Abstract
The rapid development of COVID-19 vaccines is a tremendous scientific response to the current global pandemic. However, vaccines per se do not save lives and restart economies. Their success depends on the number of people getting vaccinated. We used a survey experiment to examine the impact on vaccine intentions of a variety of public health messages identified as particularly promising: three messages that emphasize different benefits from the vaccines (personal health, the health of others, and the recovery of local and national economies) and one message that emphasizes vaccine safety. Because people will likely be exposed to multiple messages in the real world, we also examined the effect of these messages in combination. Based on a nationally quota representative sample of 3,048 adults in the United States, our findings suggest that several forms of public messages can increase vaccine intentions, but messaging that emphasizes personal health benefits had the largest impact.
The COVID-19 pandemic remains a global threat to lives, livelihoods, and lifestyles. Related deaths worldwide exceeded 2.6 million 12 mo after the World Health Organization declared the outbreak a global pandemic, and the economic costs in the United States alone are estimated at $16 trillion when accounting for health costs and lost gross domestic product (1). The rapid development of effective vaccines and their widespread distribution can greatly curtail the threat, but the potential for saving lives and livelihoods depends on how many people get vaccinated. Recent surveys suggest that 60 to 70% of United States adults intend to get a COVID-19 vaccine, which falls short of the threshold identified by public health experts for herd immunity (2, 3).
Vaccine hesitancy, however, may be malleable, enabling public information campaigns to reduce hesitancy. Studies show nearly half of hesitant people indicate they will reconsider after more information is available (2). Research preceding the COVID-19 pandemic offer mixed results about the effectiveness of information on vaccinations in general (46), but recent studies suggest that public health messaging may increase COVID-19 vaccinations. Messages about vaccine safety (7, 8), benefits to self (9) and others (810), as well as vaccines allowing life to return to normal (8) have been found to increase intended or actual vaccinations for the studied population as a whole or for subgroups.
However, it is unclear what messages have the greatest effect on vaccinations, and whether it is important to emphasize one message or if combinations of multiple messages aimed to encourage vaccinations may be more or less effective. We examined what message, or combination of messages, generated the largest effect on COVID-19 vaccine intentions. The COVID-19 vaccine presents a novel context to study hesitancy because of the speed of the vaccine development and political polarization related to the pandemic and the vaccine. We focused on messages that appeal to motivations to take or abstain from taking vaccines (e.g., rather than to psychological effects) (11), and identified messages with particularly high potential to increase COVID-19 vaccinations, based on literature that examines messages aimed to boost childhood vaccines (12) and other COVID-19 preventive behavior (13), as well as worries that deter COVID-19 preventive behavior (14, 15).
We compared three messages that described the benefits from taking the vaccinebenefits from vaccination to personal health; benefits to the health of family, friends, and community members; and benefits to local and national economiesand a fourth message that emphasized the rigor and safety protocols of the vaccine development process. Henceforth we refer to these treatments as private benefit, social benefit, economic benefit, and vaccine safety messages. We designed a survey experiment (a quota representative sample of the United States population with n = 3,048) to examine the effect on vaccine intentions from the four information treatments alone and in combinations. Participants were randomly assigned to one of nine information treatments (Table 1) and then asked about their willingness to take a vaccine.
Description of information treatments and number of participants in each treatment
Fig. 1 shows the proportion of participants who intend to get vaccinated across treatment groups. In the control group, 49% of participants were willing to take a COVID-19 vaccine, which falls within the range of similar studies around the same time period (16). The group exposed to the private benefit message had the highest intended vaccination rate (65% vs. 49% for the control group; adjusted P < 0.001). Intentions to vaccinate among participants exposed to messages that emphasized social benefits and economic benefits were 9 percentage points higher than in the control group (adjusted P = 0.063 and 0.062, respectively). According to our results, a message that highlights private health benefits is the most effective at increasing vaccine intentions. Previous research also indicates that a private benefits message may be at least as effective as a prosocial message in boosting COVID-19 vaccinations (9). Vaccine uptake may therefore respond differently to information, compared to other behaviors that protect against COVID-19. Intentions to maintain physical distance and wear masks seem more affected by prosocial messages than by messages that emphasize personal benefits (17, 18).
Share who intends to get a COVID-19 vaccine across a control treatment, a vaccine safety information treatment, and different types of benefit information treatments.
Even though safety concerns are a primary reason for COVID-19 vaccine hesitancy (14), intentions to vaccinate were only slightly higher in the group exposed to the vaccine safety message than in the control group (53% vs. 49%; adjusted P = 0.250). Combinations of private and social benefit messages, social and economic benefit messages, and economic and private benefit messages all increased the proportion who would vaccinate by about 9 percentage points relative to the control group (adjusted P = 0.057, 0.048, and 0.068, respectively).
Intentions to vaccinate in the treatment group that received all three types of benefit messages was second highest among all groups (61%), representing a 12-percentage point increase, or 24% increase, relative to the control group (adjusted P = 0.010). Compared to the treatment that presented private benefits alone, intended vaccination rates were lower in the treatments with combined messages, although differences are not statistically significant. This suggests there are no benefits to communicating several different types of benefits (potentially due to information overload) (19).
In an exploratory analysis (not preregistered), we found some evidence of modest heterogeneity in the response of vaccine intentions to different types of information, especially across annual individual income. Low income (less than $25,000) earners responded the most to the combined social, private, and economic benefit messages; medium income ($25,000 to $99,999) earners to the private benefit message only; high income ($100,000 and above) earners to the combined social and private benefit message. If we target each income group with their most effective type of information, the overall intended vaccination rate increases by 20 percentage points, compared to 16 percentage points with the uniform private benefit message, or 12 percentage points with the combination of all benefit messages. Targeted information campaigns have been used in other health contexts with some success (20), but it is unclear whether the estimated 4- to 8-percentage point increase in vaccination rates would justify the costs of targeting the messages, especially considering the likelihood of imperfect targeting in the field.
Marginal effects from a probit model indicate that women are 8 percentage points less likely to want a vaccine, and those with low (high) trust in government agencies are 14 percentage points less (6 percentage points more) likely to want a vaccine, compared to those with medium trust. Participants who had a flu vaccine in the last 2 y are 14 percentage points more likely to want a COVID-19 vaccine, and those confident in vaccines are 24 percentage points more likely, compared to those who lack such confidence. All effects are highly statistically significant (P < 0.001). Survey responses imply that of those who do not want the vaccine, 90% worry about the vaccines side effects and novelty, and 75% lack trust in vaccine developers and the Food and Drug Administration to truthfully disclose a vaccines efficacy and risks. Our vaccine safety message did little to overcome a lack of confidence in the vaccine.
Vaccine intentions seem responsive to information messages, which suggests that public information campaigns may boost COVID-19 vaccinations in the United States. Consistent with studies about flu and MMR vaccines (12, 21), we found the most effective message communicates private health benefits of vaccinating, which increased intended vaccinations by 16 percentage points, one-third larger than the rate of intended vaccinations in the control group. The strong response to the private benefit message may partly reflect the political polarization of vaccine hesitancy in the United States. Conservatives are more hesitant and have particularly individualistic worldview (16, 22). They might, therefore, be particularly responsive to information that stresses private benefits. Our data offer some support for this idea: the effect of the private benefit message on vaccine intentions is larger for conservatives than for moderates or liberals.
Three limitations of our study should be noted. First, we considered one-shot information treatments, which may understate the potential impact from an ongoing information campaign. Second, while we purposefully focused on messages that appeal to different motivations, messages that appeal to psychological effects (e.g., the endowment effect) also have been found to increase COVID-19 vaccinations (11). Third, we examined intentions to get vaccinated, rather than actual behavior, because the timing of the survey preceded widespread availability of COVID-19 vaccines. It has been found that vaccine intentions and actual behavior are highly correlated (23), but an intentionbehavior gap has been documented in the context of flu vaccines and other health behaviors (4).
The source of information also likely matters, and trusted sources may vary across subgroups. For example, messages promoting social distancing are more effective coming from a family physician than from a governor or private citizen (24). Also, those who obtain most of their COVID-19 vaccine information from social media are the most vaccine hesitant (25), which suggests social media may be an effective information channel to target those who could most benefit from information about the vaccines. Future research may explore the effectiveness of different information channels for promoting COVID-19 vaccines.
After informed consent, study participants were exposed to one of nine information message treatments and then asked if they would take a hypothetical COVID-19 vaccine that was 85% effective in preventing symptomatic COVID-19 and had a 15% chance of causing mild side effects. See SI Appendix for a full description of the survey experiment. The study was approved by the Institutional Review Board at the University of Wyoming and preregistered in the American Economic Associations registry for randomized controlled trials (AEARCTR-0006885). Participants were recruited by Qualtrics, with the requirement of being quota representative of the general United States population with respect to gender, age, regional residency, income, and education. Data were collected mid-December 2020 to mid-January 2021. We found no meaningful pairwise differences in normalized means of covariates across treatment groups, suggesting our randomization worked (26). To control the rate of type 1 errors when testing multiple hypotheses, we corrected for multiple comparisons using a bootstrap procedure (27). When presenting results, we show adjusted P values from Pearson 2 tests. We have deposited data and code in openICPSR https://www.openicpsr.org/openicpsr/project/139461/version/V8/view (28).
This project was funded by the Wyoming Health and Bioscience Innovation Hub COVID Grant-1044 (Project nr: CARES-HUB3).
Author contributions: M.A., L.T., T.L.C., S.C.N., and D.C.F. designed research; M.A. performed research; M.A. contributed new reagents/analytic tools; M.A. analyzed data; and M.A., L.T., T.L.C., S.C.N., and D.C.F. wrote the paper.
The authors declare no competing interest.
This article contains supporting information online at https://www.pnas.org/lookup/suppl/doi:10.1073/pnas.2108225118/-/DCSupplemental.
In most cases, they found, the chain of transmission stopped with the infected child, but in 27.3 percent of households, children passed the virus along to at least one other resident.
Aug. 16, 2021, 1:10 p.m. ET
Adolescents were most likely to bring the virus into the home: Children from 14 to 17 made up 38 percent of all the index cases. Children who were 3 or younger were the first to get sick in just 12 percent of households but they were the most likely to spread the virus to others in their homes. The odds of household transmission were roughly 40 percent higher when the infected child was 3 or younger than when they were between 14 and 17.
The findings may be the result of behavioral differences between toddlers and teenagers, medical experts said.
When we think about whats teen social behavior outside of the house, theyre spending a lot of time together, theyre often in quite close quarters, theyre often touching or sharing a drink, said Dr. Susan E. Coffin, an infectious disease specialist at Childrens Hospital of Philadelphia, who was not involved in the study.
Those behaviors could make teens more likely to contract the virus and bring it home, she said.
On the other hand, while very young children probably have less social interaction outside the home, they tend to be in close physical contact with others in their households, in addition to frequently putting their hands and other objects in their mouths, which could help spread the virus. Once they bring it into the household, it can be spread easily, Dr. Coffin said.
It is also possible that the youngest children may carry higher levels of virus, or have higher rates of viral shedding, than teenagers, the researchers noted. Some studies have found that even though young children rarely get seriously ill, they may carry similar, or even higher, levels of virus than adults do. Although viral load is not a perfect predictor of infectiousness, the data suggest that children could potentially be as contagious as adults.
But the dynamics of disease transmission are complicated, and the precise role that children play in spreading the virus remains uncertain.
Health officials on Monday reported a spike of 2,996 coronavirus cases over the weekend, as infections continue to surge at a troubling pace amid the more highly contagious delta variant.
Every Massachusetts county is now at high risk or substantial risk for COVID transmission, according to the CDC tracker, but Gov. Charlie Baker on Monday said he would not be implementing an indoor mask mandate amid spiking cases. Many communities, instead of waiting for Baker, have ordered mask mandates for everyone regardless of their vaccination status.
After the new 2,996 COVID infections reported over the weekend, the Bay States seven-day average of virus cases is now 911. Thats more than 14 times the daily average of 64 cases in June.
The average percent positivity is now at 2.74%, which is nearly nine times the daily average of 0.31% in June.
State health officials on Monday also reported six new COVID deaths from over the weekend, bringing the states total recorded death toll to 18,148.
Virus deaths have been higher in the last week after several weeks of rising cases and hospitalizations. The seven-day average of COVID deaths is now 5.7, up from the record-low daily average of 1.1 in mid July.
Hospitalizations continued to increase over the weekend. The state reported a jump of 27 COVID patients, bringing the statewide total of COVID patients to 402.
There are now 82 patients in intensive care units, and 38 patients are intubated.
The overall count of 402 patients is more than five times the count of 80 COVID patients on July 4. The 402 patients is back to where the state was in mid May.
More than 4.4 million people in Massachusetts have been fully vaccinated.
Every county in Illinois except one is seeing "substantial" or "high" community transmission of COVID-19, placing nearly the entire state in the category in which everyone over the age of 2 should resume wearing a mask indoors, regardless of vaccination status, federal health officials say.
The Centers for Disease Control and Prevention updated its guidance late last month to recommend that fully vaccinated people wear masks in indoor settings again in areas of the U.S. that are seeing "substantial" or "high" transmission of COVID-19.
The new guidance marked a reversal from earlier recommendations that said fully vaccinated people could remove masks in most settings.
So in which areas is the CDC advising people wear masks indoors? The agency points to its COVID-19 data tracker showing levels of community transmission, along with other data, for each county in the U.S.
As of Saturday, 101 of Illinois 102 counties were experiencing either substantial or high levels of community transmission, triggering the recommendation to mask indoors, regardless of vaccination status.
The only county still in the "moderate" transmission level is Stark County, with 98 counties - including every county in the Chicago area - seeing "high" transmission and just three in the "substantial" transmission range: Putnam, Lee and Whiteside counties, all west of the Chicago area.
The agency uses two measuresto group U.S. counties into the four levels of community transmission: the number of new cases per 100,000 residents and the percent of COVID-19 tests that are positive over the past week.
If a county has reported 50 to 100 cases per 100,000 residents over a seven-day period or has a positivity rate of 8% to 10%, it falls into the "substantial transmission" tier, while those reporting 100 cases or more per 100,000 or have a positivity rate of at least 10% are labeled as "high transmission." Those are the two groups for which the CDC recommends mask-wearing.
The CDC also said last week that fully vaccinated people also "might choose to mask regardless of the level of transmission, particularly if they or someone in their household is immunocompromised or atincreased risk for severe disease, or if someone in their household is unvaccinated."
The Illinois Department of Public Health said last month that it was "fully adopting" the CDC's updated guidance and following federal health officials' lead in recommending masking indoors at K-12 schools universally among teachers, staff, students and visitors to schools, regardless of vaccination status.
Then on Aug. 4, Gov. J.B. Pritzker announced a new mask mandate, requiring - rather than recommending - that all students, teachers and staff in K-12 schools wear masks while indoors as officials take steps to try to slow the spread of the more transmissible delta variant.
Pritzker said that the new requirement would take effect immediately, and will also apply to all students and coaches participating in indoor sports and other activities.
"As your governor, it's my duty to say that we must all take immediate and urgent action to slow the spread of the delta variant," he said. "People are dying who don't have to die."
Pritzker added that the state has a "limited amount of time" to slow the spread of the delta variant.
State employees who work in congregant care facilities, veterans' homes and correctional facilities will also be required to receive COVID-19 vaccinations, according to the governor.
BANGKOK, Aug 16 (Reuters) - Thai police used water cannon and tear gas to disperse protesters near the office of Prime Minister Prayuth Chan-ocha on Monday, as opposition parties moved to censure him in parliament over his handling of a COVID-19 crisis.
Hundreds of protesters marched on the Government House to demand Prayuth resigns, the latest show of growing public anger about a worsening epidemic and a chaotic vaccine rollout.
The rallies are being led by groups who also sought former army chief Prayuth's ouster last year, accusing him and his allies of seeking to entrench the military's control of politics.
"We are out here to stop the ongoing failure and stop the losses, because if Prayuth Chan-ocha remains in power, more people will die," activist Songpon "Yajai" Sonthirak said during the march.
People stand among tear gas during a protest over the government's handling of the coronavirus disease (COVID-19) pandemic, in Bangkok, Thailand, August 16, 2021. REUTERS/Soe Zeya Tun
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Opposition lawmakers on Monday filed a no-confidence motion against Prayuth and five of his cabinet ministers, which will lead to a censure debate over the COVID-19 crisis, likely later his month or early September, according to house speaker.
Police fired tear gas cannisters and used water cannon when protesters tried to dismantle a police barricade on Monday, the latest as in a series of recent demonstrations that led to violence, including the use of rubber bullets to disperse protests.
Clashes also took place late on Monday near Prayuth's residence in another part of the capital.
"Bangkok has declared an emergency and a gathering or activity involving more than five people is not possible, it's illegal," said Piya Tavichai, deputy head of the Bangkok police.
Reporting by Panu Wongcha-um and Panarat Thepgumpanat; Editing by Martin Petty
Our Standards: The Thomson Reuters Trust Principles.
CNN
Its no surprise that a politicians worst enemy is a vibrant news media. Journalists who stick their noses into the affairs of the powerful and expose their failures are a threat. Its therefore no great shock that even many leaders of democratic countries are happier when the press is weakened.
The Covid-19 pandemic has presented a golden window to undermine confidence in the media and, in some cases, for world leaders to launch outright assaults on some of the most respected and important journalistic institutions in their countries.
Earlier this week, the Polish parliament passed a bill that could mean curtains for the countrys largest independent news channel. TVN24, a broadcaster that is frequently critical of the Polish governing party, is in part owned by the American media group Discovery. Should this new bill become law, non-EU entities will be prohibited from being majority shareholders in Polish media companies, meaning Discovery would have to sell its majority stake.
Also this week, Austrian Chancellor Sebastian Kurz put forward his plan that would effectively pull funding from the countrys oldest newspaper.
Wiener Zeitung is a state-owned newspaper and is funded by a model that requires the government to advertise jobs and make other formal announcements in its pages. Yet the paper has an independent editorial policy and has often criticized Kurz and his administration. Under the Chancellors plans, that funding would be gone and the papers main source of income taken away.
Beata Zawrzel/NurPhoto/Getty Images
People attend "Free media" protest in Wadowice, Poland on August 10, 2021.
Whats shocking about these two incidents is that they are happening in democratic Western nations. While journalists elsewhere face risk of prosecution or even death threats, the fact this is happening in Europe and is part of a broader trend is seriously concerning for the media and citizens alike.
What has this got to do with coronavirus? Short answer: timing.
In times of crisis trust in government goes up because people just want somebody to fix things, so you see people rally around the flag, says Ben Page, chief executive of polling firm Ipsos MORI.
Page says these spikes in support provide a window of opportunity that distracts from what you are doing elsewhere. And if you are a politician seeking to capitalize on this, whacking and weakening the press is a relatively easy proposition. Im afraid journalism is one of the least-trusted professions all over the world, he adds.
The reasons for public distrust in journalism are varied.
One of our biggest problems as professional journalists is that all over the world, we have been accused as being part of the system and establishment, says Pierre Haski, president of Reporters Without Borders (RSF). So as populist movements grow and rise up against the establishment, they rise up against us.
Haski thinks that it isnt just populist movements that present a danger, but also mainstream politicians who are losing voters to more extreme opposition.
Janek Skarzynski/AFP/Getty Images
Protesters demonstrate in defence of media freedom in Warsaw on August 10, 2021.
He points specifically to an incident in 2018, when French President Emmanuel Macron reportedly said: We have a press that is no longer pursuing the truth What I see is media power that wants to become judicial power. The comments came after a member of his security team was caught on camera attacking protesters while off duty.
In one sentence he delegitimized all media and how we operate. It was eerily close to something Trump might have said, says Haski.
Haski is, of course, correct to note incidents like this happening before the pandemic. What the coronavirus has provided is a moment in history when a decent chunk of the public is happy with governments behaving in a more authoritarian way, populist leadership is more appealing, accurate information is literally a case of life or death and journalists are not particularly liked.
As soon as a government decides we are in a crisis and need unity, they can cut the ground under journalists whose job it is to get to the truth because they risk becoming the traitor who is driving the disunity, says Nic Cheeseman, professor of democracy at Birmingham University.
Someone who cannot be ignored in all of this is former US President Donald Trump.
Even before winning the 2016 election, Trump made slamming the press a central prong of his campaign. And in the years that followed his victory, nearly every negative news story, negative approval rating and election loss was dismissed as fake news.
Trumps attacks on the media intensified during the pandemic. He regularly accused it of overplaying the threat of the virus and seemed to live in a parallel universe when it came to the numbers and science. And when the most important person on the planet does something, others take notice.
photo illustration/Alberto Mier
Donald Trump's attacks on the media intensified during the pandemic.
Donald Trump gave a cue to leaders around the world that attacking the media was now fair game, says Rob Mahoney, deputy executive director of the Committee to Protect Journalists.
When he launched attacks on the media (over their coverage) of his shambolic handling of the pandemic, the very moment the public needs as accurate information as possible, leaders in India, Brazil, the Philippines and Western Europe followed suit, denying the severity of the virus to cover their own failures, he adds.
The question many are asking is what the long-term impact will be, now that going after journalists is routine in so many free, liberal countries.
The industry was already facing a lot of challenges. Proper news is expensive to make and the media landscape has shifted dramatically in ways that have not been easy for journalism.
Modern technology has made it easier for one person sitting at home to run a website that looks as legitimate as that of a centuries-old newspaper. This has created a world in which there is no longer a consensus on facts and a significant number of people are willing to believe things that are simply not true.
This lack of consensus puts journalists who speak truth to power on one side of a debate and lies on the other.
When you put all of this into the context of an unprecedented pandemic, its easy to see why the past 18 months have been an ideal time for leaders to pick a side.
And as we emerge from this crisis into whatever the new normal looks like, leaders who decided to side with lies will be remembered by everyone and, to some extent, will determine what that new normal is.
The U.S. Centers for Disease Control and Prevention wasnt allowed to visit the city of Wuhan, China, or the Wuhan Institute of Virology in early 2020. Weve been trying to find out why ever since. Had we encountered transparency rather than stonewalling, it wouldnt have been necessary to put together the circumstantial pieces of the puzzle on our own.
On Sept. 12, 2019, coronavirus bat sequences were deleted from the institutes database. Why? It changed the security protocols for the lab. Why? It put out requests for more than $600 million for a new ventilation system. What prompted this new need?
In January 2020 two hypotheses emerged about the origin of the novel coronavirus: that it began in a bat, then infected another animal before spreading to humans in a Wuhan wet market, where wild animals are sold for meat; or that it emerged from the Wuhan laboratory. The wet-market story was pushed by the Chinese CDC and the World Health Organization. Public-health leaders argued that Covid-19 was like SARS and MERS, earlier coronaviruses that emerged from bats and spread through an intermediate animal.
But neither of those viruses has ever evolved to the point where it can transmit efficiently from one human to the next. There have been fewer than 10,000 cases of each virus world-wide since SARS was discovered in 2003 and MERS in 2012. What virus comes out of a bat cave and infects humans by the millions? Its not biologically plausible. If instead it evolved slowly over many years in nature, how come no one knew of it?
One of the lab theories hypothesizes that SARS-CoV-2 was manipulated or taught to infect humans. Imagine several viruses being run through humanized mice (grafted with human tissue and immune cells) to test their ability to infect human tissue. Notably, SARS-CoV-2 includes a kind of cleavage site that allows its spike protein to change its orientation and dock more easily with a human cell.
As the contagious delta variant fueled an unprecedented spike in COVID-19 cases and hospitalization during the past month, Oregon Gov. Kate Brown and her health advisers repeated the same mantra: no more state mandates, let local leaders take action.
But virtually no one did. Weeks went by, and local officials publicly acknowledged a lack of political will for renewed safeguards absent a directive from Brown.
When Brown finally spoke to top officials for Oregons 36 counties Aug. 6, during a regularly scheduled meeting, some expected she might deliver a stern warning: Enough is enough, bring back mask mandates or other measures now, or Ill do it.
But she didnt say that. In fact, she made no specific request for action by counties, people on the call told The Oregonian/OregonLive. Brown explained that the coronavirus was now out of control and threatening to overwhelm the states hospital capacity, then asked: What are you going to do about it?
The answer, in all but a few cases, was very little. Eventually the conversation ended with no clear picture of what would come next.
It was odd, said Lane County Commission Chair Joe Berney, who was on the call. There was a total lack of direction and leadership from her.
Brown now paints that call as a pivotal moment in her controversial decision to renew the statewide mask mandate, which she announced Tuesday and that took effect Friday. Shes indicated that only during that meeting did it become clear local officials were not willing to make the tough decisions.
But that blame-shifting narrative during Oregons record-breaking summer surge ignores weeks of evidence that many local leaders across the state never had any intention of acting weeks where Brown herself delayed a difficult decision as cases soared and hospitalizations climbed faster than ever before.
It also leaves out the fact that on July 27, the Oregon Health Authority gave Brown a detailed briefing on Oregons rising coronavirus case load, the prevalence of the delta variant and slowing vaccination rates. As part of that presentation, state epidemiologist Dr. Dean Sidelinger said that universal indoor mask usage would help control the delta variants spread, although he stopped short of calling for a mandate.
Brown that day issued a public recommendation for indoor masking, citing guidance from the Centers for Disease Control and Prevention. But she and state health officials decided against a requirement.
Browns finger-pointing at counties also ignores the reality that asking 36 jurisdictions to adopt their own public health edicts in a checkerboard fashion was both impractical and ineffective. The virus knows no borders, and county officials say they lack a mechanism to enforce local mandates. Meanwhile, many county commissioners had already expressed opposition to public health requirements, while others represent constituents who are outright hostile to them.
The governors office and state health officials did begin shifting their tone as the surge worsened. In public statements, they strongly recommended on July 22 that local officials consider masking, emphasized Aug. 3 that local action was expected in hard-hit areas, declared Aug. 6 that local inaction was unacceptable, and expressly called for local officials to set mask requirements to set mask mandates on Aug. 9.
Brown, with the power to reinstate a statewide mask mandate all along, announced her plan the following day.
The widespread inaction over those crucial weeks helps explain how Oregon now finds itself a national outlier, one of only five states whose summer surge has outpaced previous pandemic peaks. Oregon set new records Friday, averaging 1,652 cases a day in the past week, with 733 people hospitalized with COVID-19, including 185 people requiring intensive care.
And the numbers are projected to get worse. Much worse.
With hospitals around the state already operating at or near full capacity, researchers at Oregon Health & Science University forecast this week that the state could expect about 1,100 people with COVID-19 hospitalized by Sept. 7 -- a surge health care providers say they dont have the beds or staff to accommodate. Brown on Friday activated the Oregon National Guard to help.
The governor declined to be interviewed for this story. Since hosting a reopening celebration June 30 to suggest the pandemics worst days had passed, she held no official news conference specifically to address the quickly deteriorating coronavirus situation until appearing Wednesday to explain the mask mandate as a necessary measure that can save lives right now.
In response to written questions, her office did not point to any specific instances this summer where state officials directly asked county leaders to take specific action to slow the spread, although they said communications about the pandemic occur regularly.
Local leaders shouldnt need an invitation to take action to protect the lives of their constituents, Charles Boyle, a spokesperson for Brown, said in an email. Throughout the pandemic, county leaders have asked for local control to make health and safety decisions for their counties. When informed about the rapid spread of the delta variant, most county leaders did nothing.
Some of those same counties remain resistant. Dan DeYoung, chair of Josephine County, said he still prefers local control and is skeptical the mask mandate will be met with broad compliance.
Only 43% of Josephine County residents are vaccinated, well below the 60% rate statewide among people of all ages. Josephine County recorded Oregons highest coronavirus case rate this week, and the areas hospitals have more than twice as many people hospitalized with COVID-19 than in earlier waves.
Theres just a lot of people who are philosophically against them, DeYoung said of state edicts.
To be sure, the delta variant is ravaging the entire country and the governor is in a no-win political situation. Her every decision during the pandemic to implement safeguards has been second guessed and loudly criticized by political opponents, local elected officials and average citizens, who have decried her as a tyrant and even burned her in effigy in front of the Capitol. A month ago, University of Oregon researchers, citing poll results, suggested the governor stop acting as a vaccine spokesperson because she was deeply unpopular among vaccine-hesitant Oregonians.
Advocates want Brown to get credit for becoming just the third governor to reinstate a statewide mask mandate. But thats in part a necessity: the other state leaders who have done so, in Louisiana and Hawaii, are also experiencing their worst outbreaks of the pandemic.
Because Oregon had done so well preventing coronavirus spread until now, with some of the nations very lowest case and death rates, thats left more people without natural immunity from previous infections. Even with the 18th highest vaccination rate, Oregon finds itself with the 16th highest case rate in the last week, according to federal data.
Resurrecting the mask mandate a few weeks ago -- even just one week ago -- could have headed off many cases, hospitalizations and ultimately deaths, one expert said.
It could have made a huge difference ... more lives could have been saved. No doubt about it, said Ali Mokdad, an epidemiologist with the University of Washingtons COVID-19 forecasting arm, the Institute for Health Metrics and Evaluation. The institute on July 22 projected that Oregon could set hospitalizations records, albeit not until this fall.
Mokdad said Browns decision to require masks is a smart move. He said masks, which reduce aerosol spray and limit coronavirus spread, are needed coast to coast.
Every state should have had it, he said, and every state should have had it a long time ago.
*
The mood was jovial June 30 as Brown announced the states official reopening after more than a year of pandemic restrictions. Standing on a stage at Providence Park for a Reopening Oregon celebration, Brown declared: We celebrate brighter days ahead. And, today, we celebrate that Oregon is 100% open for business.
Those brighter days lasted about a week.
Oregon soon saw its lowest numbers in months, bottoming out at 150 cases a day and 99 people hospitalized with COVID-19. And the Oregon Health Authority, which since February 2020 had led the states public health pandemic response, made clear local health authorities would now be responsible for managing outbreaks going forward.
But the delta variant had other plans.
By July 12, the states case and hospitalization numbers were clearly climbing once again. Ten days later, on July 22, with cases and hospitalizations still rising, the Oregon Health Authority doubled down on its hands-off approach.
A localized pandemic demands effective localized public health interventions, not a statewide response, Patrick Allen, the agencys director, said at the time.
Only Oregons largest county, heavily vaccinated Multnomah, prepared to heed that guidance.
County Chair Deborah Kafoury said her public health team began warning her around July 25 that a local mask mandate likely would be necessary. Input from local hospitals and the departments own data modeling forecast a spike in cases driven by the delta variant.
But, Kafoury said, issuing a mandate too early might erode public confidence because the numbers didnt yet reflect the dire predictions. So the county decided to issue a public health advisory July 26 recommending everyone over the age of five wear masks in all indoor public spaces, regardless of whether they had been vaccinated.
We thought if we were to do a mandate closer to school opening, we could frame it around keeping business open and getting kids back in school, she said.
Officials at the Oregon Health Authority were coming to similar conclusions. The Centers for Disease Control and Prevention on July 27 formally recommended indoor masking, and the state followed suit that same day.
Sidelinger, the state epidemiologist, updated Brown and public health officials in a biweekly meeting on the states vaccination progress, the prevalence of the delta variant and the early uptick in hospitalized COVID patients, including those in intensive care units. Sidelinger noted that although vaccines were still preventing serious illness among people sickened by the delta variant, it was much more contagious and research in Israel showed the variant spread among vaccinated, unmasked people.
Sidelinger listed universal mask use in indoor public places as one of the states available tools to combat rising infections, according to records of the presentation, but he stopped short of advising Brown to issue a mandate.
Officials had a vigorous discussion of an indoor mask mandate in public settings, Robb Cowie, a spokesperson for the health authority, said in an email answering questions about the meeting.
Brown and state public health officials ultimately recognized that broad buy-in and adherence were just as important to the success of a mask mandate as issuing the actual requirement, Cowie said.
State policy-makers decided to give local leaders another opportunity to take action, he added, and state officials continued their discussions with local commissioners, public health officials and hospitals.
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The situation spiraled out of control in the following weeks, particularly in southern and eastern Oregon, two areas most resistant to restrictions.
By Aug. 2, Oregon was averaging more cases a day than in the spring peak, and hospitalizations were about to pass that similar crest.
Brown did not spend the week working the phones with county officials to convince them to issue mask mandates. Instead, she met with representatives of at least 10 major employers or industry groups, including Intel and the bankers and grocers associations, to ask if they were going to require their employees to get vaccinated.
Brown implied the state was preparing to mandate its employees get vaccinated and she would appreciate it if other major employers did the same, perhaps hoping it would lead to action among even smaller companies.
Sandra McDonough, president of Oregon Business & Industry, which is the states largest business lobbying group, said she spoke with Brown several times in recent weeks. As hospitals struggled with an influx of mostly unvaccinated COVID patients, McDonough said, she told the governors team and others that they need to do a better job of helping the public understand whats going on in the health system right now.
Meanwhile, two days before Browns Aug. 6 meeting with county officials, Multnomah County health experts came back to Kafoury.
They were strongly recommending a mask mandate right now, Kafoury said. We had another discussion and decided wed announce it the following week.
We needed to have it done at a statewide level but when we saw that wasnt going to happen we needed to move, said Kafoury, who added that she was glad Brown acted but wished it happened sooner.
Officials in Lane County expressed similar frustration. Four days after Browns Aug. 6 call with county chairs across the state, County Administrator Steve Mokrohisky told commissioners there was no mechanism to enforce a local mandate and no staff available to follow up on complaints. They planned to issue a recommendation.
Without the state taking action we have to do what we can locally, Mokrohisky said, adding that businesses and organizations were crying out for clear guidance. They just want someone to tell (them) what to do.
The governors call with county leaders seemingly helped convince only one person, Washington County Chair Kathryn Harrington, that more action was needed. Harrington also knew Multnomah County was planning to enact a mask mandate.
Harrington made an impassioned plea to her fellow commissioners to protect children by adopting a mask mandate in Washington County. Four of the five expressed support during a meeting Tuesday, and county staff were instructed to draft the legislation for a vote at a special meeting.
Harrington said she isnt critical of the governors timing. But she is concerned that rural counties with low and slowing vaccination numbers are exporting their problems to the metro area, where vaccination rates are among the highest in the state.
In Josephine and Jackson counties, 20% of people that go to hospitals get transferred up to our metro area hospitals, she said. Were having to bear the burden of other counties not being successful in their vaccination efforts. Thats a real problem.
Don Russell, chair of the Morrow County board in eastern Oregon, said he doesnt understand vaccine resistance in his community, where only 38% of the population among all ages is vaccinated.
But the reasons to them are real and you cant convince them, he said.
Russell, like other county officials interviewed for this story, said hes unaware of any specific requests that the governor or the Oregon Health Authority made to counties regarding local public health mandates.
It almost has to come from the governor, he said. We dont have any hammer. How would we enforce it? ... Maybe I should look at (the mask mandate) as a bonus. She took that rotten egg out of our pocket.
Ultimately, any deeper reasons behind the timing of Browns decision to renew the mask mandate remain opaque. While she declined an interview request from The Oregonian/OregonLive, Brown made time for a national television appearance Thursday.
The timing was right to take action and thats what its taken during the pandemic, quick and decisive action, and thats what Im taking, Brown told a national ABC News host.
Asked by The Oregonian/OregonLive why Brown ever thought local leaders in certain communities would renew restrictions, the governors spokesperson reiterated that those officials shouldnt need an invitation to save lives.
Local leaders in counties with low vaccination rates were in a unique position to help convince their constituents about the effectiveness of vaccines and masks, Boyle wrote. Its unfortunate that hospitals in those regions are now facing the sharpest increases in COVID-19 hospitalizations, and those same local leaders are requesting help from the state and federal governments.
Oregon now heads forward with 1.7 million Oregonians, including all children under the age of 12, unvaccinated and delta running rampant.
Schools plan to open full-time next month.
In California, Gov. Gavin Newsom recently announced he would require teachers to get vaccinated or take weekly COVID tests.
Brown, in her news conference Wednesday, said she plans to issue no such state mandate, leaving any action to local superintendents and school boards.
That, she said, is in their very capable hands.
To see more data and trends, visit https://projects.oregonlive.com/coronavirus/
-- Staff writer Aimee Green contributed to this story
-- Ted Sickinger; tsickinger@oregonian.com; 503-221-8505; @tedsickinger
In late June alone, the initiative known as Covax sent some 530,000 doses to Britain more than double the amount sent that month to the entire continent of Africa.
Under Covax, countries were supposed to give money so vaccines could be set aside, both as donations to poor countries and as an insurance policy for richer ones to buy doses if theirs fell through. Some rich countries, including those in the EU, calculated that they had more than enough doses available through bilateral deals and ceded their allocated Cova doses to poorer countries.
But others, including Britain, tapped into the meagre supply of Covax doses themselves, despite being among the countries that had reserved most of the worlds available vaccines. In the meantime, billions of people in poor countries have yet to receive a single dose.
The result is that poorer countries have landed in exactly the predicament Covax was supposed to avoid: dependent on the whims and politics of rich countries for donations, just as they have been so often in the past. And in many cases, rich countries dont want to donate in significant amounts before they finish vaccinating all their citizens who could possibly want a dose, a process that is still playing out.
If we had tried to withhold vaccines from parts of the world, could we have made it any worse than it is today? asked Dr. Bruce Aylward, a senior advisor at the World Health Organization, during a public session on vaccine equity.
The government is a strong champion of Covax, the UK said, describing the initiative as a mechanism for all countries to obtain vaccines, not just those in need of donations. It declined to explain why it chose to receive those doses despite private deals that have reserved eight injections for every UK resident.
While some breakthrough cases among those who are fully vaccinated against Covid-19 are inevitable, they are unlikely to result in hospitalization or death. But one important question about breakthrough infection that remains unanswered is: Can the vaccinated develop so-called long Covid?
Long Covid refers to a set of symptoms such as severe fatigue, brain fog, headache, muscle pain and sleep problems that can persist for weeks or months after the active infection has ended. The syndrome is poorly understood, but studies suggest that between 10 and 30 percent of adults who catch the virus may experience long Covid, including those who experienced only mild illness or no symptoms at all.
But the vast majority of data collected about long Covid has been in the unvaccinated population. The risk of developing long Covid for the fully vaccinated who get infected after vaccination hasnt been studied.
While preliminary research suggests that it is, in fact, possible for a breakthrough case to lead to symptoms that can persist for weeks to months, there are still more questions than answers. What percent of breakthrough cases result in lingering symptoms? How many of those people recover? Are the persistent symptoms after breakthrough infection as severe as those that occur in the unvaccinated?
I just dont think there is enough data, said Dr. Zijian Chen, medical director at the Center for Post-Covid Care at Mount Sinai Health System in New York. Its too early to tell. The population of people getting sick post vaccination isnt that high right now, and theres no good tracking mechanism for these patients.
One recent study of Israeli health care workers published in the New England Journal of Medicine offers a glimpse of the risk of long Covid after a breakthrough infection. Among 1,497 fully vaccinated health care workers, 39 of them about 2.6 percent developed breakthrough infections. (All of the workers were believed to be infected after contact with an unvaccinated person, and the study was conducted before the Delta variant became dominant.)
While most of the breakthrough cases were mild or asymptomatic, seven out of 36 workers tracked at six weeks (19 percent) still had persistent symptoms. These long Covid symptoms included a mix of prolonged loss of smell, persistent cough, fatigue, weakness, labored breathing or muscle pain.
But the studys authors caution against drawing too many conclusions from the research. The sample size just seven patients is small. And the research was designed to study antibody levels in the infected, said Dr. Gili Regev-Yochay, director of the infectious disease epidemiology unit at Sheba Medical Center. It was not designed to study the risk of long Covid after a breakthrough infection.
It was not the scope of this paper, Dr. Regev-Yochay said. I dont think we have an answer to that.
Even so, the fact that one in five of the health care workers who had breakthrough infections still had lingering symptoms after six weeks appears to be the first indication from a peer-reviewed study that long Covid is possible after a breakthrough infection.
Aug. 16, 2021, 1:10 p.m. ET
People have said to me, Youre fully vaccinated. Why are you being so careful? said Dr. Robert M. Wachter, professor and chair of the department of medicine at the University of California, San Francisco. Im still in the camp of I dont want to get Covid. I dont want to get a breakthrough infection.
Dr. Wachter said that despite the many limitations of the Israeli study, the data offer more evidence that the vaccinated should keep taking reasonable precautions to avoid the virus.
Im going to take it at face value that one in five people, six weeks after a breakthrough case, continued to feel crummy, Dr. Wachter said. Thats enough to make me want to wear two masks when I go into the grocery store, which is not that burdensome anyway.
Understandthe State of Vaccine and Mask Mandates in the U.S.
Complicating the study of breakthrough infections is the fact that the U.S. Centers for Disease Control and Prevention only tracks post-vaccination infections that result in hospitalization or death. While the C.D.C. does continue to study breakthrough infections in several large cohorts, the lack of data on all breakthrough cases remains a source of frustration among scientists and patient advocacy groups.
Its very frustrating not to have data at this point in the pandemic to know what happens to breakthrough cases, said Akiko Iwasaki, an immunologist at Yale School of Medicine who is conducting studies of long Covid. If mild breakthrough infection is turning into long Covid, we dont have a grasp of that number.
Diana Berrent, founder of Survivor Corps, a Facebook group for people affected by Covid-19 that has about 171,000 members, took an informal poll and found 24 people who said they had lingering symptoms after a breakthrough infection. Its not a scientific sample, and the cases havent been validated, but the poll shows the need for more data on breakthrough cases, Ms. Berrent said.
You cant extrapolate it to the general population, but its a very strong signal that the C.D.C. needs to be mandating reporting of every breakthrough case, Ms. Berrent said. We cant know what were not counting.
But some experts predict the surge of new cases caused by the spread of the Delta variant will, unfortunately, lead to more breakthrough cases in the coming months. Dr. Chen of Mount Sinai said it will take several months before patients with long Covid from a breakthrough infection are enrolled in studies.
Were waiting for these patients to show up at our doors, Dr. Chen said.
Despite the lack of data, one thing is clear: Getting vaccinated will reduce the risk of getting infected and getting long Covid, said Athena Akrami, a neuroscientist at University College London who collected and published data from nearly 4,000 long Covid patients after developing long Covid herself after a March 2020 bout with Covid-19.
Its simple math, said Dr. Akrami. If you reduce infections, then the likelihood of long Covid will drop automatically.
