant secretary for preparedness and response during the Obama administration.

“It’s hard to think about the unthinkable,” Lurie said. “For people whose focus and fear was bioterrorism, they had a world view that Mother Nature could never be such a bad actor. If it wasn’t bioterrorism, then it couldn’t be so bad.”

Had more experts realized what was coming, the nation could have been far better prepared. The U.S. could have gotten a head start on manufacturing personal protective equipment, ventilators and other supplies, said Dr. Nicholas Christakis, author of “Apollo’s Arrow: The Profound and Enduring Impact of Coronavirus on the Way We Live.”

“Why did we waste two months that the Chinese essentially bought for us?” Christakis asked. “We could have gotten billions of dollars into testing. We could have had better public messaging that we were about to be invaded. … But we were not prepared.”

Dr. Fauci Doesn’t Cast Blame

Dr. Anthony Fauci, the nation’s top infectious disease official, isn’t so critical. In an interview, he said there was no way for scientists to predict how dangerous the coronavirus would become, given the limited information available in January.

“I wouldn’t criticize people who said there’s a pretty good chance that it’s going to turn out to be like SARS or MERS,” said Fauci, director of the National Institute of Allergy and Infectious Diseases, noting this was “a reasonable assumption.”

Fauci noted that solutions are always clearer in hindsight, adding that public health authorities lose credibility if they respond to every new germ as if it’s a national disaster. He has repeatedly said scientists need to be humble enough to recognize how little we still don’t know about this new threat.

“It’s so easy to go back with the retrospect-o-scope and say ‘You coulda, shoulda, woulda,’” Fauci said. “You can say we should have shut things down much earlier because of silent spread in the community. But what would the average man or woman on the street have done if we said, ‘You’ve got to close down the country because of three or four cases?’”

Scientists largely have been willing to admit their errors and update their assessments when new data becomes available.

“If you’re going to be wrong, be wrong in front of millions of people,” Offit joked about his PBS interview. “Make a complete ass of yourself.”

Scientists say their response to the novel coronavirus would have been more aggressive if people had realized how easily it spreads, even before infected people develop symptoms — and that many people remain asymptomatic. “For a virus to have pandemic potential, that is one of the greatest assets it can have,” Adalja said.

Although COVID-19 has a lower death rate than SARS and MERS, its ability to spread silently throughout a community makes it more dangerous, said Dr. Kathleen Neuzil, director of the Center for Vaccine Development at the University of Maryland School of Medicine.

People infected with SARS and MERS are contagious only after they begin coughing and experiencing other symptoms; patients without symptoms don’t spread either disease.

With SARS and MERS, “when people got sick, they got sick pretty badly and went right to the hospital and weren’t walking around transmitting it,” Christakis said.

Because it’s possible to quarantine people with SARS and MERS before they begin spreading the virus, “it was easier to put a moat around them,” said Offit.

Based on their knowledge of SARS and MERS, doctors believed they could contain the novel coronavirus by telling sick people to stay home. In the first few months of the pandemic, there appeared to be no need for healthy people to wear masks. That led health officials, including U.S. Surgeon General Jerome Adams, to admonish Americans not to buy up limited supplies of face masks, which were desperately needed by hospitals.

Seriously people- STOP BUYING MASKS! They are NOT effective in preventing general public from catching #Coronavirus, but if healthcare providers can’t get them to care for sick patients, it puts them and our communities at risk! https://t.co/UxZRwxxKL9

— U.S. Surgeon General (@Surgeon_General) February 29, 2020

“We are always fighting the last epidemic,” Markel said. “Our experiences with coronaviruses was that they kind of burn themselves out in warm weather and they didn’t have the capacity to spread as viciously as this one has.”

Many scientists were skeptical of early anecdotes of pre-symptomatic spread.

“It takes a lot to overturn established dogma,” Wilson said. “Jumping on an initial finding, without corroborating it, can be just as bad as missing a new finding.”

As evidence of pre-symptomatic spread accumulated, the Centers for Disease Control and Prevention in April changed its advice and urged Americans to mask up in public.

Adalja notes that the CDC’s earlier advice against wearing masks was based on research that found them to be ineffective against spreading influenza. New research, however, has shown masks reduce the transmission of the novel coronavirus, which spreads mainly through respiratory droplets but can travel in the air as tiny particles.

Adalja said the U.S. should have learned from its early stumbles. Yet in spite of abundant evidence, many communities still resist mandating masks or physical distancing.

“I continue to be baffled that we keep making the same mistakes,” Adalja said. “It’s almost like we’re doomed to repeat this cycle endlessly.”

Some Saw It Coming

There were scientists and journalists who immediately recognized the threat from the novel coronavirus.

“We had to immediately react as if this were going to hit every corner of the Earth,” said Adalja, who began blogging about the novel virus Jan. 20. It was clear “this was not a containable virus.”

Adalja led a 2018 project identifying the features that allow emerging viruses to become pandemic. In that prescient report, Adalja and his co-authors highlighted the threat of certain respiratory viruses that use RNA as their genetic material.

The more Adalja learned about the novel coronavirus, the more it seemed to embody the very type of threat he had warned about: one with “efficient human-to-human transmissibility, an appreciable case fatality rate, the absence of an effective or widely available medical countermeasure, an immunologically naïve population, virulence factors enabling immune system evasion, and respiratory mode of spread.”

Although the CDC set the wheels of its response in motion early, establishing an incident management structure on Jan. 7, the agency’s early missteps with testing are well known. The outbreak escalated rapidly, leading the World Health Organization to declare a health emergency on Jan. 30 and the U.S. to announce a public health emergency the next day.

Adalja and other experts dismissed some of the Trump administration’s early responses, such as quarantines and a travel ban on China, as “window dressing” that “squandered resources” and did little to contain the virus.

“There was political inertia about the public health actions that could have avoided lockdowns,” Adalja said. “We let this spill into hospitals … [and] if you give a virus a three-month head start, what do you expect?”

In a Jan. 7 post on a website of the Infectious Diseases Society of America, Dr. Daniel Lucey labeled the pneumonia “Disease X,” using the WHO’s term for an emerging pathogen capable of causing a devastating epidemic, for which there are no tests, treatments or vaccines.

Lucey, adjunct professor of infectious diseases at Georgetown University Medical Center, notes that the international response was hampered by misinformation from Chinese officials. “The Chinese government said there was no person-to-person spread,” said Lucey, who traveled to China hoping to visit Wuhan. “That was a lie.”

When China revealed on Jan. 20 that 14 health workers had been infected, Lucey knew the virus would spread much farther. “To me, that was like Pandora’s box,” Lucey said. “I knew there would be more.”

When the number of infected health workers grew to 1,716 on Feb. 14, Lucey said, “I almost threw up.”

Although his blog is read by thousands of infectious disease specialists, Lucey emailed a special warning to journalists and a dozen doctors and public health officials, hoping to alert influential leaders.

“I put this heartfelt commentary in my email and just got silence,” Lucey said.

Succeeding With Vaccines

At the National Institute of Allergy and Infectious Diseases, scientists had studied the protein structure of coronaviruses for years.

Researchers had developed a vaccine against SARS, Fauci said, although the epidemic ended before researchers could widely test it in humans.

“We showed it was safe and induced an immune response,” Fauci said. “The cases of SARS disappeared, so we couldn’t test it. … We put the vaccine in cold storage. If SARS comes back, we will do a phase 3 [clinical] trial.”

Dr. Barney Graham, deputy director of the Vaccine Research Center, asked Chinese scientists to share the coronavirus’s genetic information. After the genome was published, Graham went immediately to work.

“We jumped all over it,” Fauci said. “We had a meeting on Jan. 10 and five days later they started [working on] a vaccine.”

Although scientists knew the COVID outbreak might end before a vaccine was needed, “we couldn’t take the chance,” Fauci said.

“We said, ‘We have no idea what is going to happen, so why don’t we just go ahead and proceed with a vaccine anyway?’”

Although his team worried about finding the money to pay for it all, Fauci told them, “‘Don’t worry about the money. I’ll find it, you do it, if we really need it, I’m sure we’ll get it.’”

Health experts hope the U.S. will learn from its mistakes and be better prepared for the next threat.

Given how many novel viruses have emerged in the past two decades, it’s likely that “pandemics are going to become more frequent,” Gounder said, making it critical to be ready for the next one.

Of all the lessons learned during the pandemic, the most important is that “we can’t be this unprepared again,” said Dr. Tom Frieden, who directed the CDC during the Obama administration.

“To me, this should be the most teachable moment of our lifetime, in terms of the need to strengthen public health in the United States and globally,” Frieden said.

But Gounder notes that U.S. public health funding tends to follow a cycle of crisis and neglect. The U.S. increased spending on public health and emergency preparedness after the 9/11 and anthrax attacks in 2001, but that funding has declined sharply over the years.

“We tend to invest a lot in that moment of crisis,” Gounder said. “When the crisis fades, we cut the budget. That leads us to be really vulnerable.”

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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In March, during the first week of the San Francisco Bay Area’s first-in-the-nation stay-at-home order, California Healthline spoke with emergency department physicians working on the front lines of the burgeoning COVID-19 pandemic. At the time, these doctors reported dire shortages of personal protective equipment and testing supplies. Health officials had no idea how widespread the virus was, and some experts warned hospitals would be overwhelmed by critically ill patients.

In the end, due to both the early sweeping shutdown order and a state-sponsored effort to bolster the supply chain, Bay Area hospitals were able to avert that catastrophe. The region so far has fared much better than most other U.S. metro regions when it comes to rates of COVID infection and death. Even so, with intensive care unit capacity dwindling to critical levels statewide, San Francisco on Thursday issued another drastic order, announcing a mandatory 10-day quarantine for anyone returning to the city who has spent time outside the region.

Amid this fierce second surge, we circled back last week to check in with Dr. Jeanne Noble, director of the COVID response at the University of California-San Francisco medical center emergency department, to get her reflections on the Bay Area’s experience. She explained how even as her hospital has made so many improvements, including recently launching universal testing so that everyone who comes to the emergency room is tested for COVID-19, the lockdown and burnout are wearing on her and her colleagues. The conversation has been edited for length.

Q: How are you doing at UCSF right now? 

We’re OK in terms of our numbers. We have our ICU capacity; today’s numbers are 74% occupied. Acute care is a little bit tighter; the emergency department is seeing an increase in patients. [Editor’s note: As of Sunday, ICU capacity had dropped to 13%.]

We did have a period of time before this last surge where we often had a few days with no COVID patients. That was great. That ended in late September. This morning we have 11 patients on ventilators in the ICU.

I think we’re the first hospital in the state for universal testing. Everyone who comes to the ER gets tested. I’ve been working on this for months, but it’s new this week. Now we have testing, so we don’t have to do so much guesswork.

Q: When we spoke during the week of the first stay-at-home order, back in March, you were very worried. How do things compare now?

The supply [of masks] is just much better than it was back in March. In March, we had furloughed engineers from our local museum, the Exploratorium, making us face shields, and we started a makers lab in the library across the street to make supplies. It doesn’t feel like that this time around. We have a longer horizon.

I think in terms of our COVID care and our hospital capacity, we are fine. But my own sort of perspective on all of this is: When are we going to be done with this? Because even though things are smoother — we have PPE, we have testing — it’s a tremendous amount of work and stress. Frankly, the fact that my children have not been in school since March is one of my major sources of stress.

We’re all working way more than we ever have before. And nine months into it, the adrenaline is gone and it’s just purely exhausting.

Q: Can you tell me more about that, the physical and emotional toll on the hospital staff?

We don’t allow eating in the ED anymore, so we don’t have break rooms. Especially if you’re the supervising doctor, you need to do this elaborate handoff to another doctor if you need to eat. You know, it’s 10 hours into your shift and you want a cup of coffee.

The hassles and the discomforts. Wearing an N95 day after day is really uncomfortable. A lot of us have ulcers on our noses. They become painful.

And the lack of being able to socialize with colleagues is hard. The ED has always been a pretty intense environment. That’s offset by this closeness and being a team. All of this emotional intensity, treating people day after day at these incredible junctures in their lives — a lot of the camaraderie and morale comes from being able to debrief together. When you’re not supposed to be closer than a few feet from one another and you don’t take off your masks, it’s a lot of strain.

People are much less worried about coming home to their families. It hasn’t been the fomite disease we were all worried about initially, worried we’d give our kids COVID from our shoes. But there’s still the concern. Every time you get a runny nose or a sore throat you need to get tested, and you worry about what if you infected your family.

Q: So will you and your colleagues be able to take a break over the holidays?

We’ll see what happens. We’re just now starting to feel like we’re seeing the post-Thanksgiving numbers. But I think that even without having to do extra shifts in the ED, certainly for someone like me doing COVID response, there’s always a huge number of issues to work through. We just got the monoclonal antibodies, which is great, but that’s a whole new workflow.

I think what is going to bother people the most is that we are in lockdown. Kind of longing for that relaxation and time with family that we’re all kind of craving.

Q: It sounds like things are hard, but the hospital is in a relatively good place.

I was deployed to the Navajo Nation and helped with their surge in May in Gallup, New Mexico, and that is much, much harder than what we’ve faced in the Bay Area. In Gallup, at Indian Health Service, they were incredible in just the can-do attitude with way fewer resources than we have here. As of this summer, they had had the worst per capita surge in the country. They redesigned their ED essentially by cutting every room in half, hanging plastic on hooks you would use to hang your bicycle wheel. They hung thick plastic and right there doubled their capacity of patients they could see.

Our tents at UCSF are these blue medical tents with HVAC systems, heaters, negative pressure. They are really nice. There they had what looked like beach cabanas — open walls with just a tent overhead. In March and April they were taking care of patients in the snow. In the summer, it was hot and windy. When I was there, almost every single one of my patients had COVID.

That level of intensity was not something we had to go through in the Bay Area. Not to say that it’s easy [here]; I just told you all the ways it’s hard. But everything is relative. In terms of the COVID landscape, we have been very lucky.

Q: The Bay Area was early to close and has had stricter regulations than many parts of the country. As someone directly affected, what do you think of the response?

I think that we have benefited from early closures, unquestionably, when we did our shelter-in-place in March and probably saved 80,000 lives. It was really a tremendous and a bold move.

We’ve done some things well and other things not so well. We were very late to implement closures in a targeted fashion. Restaurants and dining reopened this summer, and a lot of us couldn’t figure out why indoor dining was open. Why is indoor dining something we need to even be considering when we’ve just barely flattened our curve? It was very predictable that cases would go up when dining happened. And they did.

We need to evaluate what is more important for our society and well-being, and to say what is the risk associated with that activity. Schools are of high social value. And [the closures are] really hard for kids. We’re seeing a lot of adolescents with suicidal ideation brought to the emergency department, which is related to school closure. I would put dining and restaurants as being of minimal social importance and very high risk.

We could have done this better. Closing [down society] when numbers go up is reasonable and that saves lives. But I think we know enough that it should not be an across-the-board closing. I mean, with this latest order, they temporarily closed parks. And we’ve been telling people to go outside. It’s like, what? Are you kidding?

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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TELLURIDE, Colo. — The day after Thanksgiving, Dr. Jana Eller and Dr. Shiraz Naqvi were seated beside an outdoor fire pit at the base of Telluride Ski Resort, taking a short break from skiing.

The two physicians from Houston had driven more than 18 hours to get here for the holiday weekend, and they were staying (and preparing meals) in a rented home. They traveled with another couple and their kids, colleagues they’ve been “bubbling” with in Houston.

“We got a COVID test prior to leaving and will get another when we return,” Naqvi said.

The skiing itself doesn’t feel much different during the pandemic, Eller said, but “the après ski scene is just gone.”

In March, at the beginning of the pandemic, Colorado Gov. Jared Polis issued an executive order requiring the state’s ski resorts to close in response to COVID-19, which had hit the state’s ski towns early and hard. Now, as the resorts enter their busy season, the state has taken pains to avoid blanket closures even though cases of COVID-19 are reaching their highest levels yet.

How to stay open amid the pandemic is an issue resorts across the U.S. are facing. Mandatory face coverings have become the norm, but other COVID mitigation efforts vary by site. Vermont resorts ask skiers to certify their compliance with rules governing interstate travel during the pandemic when buying a lift ticket, and in Colorado’s Pitkin County (home to Aspen), visitors will be required to confirm they’ve had a negative COVID test result within 72 hours of travel or pledge to quarantine for 14 days after arrival or until they obtain a negative test result.

Telluride is an internationally renowned destination trying to operate safely while protecting the 8,000 or so permanent residents in the area. Located in a remote southwestern part of Colorado, its economy depends on tourism, and the resort posts as many as 6,500 visitors on its busiest days.

On Nov. 25, with its COVID case numbers skyrocketing and its positivity rate hitting 4.6%, San Miguel County, which includes Telluride, closed its bars and restricted its restaurants to takeout and outdoor dining only. Signs posted throughout the resort remind visitors of the “five commitments of containment” — wear a mask, maintain 6 feet of physical distance, minimize group size, wash hands frequently and, when you feel sick, stay home and get tested.

How bad would things have to get to close the resort? That’s hard to gauge, said Grace Franklin, public health director for the county. People are going to do what they will regardless, she said.

“If we shut down the ski resort, how many people will take to the backcountry and get injured or trigger avalanches where the impact is greater? It’s a ‘damned if you do, damned if you don’t’ situation,” Franklin said.

Instead, Franklin said, the question becomes “How do we create safer, engineered events so people have an outlet, but we minimize as much risk as possible?”

Skiing itself poses relatively little risk, said Kate Langwig, an epidemiologist at Virginia Tech. “You’re outside with a lot of airflow, you’ve got something strapped to your feet so you’re not in super close contact with other people, and most of the time you’re riding the lift with people in your group.”

Gathering in the lodge or bar is by far the biggest COVID risk associated with skiing, said Langwig, who grew up skiing in northern New York. “In my family, one of the things you do after a day of skiing is connect with friends and have a beer in the lodge,” and it’s this social aspect of skiing that’s too risky right now, she said.

In an effort to discourage tourists and residents from congregating, local governments, medical facilities and the ski resort released a co-signed letter in November urging people to cancel any plans to gather with those outside their immediate household and celebrate the holidays solely with people from their own household. Keeping the resort open will require everybody to do their part, said Lindsey Mills, COVID public information consultant for San Miguel County.

“We are not telling anybody not to come, at least not yet,” said Todd Brown, Telluride’s mayor pro tem. But local officials are broadcasting a strong message to everyone in the area — “Chill out. Don’t have the big party with five families.”

Officials aren’t worried only about coronavirus transmission; they’re also concerned about overtaxing their medical facilities. San Miguel County has an urgent care center but no hospital, and its medical center experienced a 22% staffing shortage at the end of November, mostly because so many employees are in quarantine. Hospitals in nearby Mesa County reached their ICU capacity last month, and other hospitals in the region are also pinched.

“We can’t have a situation where people break their legs on the slopes and we can’t get them care,” said Franklin.

The resort has taken steps to facilitate physical distancing among visitors. Reservations aren’t required at Telluride, but lift tickets must be purchased in advance, and the resort can restrict ticket sales if necessary, said Jeff Proteau, vice president of operations and planning at the Telluride Ski Resort. Gondolas are operating with the windows open and each load is restricted to members of the same household.

To reduce contact in and around the lifts, workers have created “ghost lines” of empty space to ensure a 6-foot distance between groups while they wait in lift lines. People from the same household can stand in line together and ride the two- to four-person lifts next to one another, Proteau said, but when riding a lift with someone from another household, guests are asked to leave a vacant seat between them.

Langwig was a children’s ski instructor for many years and worries about ski school. “You interact pretty closely with the kids,” she said, noting that runny noses are common. “You spend a lot of time getting kids bundled up and to and from the bathroom.” This could be especially challenging if indoor spaces are closed, she said. “Hot chocolate breaks are one of the ways you get kids through the day, and that’s not safe anymore.”

In anticipation of visitors needing to take breaks to warm up, the resort has installed six temporary structures around the mountain with insulated ceilings and heated panels. When the sides are rolled up, they’re considered outdoor spaces, Proteau said, but they can be closed into confined spaces with limited occupancy as needed, especially on a blustery day.

The risk for most employees on the mountain should be relatively minimal, Langwig said, at least at work. “Lift attendants are outside wearing thick gloves and a mask most of the time. Compared to someone who works in a restaurant, their risk is pretty low.”

Employees are generally assigned to work in small groups that can be quarantined, if necessary, without wiping out a whole department, Proteau said. There’s also contact tracing in place for resort employees.

Arizona native Joey Rague moved to Telluride last year and works as a ski valet on the mountain. He said there’s a huge incentive among employees to keep the resort open. With affordable housing sparse in Telluride, “all of us are struggling seasonally to be able to pay rent.”

So far, he said, most visitors have been respectful and conscientious of the rules.

“It seems as though people understand that if we want to stay open, we have to come together,” he said.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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