The pandemic illustrated how a rift between the CDC and workplace safety officials can have serious repercussions. Most recently, the giant hospital system Sutter Health in California appealed a citation from the state’s Division of Occupational Safety and Health, known as Cal/OSHA, by pointing to the CDC’s shifting advice on when and whether N95 masks were needed at the start of the pandemic. By contrast, Cal/OSHA requires employers in high-risk settings like hospitals to improve ventilation, use air filtration, and provide N95s to all staff exposed to diseases that are — or may be — airborne.

The agencies are once again at odds. The CDC’s advisory committee prescribes varying degrees of protection based on ill-defined categories, such as whether a virus or bacteria is considered common or how far it seems to travel in the air. As a result, occupational safety experts warn that choices on how to categorize covid, influenza, and other airborne diseases — and the corresponding levels of protection — may once again be left to administrators at hospitals, nursing homes, and jails or prisons.

Eric Berg, deputy chief of health at Cal/OSHA, warned the CDC in November that, if it accepted its committee’s recommendations, the guidelines would “create confusion and result in workers being not adequately protected.”

Also called respirators, N95 masks filter out far more particles than looser-fitting surgical masks but cost roughly 10 times as much, and were in short supply in 2020. Black, Hispanic, and Asian health workers more often went without N95 masks than white staffers, which helped explain why members of racial and ethnic minorities tested positive for covid nearly five times as often as the general population in the early months of the pandemic. (Hispanic people can be of any race or combination of races.)

Cal/OSHA issued dozens of citations to health care facilities that failed to provide N95 masks and take other measures to protect workers in 2020 and 2021. Many appealed, and some cases are ongoing. In October, the agency declined Sutter’s appeal against a $6,750 citation for not giving its medical assistants N95 masks in 2020 when they accompanied patients who appeared to have covid through clinics. Sutter pointed to the CDC’s advice early in the pandemic, according to court testimony. It noted that the CDC called surgical masks an “acceptable alternative” in March 2020, “seemed to recommend droplet precautions rather than airborne precautions,” and suggested that individuals were unlikely to be infected if they were farther than 6 feet away from a person with covid.

This is a loose interpretation of the CDC’s 2020 advice, which was partly made for reasons of practicality. Respirators were in short supply, for example, and physical distancing beyond 6 feet is complicated in places where people must congregate. Scientifically, there were clear indications that the coronavirus SARS-CoV-2 spread through the air, leading Cal/OSHA to enact its straightforward rules created after the 2009 swine flu pandemic. Workers need stiffer protection than the general population, said Jordan Barab, a former official at the federal Occupational Safety and Health Administration: “Health workers are exposed for eight, 10, 12 hours a day.”

The CDC’s advisory committee offers a weaker approach in certain cases, suggesting that health workers wear surgical masks for “common, often endemic respiratory pathogens” that “spread predominantly over short distances.” The draft guidance pays little attention to ventilation and air filtration, and advises N95 masks only for “new or emerging” diseases and those that spread “efficiently over long distances.” Viruses, bacteria, and other pathogens that spread through the air don’t neatly fit into such categories.

“Guidelines that are incomplete, weak, and without scientific basis will greatly undermine CDC’s credibility,” said a former OSHA director, David Michaels, in minutes from an October meeting where he and others urged CDC Director Mandy Cohen to reconsider advice from the committee before it issues final guidance next year.

Although occupational safety agencies — not the CDC — have the power to make rules, enforcement often occurs long after the damage is done, if ever. Cal/OSHA began to investigate Sutter only after a nurse at its main Oakland hospital died from covid and health workers complained they weren’t allowed to wear N95 masks in hallways shared with covid patients. And more than a dozen citations from Cal/OSHA against Kaiser Permanente, Sharp HealthCare, and other health systems lagged months and years behind health worker complaints and protests.

Outside California, OSHA faces higher enforcement obstacles. A dwindling budget left the agency with fewer workplace inspectors than it had in 45 years, at the peak of the pandemic. Plus, the Trump and Biden administrations stalled the agency’s ongoing efforts to pass regulations specific to airborne infections. As a result, the agency followed up on only about 1 in 5 covid-related complaints that employees and labor representatives officially filed with the group from January 2020 to February 2022 — and just 4% of those made informally through media reports, phone calls, and emails. Many deaths among health care workers weren’t reported to the agency in the first place.

Michaels, who is now on the faculty at the George Washington University School of Public Health, said the CDC would further curtail OSHA’s authority to punish employers who expose staff members to airborne diseases, if its final guidelines follow the committee’s recommendations. Such advice would leave many hospitals, correctional facilities, and nursing homes as unprepared as they were before the pandemic, said Deborah Gold, a former deputy chief of health at Cal/OSHA. Strict standards prompt employers to stockpile N95 masks and improve air filtration and ventilation to avoid citations. But if the CDC’s guidance leaves room for interpretation, she said, they can justify cutting corners on costly preparation.

Although the CDC committee and OSHA both claim to follow the science, researchers arrived at contradictory conclusions because the committee relied on explicitly flawed trials comparing health workers who wore surgical masks with those using N95s. Cal/OSHA based its standards on a variety of studies, including reviews of hospital infections and engineering research on how airborne particles spread.

In decades past, the CDC’s process for developing guidelines included labor representatives and experts focused on hazards at work. Barab was a health researcher at a trade union for public sector employees when he helped the CDC develop HIV-related recommendations in the 1980s.

“I remember asking about how to protect health care workers and correction officers who get urine or feces thrown at them,” Barab said. Infectious disease researchers on the CDC’s committee initially scoffed at the idea, he recalled, but still considered his input as someone who understood the conditions employees faced. “A lot of these folks hadn’t been on hospital floors in years, if not decades.”

The largest organization for nurses in the United States, National Nurses United, made the same observation. It’s now collecting signatures for an online petition urging the CDC to scrap the committee’s guidelines and develop new recommendations that include insights from health care workers, many of whom risked their lives in the pandemic.

Barab attributed the lack of labor representation in the CDC’s current process to the growing corporate influence of large health systems. Hospital administrators prefer not to be told what to do, particularly when it requires spending money, he said.

In an email, CDC communications officer Dave Daigle stressed that before the guidelines are finalized, the CDC will “review the makeup of the workgroups and solicit participation to ensure that the appropriate expertise is included.”

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Kissane’s autoimmune arthritis seems to make her susceptible to unusual vaccine side effects. After getting an mRNA booster last year, her joints ached so painfully that her doctor prescribed steroids to dampen the inflammation. She still considers the mRNA vaccines “miraculous,” knowing covid could be far worse than temporary aches.

Nonetheless, when the pain subsided, she pored through studies on Novavax’s shot, a vaccine that is based on proteins rather than mRNA and has been used since early 2022 in other countries. Data from the United Kingdom found that people more frequently reported temporary reactions — like low fevers, fatigue, and pain — as their immune system ramped up in the days following booster vaccination with Moderna’s mRNA vaccine versus the one by Pfizer. And those boosted with Novavax’s had fewer complaints than either of those. That finding was corroborated in an analysis of international data published last year.

Such studies have driven people with long covid and chronic fatigue syndrome (also known as myalgic encephalomyelitis, or ME/CFS) to seek out Novavax, too, since the FDA and the Centers for Disease Control and Prevention greenlighted Novavax’s vaccine — updated to protect against recent omicron coronavirus variants — about three weeks after recommending updated mRNA vaccines in September.

Waiting paid off for Kissane, whose arm was briefly sore. “It was a dramatically different experience for me,” she said. “I hope that plays out for others.”

Another group who waited on Novavax are biologists who geek out over its technology. When asked why he opted for Novavax, Florian Krammer, a virologist at the Icahn School of Medicine at Mount Sinai, replied on X, formerly known as Twitter: “Because I am [a] vaccine nerd, I like insect cell produced vaccines.”

Whereas mRNA vaccines direct the body to produce spike proteins from the coronavirus SARS-CoV-2, which then train a person’s immune system to recognize and fight the virus, Novavax simply injects the proteins. These proteins are grown within moth cells in a laboratory, while other protein-based shots use cells from mammals. And Novavax has said that a special ingredient derived from the bark of Chilean soapbark trees enhances the vaccine’s power.

Research suggests that the Novavax vaccine is about as safe and effective as the mRNA shots. Its main disadvantage is arriving late to the scene. Vaccine uptake has plummeted since the first shots became widely available in 2021. Nearly 70% of people got the primary vaccines, compared with fewer than 20% opting for the mRNA covid boosters released last year. Numbers have dwindled further: As of Oct. 17, only 5% of people in the United States had gotten the latest covid vaccines, according to the Department of Health and Human Services.

Daniel Park, an epidemiologist at George Washington University, said low rates might improve if people who felt lousy after their last mRNA shots gave Novavax a try. It protects against severe illness, but researchers struggle to specify just how effective this and other vaccines are, at this point, because studies have gotten tricky to conduct: New coronavirus variants continuously emerge, and people have fluctuating levels of immunity from previous vaccines and infections.

Still, a recent study in Italy suggests that Novavax is comparable to mRNA vaccines. It remained more than 50% effective at preventing symptomatic covid four months after vaccination. Some data suggests that mixing and matching different types of vaccines confers stronger protection — although other studies have found no benefit.

Given all this, Park held out for the Novavax vaccine on account of its potentially milder side effects. “Between a demanding full-time job and two young kids at home, I wanted to stay operational,” he said. His arm was sore, but he didn’t have the 24-hour malaise accompanying his last mRNA shot.

Most people don’t strike a fever after mRNA shots. Even when they do, it is brief and therefore far less detrimental than many cases of covid. In fact, most reactions are so minor that they’re hard to interpret. During clinical trials on mRNA vaccines, for example, up to a third of people in the placebo group reported fatigue and headaches after injection.

People with ME/CFS and long covid — a potentially debilitating condition that persists months after a covid infection — have responded to covid vaccinations in a wide variety of ways. Most participants with long covid in an 83-person Canadian study said their levels of fatigue, concentration, and shortness of breath improved following vaccination. Inflammatory proteins that have been linked to long covid dropped as well.

However, larger studies have yet to corroborate the hopeful finding. Jennifer Curtin, a doctor who co-founded a telehealth clinic focused on long covid and ME/CFS, called RTHM, said vaccines seem to temporarily aggravate some patients’ conditions. To learn how Novavax compares, she posted polls on X in late October asking if people with long covid or ME/CFS felt that their symptoms worsened, improved, or stayed the same after Novavax. Most replied: unchanged.

“It’s not scientific, but we need to figure it out since these folks don’t want to get covid,” Curtin said. “My patients are all wondering about what vaccine to get right now.”

Adding to the uncertainty, the rollout of Novavax and mRNA vaccines has been bumpy as pharmacies struggle to predict demand and insurance companies figure out how to reimburse providers for the shots. Unlike previous vaccine offerings, these options are no longer fully covered by the federal government. A testament to this season’s struggle to get vaccinated is that at least one do-gooder has created an online tool to find open appointments for Novavax.

Buoyed by anecdotes of relief from others with long covid, Hayley Brown, a researcher at the Center for Economic and Policy Research who has the condition, opted for Novavax recently. Unfortunately, her symptoms have flared. She said a temporary discomfort will still be preferable to risking another infection. “As someone with long covid, the idea of getting covid again is terrifying.”

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Pero no puede.

Una norma agregada al presupuesto de Texas, que entró en vigencia el 1 de septiembre, prohíbe a los departamentos de salud y otras organizaciones financiadas por el gobierno estatal anunciar, recomendar o incluso enumerar las vacunas contra covid por sí mismas.

La norma permite que “las clínicas informen a los pacientes que las vacunas contra covid-19 están disponibles si no se las destaca de otras vacunas”.

Texas no es el único estado que restringe la conversación pública sobre estas vacunas. La página de internet del Departamento de Salud de Tennessee, por ejemplo, ofrece información sobre la gripe, el vapeo y la detección del cáncer, pero omite hablar de covid y de las vacunas. Florida es un caso extremo: su Departamento de Salud ha emitido directrices contra estas vacunas que van en contra de los estudios científicos y los consejos de los Centros para el Control y Prevención de Enfermedades (CDC).

El cambio en la información sobre salud sigue la retórica de políticos, principalmente republicanos, que han dado marcha atrás en sus posturas sobre las vacunas de covid.

La feroz oposición a medidas como el uso de máscaras y el cierre de negocios, al principio de la pandemia, alimentó la desconfianza hacia los CDC y otras instituciones científicas, y a menudo coincide con líneas partidistas: el mes pasado, una encuesta de KFF reveló que el 84% de los demócratas confiaba en la seguridad de las vacunas contra covid, frente al 36% de los republicanos. Es un descenso drástico desde 2021, cuando dos tercios de los republicanos estaban vacunados.

Ante la llegada de las nuevas vacunas, algunas autoridades de salud actúan con cautela para evitar el rechazo del público y de los responsables políticos. Hasta el momento, la aceptación de las vacunas es baja: menos del 5% de los estadounidenses han recibido la vacuna actualizada, según el Departamento de Salud y Servicios Humanos (HHS). Wells teme que las consecuencias sean nefastas: “Veremos una enorme disparidad de los impactos en la salud debido a los cambios en el lenguaje”.

Un estudio publicado en julio descubrió que los republicanos y demócratas de Ohio y Florida morían en tasas más o menos similares antes de que aparecieran las vacunas de covid, pero la disparidad entre partidos creció una vez que las primeras vacunas estuvieron ampliamente disponibles en 2021 y la aceptación fue divergente. A finales de año, los republicanos tenían una tasa de exceso de muertes, un 43% más alta que los demócratas.

Las iniciativas de salud pública llevan tiempo creando polémicas: la fluoración del agua, el intercambio de agujas y la atención de salud universal, por nombrar algunas. Pero la pandemia agravó la situación, según los funcionarios de salud pública.

Más de 500 dejaron su trabajo bajo coacción en 2020 y 2021, y los legisladores de al menos 26 estados aprobaron leyes para impedir que funcionarios públicos establecieran políticas de salud. Trent Garner, senador republicano por Arkansas, dijo a KFF Health News en 2021: “Es hora de quitarles el poder a los llamados expertos”.

Al principio, los mandatos de vacunación fueron polémicos, pero las vacunas en sí no lo eran. Scott Rivkees, ex cirujano general de Florida, ahora en la Universidad Brown, sitúa el cambio en los meses después de que Joe Biden fuera elegido presidente.

Aunque el gobernador de Florida, Ron DeSantis, promovió inicialmente la vacunación contra covid, su postura cambió cuando la resistencia a las medidas sobre covid se convirtió en un elemento central de su campaña presidencial. A finales de 2021, nombró a Joseph Ladapo cirujano general. Para entonces, Ladapo había escrito artículos de opinión en The Wall Street  Journal en los que se mostraba escéptico con los consejos de la medicina tradicional, como uno en el que se preguntaba: “¿Son las vacunas de covid más arriesgadas de lo que se anuncia?”.

Con la introducción de las vacunas bivalentes el año pasado, la página web del Departamento de Salud de Florida eliminó la información sobre las vacunas de covid. En su lugar había normas contra los mandatos y detalles sobre cómo obtener exenciones de las vacunas. Luego, a principios de este año, el departamento desaconsejó vacunar a niños y adolescentes.

El consejo del estado cambió una vez más cuando los CDC recomendaron vacunas actualizadas contra covid en septiembre. DeSantis declaró, de manera incorrecta, que las vacunas “no habían demostrado ser seguras o eficaces”. Y el departamento de salud modificó sus orientaciones para decir que los hombres menores de 40 años no debían vacunarse porque el departamento había realizado investigaciones y consideraba inaceptable el riesgo de complicaciones cardíacas como la miocarditis.

El informe se refiere a un documento breve, y sin autor, publicado en Internet en lugar de en una revista científica, donde se habría comprobado su veracidad. El informe utiliza un método poco habitual para analizar los historiales médicos de los floridanos vacunados. Citando graves defectos, la mayoría de los demás investigadores lo califican de información errónea.

Estudios científicamente constatados, y la propia revisión de los CDC, contradicen la conclusión de Florida contra la vacunación. Se han dado casos de miocarditis a causa de vacunas con ARNm, pero son mucho menos frecuentes que los casos provocados por covid. Según un análisis publicado en una revista médica a partir de una revisión de otros 22 estudios, el riesgo es siete veces mayor por esta enfermedad que por las vacunas de ARNm.

Desde que dejó su cargo, Rivkees ha visto con estupor cómo el departamento estatal de salud quedaba condicionado por las intromisiones políticas.

Unos 28,700 niños y adultos desde el nacimiento hasta los 39 años han muerto de covid en Estados Unidos. El mensaje antivacunas de Florida afecta a personas de todas las edades, añadió Rivkees, no sólo a los más jóvenes.

Señaló que Florida se desempeñó bien en comparación con otros estados en 2020 y 2021, ocupando el puesto 38 en muertes por covid per cápita a pesar de tener una gran población de adultos mayores. Ahora tiene la sexta tasa más alta de muertes por covid del país.

“No hay duda de que el aumento de la desinformación y la politización de la respuesta han pasado factura a la salud pública”, dijo Rivkees.

Al igual que en Florida, el departamento de salud de Texas promovió inicialmente las vacunas contra covid, advirtiendo de que los tejanos que no estaban vacunados tenían 20 veces más probabilidades de sufrir una muerte asociada a covid.

Pero esta visión se desvaneció el año pasado, cuando los líderes estatales aprobaron políticas para bloquear los mandatos de vacunación y otras medidas de salud pública. La última es la prohibición del uso de fondos públicos para promover las vacunas contra covid. En Texas, la aceptación de la vacuna ya es baja, con menos del 4% de los residentes vacunados con el refuerzo bivalente que se puso en marcha el año pasado.

En el departamento de salud de Lubbock, Wells se las arregló para publicar un comunicado de prensa diciendo que la ciudad ofrece vacunas contra covid, pero se abstuvo de recomendarlas. “No podemos hacer tanta campaña como en otros estados”, afirmó.

Algunos funcionarios de salud han modificado sus recomendaciones, dada la presión en la que viven. Janet Hamilton, directora ejecutiva del Council of State and Territorial Epidemiologists, dijo que el consejo dejó claro que vacunarse contra covid funciona cuando la gente confía en la comunidad científica, pero se corre el riesgo de alejar a otros de todas las vacunas. “Es importante que la salud pública vaya al encuentro de todas las personas”, afirmó Hamilton.

El Departamento de Salud de Missouri adoptó esta táctica en X (ex Twitter): “Las vacunas de covid estarán disponibles en Missouri en breve… si te interesan estas cosas. Si no, ¡sigue mirando posteos!”.

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But she can’t.

A rule added to Texas’ budget that went into effect Sept. 1 forbids health departments and other organizations funded by the state government to advertise, recommend, or even list covid vaccines alone. “Clinics may inform patients that COVID-19 vaccinations are available,” the rule allows, “if it is not being singled out from other vaccines.”

Texas isn’t the only state curtailing the public conversation about covid vaccines. Tennessee’s health department homepage, for example, features the flu, vaping, and cancer screening but leaves out covid and covid vaccines. Florida is an extreme case, where the health department has issued guidance against covid vaccines that runs counter to scientific studies and advice from the Centers for Disease Control and Prevention.

Notably, the shift in health information trails rhetoric from primarily Republican politicians who have reversed their positions on covid vaccines. Fierce opposition to measures like masking and business closures early in the pandemic fueled a mistrust of the CDC and other scientific institutions and often falls along party lines: Last month, a KFF poll found that 84% of Democrats said they were confident in the safety of covid vaccines, compared with 36% of Republicans. It’s a dramatic drop from 2021, when two-thirds of Republicans were vaccinated.

As new vaccines roll out ahead of the expected winter surge of covid, some health officials are treading carefully to avoid blowback from the public and policymakers. So far, vaccine uptake is low, with less than 5% of Americans receiving an updated shot, according to the Department of Health and Human Services. Wells fears the consequences will be dire: “We will see a huge disparity in health outcomes because of changes in language.”

A study published in July found that Republicans and Democrats in Ohio and Florida died at roughly similar rates before covid vaccines emerged, but a disparity between parties grew once the first vaccines were widely available in 2021 and uptake diverged. By year’s end, Republicans had a 43% higher rate of excess deaths than Democrats.

Public health initiatives have long been divisive — water fluoridation, needle exchanges, and universal health care, to name a few. But the pandemic turned up the volume to painful levels, public health officials say. More than 500 left their jobs under duress in 2020 and 2021, and legislators in at least 26 states passed laws to prevent public officials from setting health policies. Republican Arkansas state Sen. Trent Garner told KFF Health News in 2021, “It’s time to take the power away from the so-called experts.”

At first, vaccine mandates were contentious but the shots themselves were not. Scott Rivkees, Florida’s former surgeon general, now at Brown University, traces the shift to the months after Joe Biden was elected president. Though Florida Gov. Ron DeSantis initially promoted covid vaccination, his stance changed as resistance to covid measures became central to his presidential campaign. In late 2021, he appointed Joseph Ladapo surgeon general. By then, Ladapo had penned Wall Street Journal op-eds skeptical of mainstream medical advice, such as one asking, “Are Covid Vaccines Riskier Than Advertised?”

As bivalent boosters rolled out last year, the Florida health department’s homepage removed information on covid vaccines. In its place were rules against mandates and details on how to obtain vaccine exemptions. Then, early this year, the department advised against vaccinating children and teens.

The state’s advice changed once more when the CDC recommended updated covid vaccines in September. DeSantis incorrectly said the vaccines had “not been proven to be safe or effective.” And the health department amended its guidance to say men under age 40 should not be vaccinated because the department had conducted research and deemed the risk of heart complications like myocarditis unacceptable. It refers to a short, authorless document posted online rather than in a scientific journal where it would have been vetted for accuracy. The report uses an unusual method to analyze health records of vaccinated Floridians. Citing serious flaws, most other researchers call it misinformation.

Scientifically vetted studies, and the CDC’s own review, contradict Florida’s conclusion against vaccination. Cases of myocarditis following mRNA vaccines have occurred but are much less frequent than cases triggered by covid. The risk is sevenfold higher from the disease than from mRNA vaccines, according to an analysis published in a medical journal based on a review of 22 other studies.

Since leaving his post, Rivkees has been stunned to see the state health department subsumed by political meddling.

About 28,700 children and adults from birth to age 39 have died of covid in the United States. Florida’s anti-vaccine messaging affects people of all ages, Rivkees added, not just those who are younger.

He points out that Florida performed well compared with other states in 2020 and 2021, ranking 38th in covid deaths per capita despite a large population of older adults. Now it has the sixth-highest rate of covid deaths in the country.

“There is no question that the rise of misinformation and the politicization of the response has taken a toll on public health,” he said.

As in Florida, the Texas health department initially promoted covid vaccines, warning that Texans who weren’t vaccinated were about 20 times as likely to suffer a covid-associated death. Such sentiments faded last year, as state leaders passed policies to block vaccine mandates and other public health measures. The latest is a prohibition against the use of government funds to promote covid vaccines. Uptake in Texas is already low, with fewer than 4% of residents getting the bivalent booster that rolled out last year.

At Lubbock’s health department, Wells managed to put out a press release saying the city offers covid vaccines but stopped short of recommending them. “We aren’t able to do as big a push as other states,” she said.

Some health officials are altering their recommendations, given the current climate. Janet Hamilton, executive director at the Council of State and Territorial Epidemiologists, said clear-cut advice to get vaccinated against covid works when people trust the scientific establishment, but it risks driving others away from all vaccines. “It’s important for public health to meet people where they are,” Hamilton said.

Missouri’s health department took this tack on X, formerly known as Twitter: “COVID vaccines will be available in Missouri soon, if you’re in to that sort of thing. If not, just keep scrolling!”

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Like blizzards, the specific timing and severity of these outbreaks are hard to forecast. But their damage can be limited in more ways than ever before. More protective vaccines against influenza are on the horizon. And new vaccines against respiratory syncytial virus, or RSV, were approved this year, as were updated covid vaccines. Although the first days of rollout for the Moderna and Pfizer vaccines saw hiccups, with short supplies at some pharmacies and billing confusion with some insurers, the shots now are generally available at no cost.

What’s more, after enduring the worst pandemic in a century, people are more attuned to protecting themselves and those around them. Wearing face masks and staying home when sick can stop the spread of most respiratory infections. The rate of flu vaccinations has climbed over the past five years.

“It seems like the pandemic reminded them of how important vaccination is,” said Brian Poole, a microbiologist at Brigham Young University in Utah. In a study of college students, Poole and other researchers found that flu vaccination rates have nearly tripled since 2007, from 12% to 31% in the respiratory infection season of 2022-23. Only a minority of students expressed “vaccine fatigue.”

There is, however, one dangerous departure from the past. Vaccination has become politicized, with college students and older adults who identify as Republican or conservative being less likely to get covid vaccines, as well as vaccinations against flu. Before 2018, studies found that political affiliation had no influence on vaccine uptake. But as measures to limit covid, such as school and church closures, became controversial, some political leaders downplayed the effects of covid — even as the pandemic’s U.S. death toll soared above 1 million.

That messaging has led to a disbelief in public health information. The Centers for Disease Control and Prevention reports data showing that covid hospitalizations nearly tripled in the latest surge, with more than 40,000 hospitalizations in the first two weeks of September compared with about 13,600 in the same period of July. But in a recent KFF poll, half of Republicans did not believe in the surge, compared with just 23% of Democrats.

Messaging to minimize the toll of covid also makes vaccines seem unnecessary, with 24% of Republicans leaning toward getting the updated covid shot versus 70% of Democrats in the KFF poll. A larger share of vaccine-eligible adults said they planned to get, or have gotten, the flu shot and a new RSV vaccine.

“It’s important to recognize that the flu, covid, and respiratory viruses still kill a lot of people, and that the vaccines against those viruses save lives,” said David Dowdy, an epidemiologist at Johns Hopkins University in Baltimore. Flu vaccines prevent up to 87,000 hospitalizations and 10,000 deaths each year in the United States. “I like to highlight that,” Dowdy added, “as opposed to making up terms like ‘triple-demic’ to make people cower in fear.”

Dowdy predicted this fall and winter will be better than the past few, when patients with covid, influenza, or RSV filled hospitals. Even so, he estimated that more people will die than in the seasons before covid appeared. About 58,000 people died from the flu last season, and hundreds of thousands more were sickened, staying home from school and work. This year, the flu doesn’t appear to be kicking off unusually early, as it did last year with cases picking up in November, rather than in January. And more people are partially immune to covid due to vaccines and prior infections.

The effectiveness of flu vaccines varies depending on how well its formula matches the virus circulating. This year’s vaccine appears more protective than last year’s, which reduced the risk of hospitalization from the flu by about 44% among adults. This year, researchers expect an effectiveness of about 52%, based on data collected during South America’s earlier flu season. Its benefit was higher for children, reducing hospitalizations by 70%.

The flu’s toll tends to be uneven among demographic groups. Over the past decade, hospitalization rates due to the flu were 1.8 times as high among Black people in the United States as among white individuals. Just 42% of Black adults were vaccinated against the flu during that period, compared with 54% of white or Asian adults. Other issues, ranging from a lack of paid sick leave and medical care to a prevalence of underlying conditions, probably contribute to this disparity. People who have asthma, diabetes, or cardiovascular issues or are immunocompromised are at higher risk of a severe case of flu.

Sean O’Leary, an infectious disease pediatrician and the chair of the American Academy of Pediatrics committee on infectious diseases, urges parents to vaccinate their kids against influenza and covid. Children hospitalized with co-infections of the two viruses last year were put on ventilators — an intense form of life support to allow them to breathe — far more often than those hospitalized for the flu alone. And covid is surging now, O’Leary said. Hospitalizations among children under age 18 increased nearly fivefold from June to September. “Almost all of our kids who have died have been completely unvaccinated” against covid, he said.

The FDA greenlighted new RSV vaccines from the pharmaceutical companies GSK and Pfizer this year. On Sept. 22, the CDC recommended that pregnant mothers get vaccinated to protect their newborns from RSV, as well as infants under 8 months old. The disease is the leading cause of hospitalization for infants in the United States. The agency also advises people age 60 and older to get the vaccine because RSV kills between 6,000 to 10,000 older adults each year.

Rather than vaccination, the CDC advised a new long-acting antibody treatment, nirsevimab, for children between 8 to 19 months old who are at risk of RSV. However, the price could be cost-prohibitive — anticipated at $300 to $500 a dose — and many hospitals lack the staff needed to administer it. Although insurers cover it, the American Academy of Pediatrics warns that reimbursement often lags for a year. “We don’t have the infrastructure in place to ensure all children can access the product,” said its president, Sandy Chung, in a statement. “And that is alarming.”

If the wrinkles can be ironed out, said Helen Chu, an infectious disease specialist at the University of Washington in Seattle, better tools could arrive as early as next year. Pfizer, Moderna, and other pharmaceutical companies are developing mRNA vaccines against influenza and RSV that may more precisely target each year’s circulating virus.

Today’s flu and RSV vaccines are produced using traditional vaccine platforms, such as within chicken eggs, that are more cumbersome to handle, and therefore the vaccines take longer to develop each year. And President Joe Biden has awarded companies $1 billion to develop covid vaccines that provide longer protection.

“The future is going to be all three vaccines together,” Chu said, “but that will be a while yet.”

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A CDC advisory committee has been updating its 2007 standards for infection control in hospitals this year. Many health care professionals and scientists expressed outrage after the group released a draft of its proposals in June.

The draft controversially concluded that N95 face masks are equivalent to looser, surgical face masks in certain settings — and that doctors and nurses need to wear only surgical masks when treating patients infected by “common, endemic” viruses, like those that cause the seasonal flu.

The committee was slated to vote on the changes on Aug. 22, but it postponed action until November. Once the advice is final, the CDC begins a process of turning the committee’s assessment into guidelines that hospitals throughout the United States typically follow. After the meeting, members of the public expressed concern about where the CDC was headed, especially as covid-19 cases rise. Nationwide, hospital admissions and deaths due to covid have been increasing for several consecutive weeks.

“Health care facilities are where some of the most vulnerable people in our population have to frequent or stay,” said Gwendolyn Hill, a research intern at Cedars-Sinai Medical Center in Los Angeles, after the committee’s presentation. She said N95 masks, ventilation, and air-purifying technology can lower rates of covid transmission within hospital walls and “help ensure that people are not leaving sicker than they came.”

“We are very happy to receive feedback,” Alexander Kallen, chief of the Prevention and Response Branch in the CDC’s Division of Healthcare Quality Promotion, told KFF Health News. “It is our goal to develop a guideline that is protective of patients, visitors, and health workers.” He added that the draft guidelines are far from final.

In June, members of the CDC’s group — the Healthcare Infection Control Practices Advisory Committee — presented a draft of their report, citing studies that found no difference in infection rates among health providers who wore N95 masks versus surgical masks in the clinic. They noted flaws in the data. For example, many health workers who got covid in the trials were not infected while wearing their masks at work. But still, they concluded the masks were equivalent.

Their conclusion runs contrary to the CDC’s 2022 report, which found that an N95 mask cuts the odds of testing positive for the coronavirus by 83%, compared with 66% for surgical masks and 56% for cloth masks. It also excludes a large clinical trial published in 2017 finding that N95 masks were far superior to surgical masks in protecting health workers from influenza infections. And it contradicts an extensive evaluation by the Royal Society, the United Kingdom’s national academy of sciences, finding that N95 masks, also called N95 respirators, were more effective against covid than surgical masks in health care settings around the world.

“It’s shocking to suggest that we need more studies to know whether N95 respirators are effective against an airborne pathogen,” said Kaitlin Sundling, a physician and pathologist at the University of Wisconsin-Madison, in a comment following the June meeting. “The science of N95 respirators is well established and based on physical properties, engineered filtered materials, and our scientific understanding of how airborne transmission works.”

Her assertion is backed by the California occupational safety agency, Cal/OSHA, whose rules on protecting at-risk workers from infections might be at odds with the CDC’s if the proposals are adopted. “The CDC must not undermine respiratory protection regulation by making the false and misleading claim that there is no difference in protection” between N95 masks and surgical masks, commented Deborah Gold, an industrial hygienist at Cal/OSHA, at the August meeting.

Researchers and occupational safety experts were also perplexed by how the committee categorized airborne pathogens. A surgical mask, rather than an N95, was suggested as protection for a category they created for “common, endemic” viruses that spread over short distances, and “for which individuals and communities are expected to have some immunity.” Three committee representatives, researchers Hilary Babcock, Erica Shenoy, and Sharon Wright, were among the authors of a June editorial arguing that hospitals should no longer require all health care workers, patients, and visitors to wear masks in hospitals. “The time has come to deimplement policies that are not appropriate for an endemic pathogen,” they wrote.

However, in a call with KFF Health News, Kallen clarified that the committee put coronaviruses that cause colds in that category, but not yet the coronavirus causing covid.

The committee’s next tier consisted of viruses in a “pandemic-phase,” when the pathogen is new and little immunity through infection or vaccination exists. It recommended that health workers wear an N95 mask when treating patients infected by bugs in this category. Its third, highest tier of protection was reserved for pathogens like those causing measles and tuberculosis, which, they claimed, can spread further than lower-tier threats and require an N95.

Virologists said the committee’s categories hold little water, biologically speaking. A pathogen’s mode of spreading isn’t affected by how common it is; common viruses can still harm vulnerable populations; and many viruses, including SARS-CoV-2, can travel significant distances on microscopic droplets suspended in the air.

“Large COVID outbreaks in prisons and long-term health care facilities have demonstrated that the behavior of infectious aerosols is not easily classified, and these aerosols are not easily confined,” wrote the deputy chief of health at Cal/OSHA, Eric Berg, in a letter of concern to the CDC committee, obtained by KFF Health News.

The committee pitted its assessment of N95 masks against their drawbacks. Its draft cites a study from Singapore in which nearly a third of health care personnel, mostly nurses, said wearing such masks negatively affected their work, causing acne and other problems exacerbated by hot and humid conditions and prolonged shifts. Rather than discard the masks, the authors of that study recommend better-fitting masks and rest breaks.

Noha Aboelata, a doctor and the CEO of Roots Community Health Center in Oakland, California, agrees. “There are other strategies to bring to bear, like improved mask design and better testing,” she said, “if we decide it’s unacceptable to give a patient covid when they go to the hospital.”

Aboelata is one of hundreds of doctors, researchers, and others who signed a letter to CDC Director Mandy Cohen in July, expressing concern that the CDC committee will weaken protections in hospitals. They also warned that scaling back on N95 masks could have repercussions on emergency stockpiles, rendering doctors and nurses as vulnerable as they were in 2020 when mask shortages fueled infections. More than 3,600 health workers died in the first year of the pandemic in the United States, according to a joint investigation by KFF Health News and The Guardian.

The concerned clinicians hope the committee will reconsider its report in light of additional studies and perspectives before November. Referring to the draft, Rocelyn de Leon-Minch, an industrial hygienist for National Nurses United, said, “If they end up codifying these standards of care, it will have a disastrous impact on patient safety and impact our ability to respond to future health crises.”

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“Urging people to get boosters has really only worked for Democrats, college graduates, and people making over $90,000 a year,” said Gregg Gonsalves, an epidemiologist at Yale University. “Those are the same people who will get this booster because it’s not like we’re doing anything differently to confront the inequities in place.”

As the effects of vaccines offered in 2021 have diminished over time, boosters have been shown to strongly protect people against severe covid and death, and more modestly prevent infection. They can have a dramatic impact on those most likely to die from covid, such as older adults and immunocompromised people. Public health experts say re-upping vaccination is also important for those in group housing, like prisons and nursing homes, where the virus can move swiftly between people in close quarters. A boost in protection is also needed to offset the persistent disparities in the toll of covid between racial and ethnic groups.

However, the intensive outreach efforts that successfully led to decent vaccination rates in 2021 have largely ended, along with mandates and the urgency of the moment. Data now suggests that the people getting booster doses are often not those most at risk, which means the toll of covid in the U.S. may not be dramatically reduced by this round of vaccines. Hospitalizations and deaths due to covid have risen in recent weeks, and covid remains a leading cause of death, with roughly 7,300 people dying of the disease in the past three months.

Tyler Winkelman, a health services researcher at Hennepin Healthcare in Minneapolis, said outreach of the intensity of 2021 is needed again. Back then, throngs of people were hired to tailor communication and education to various communities, and to administer vaccines in churches, homeless encampments, and stadiums. “We can still save lives if we are thoughtful about how we roll out the vaccines.”

Complicating matters, this is the first round of covid vaccines not fully covered by the federal government. Private and public health insurers will get them to members at no cost, but the situation for some 25 million-30 million uninsured adults — predominantly low-income people and people of color — is in flux. On Sept. 14, the CDC announced a kickoff of plans to temporarily provide vaccines for the uninsured, at least partly through $1.1 billion left over in pandemic emergency funds through the Bridge Access Program.

Costs are probably an issue, said Peter Maybarduk, at Washington-based advocacy organization Public Citizen. Moderna and Pfizer have more than quadrupled the price of the vaccines to about $130 a dose, compared with about $20 for the first vaccines and $30 for the last boosters, raising overall health care costs. Maybarduk pointed out that the U.S. government funded research involved in developing mRNA vaccines, and said the government missed an opportunity to request price caps in return for that investment. Both companies earned billions from vaccine sales in 2021 and 2022. Moderna’s latest investor report predicts another $6 billion to $8 billion in covid vaccine sales this year and Pfizer expects $14 billion. Maybarduk suggests the government would have more funds for equity initiatives if so much weren’t being spent on the boosters through Medicare, Medicaid, and its access program. “If these vaccines had been kept at the same price, what decisions would be made to expand the response?”

People age 75 and up have accounted for more than half of the country’s pandemic deaths. But whereas the first vaccines were quickly taken up in nursing homes, boosters have been less popular, with fewer than 55% of residents in Arizona, Florida, Nevada, and Texas getting the bivalent booster released last year. At some facilities nationwide, rates are below 10%.

Jails and prisons have seen some of the largest U.S. outbreaks — yet booster uptake there often appears to be poor. In Minnesota, just 8% of incarcerated people in jails and 11% in prisons have gotten last year’s booster, according to analyses of electronic health records by the Minnesota EHR Consortium. About 38% of people in prisons in California are up to date on boosters. Boosters make a difference. A study of California prisons found that among incarcerated people, the effectiveness of the first two doses was about 20% against infection, compared with 40% for three doses. (Prison staff saw larger benefits from three doses, an effectiveness of 72%, presumably because the chance of infection is lower when not living within the facilities.)

Low-income groups are also at heightened risk, for reasons including a lack of paid sick leave and medical care. In surveys of homeless people in California, about 60% reported chronic health conditions, said Tiana Moore, the policy director at the Benioff Homelessness and Housing Initiative at the University of California-San Francisco. Studies have found that members of this community age more rapidly, with people in their 50s experiencing strokes, falls, and urinary incontinence at rates typical of people in their late 70s and 80s.

Booster rates among people who lack housing are largely unknown, but Moore is concerned, saying they face high barriers to vaccination since many also lack medical providers, knowledge about where to go for vaccines, and the means to get there. “Many of our participants talked about concerns about leaving their belongings when unsheltered since they don’t have a door to lock,” she said. “That underscores the need to meet people where they are in an effective booster campaign.”

Black and Hispanic people have faced higher hospitalization and death rates than white people throughout the pandemic. And these groups are significantly less likely to be treated with the covid drug Paxlovid than white patients. (Hispanic people can be of any race or combination of races.)

Uneven rates of booster uptake may exacerbate these inequalities. An analysis of Medicare claims across the U.S. found that 53% of Hispanic people and 57% of Black people age 66 and older had received a booster by May 2022, compared with about 68% of their white and Asian counterparts. Disparities were most dramatic in cities where booster uptake among white people was above average. In Boston, for example, 73% of white people were boosted compared with 58% of Black people.

People opt out of vaccination for many reasons. Those living farther from vaccine sites, on average, have lower rates of uptake. Misinformation spread by politicians may account for disparities seen along political lines, with 41% of Democrats having gotten a bivalent booster compared with 11% of Republicans. Lower vaccine coverage among Black communities has been found to stem from discrimination by the medical system, along with worse health care access. However, many Black people who hesitated at first eventually got vaccines when given information and easy access to them, suggesting it could happen again.

But Georges Benjamin, executive director of the American Public Health Association, said the downturn of reporting on vaccination and covid rates makes it harder to tailor outreach.

“If we had the data, we could pivot quickly,” he said, adding that this was once possible but that reporting lapsed after the end of the public health emergency this spring. “We’ve gone back to the old way, re-creating the conditions in which inequities are possible.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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El cansancio y las náuseas de su marido fueron tan intensas que no fue a trabajar por tres días. Pero bebió agua con lima en lugar de ir al médico porque no tienen seguro médico. “A mucha gente le pasa esto”, agregó.

No existen normas federales para proteger a los trabajadores como los García cuando los días son excesivamente calurosos. Y sin el apoyo bipartidista del Congreso, incluso con la atención urgente de la administración Biden, es posible que el alivio no llegue en años.

El presidente Joe Biden encargó en 2021 a la Administración de Seguridad y Salud Ocupacional (OSHA) la elaboración de normas para prevenir los accidentes y las enfermedades causados por el calor.

Pero ese proceso de 46 pasos puede llevar más de una década y podría estancarse si un republicano es elegido presidente en 2024, porque el Partido Republicano se ha opuesto generalmente a las regulaciones de salud laboral en los últimos 20 años.

Estas normas podrían obligar a los empleadores a proporcionar abundante agua potable, descansos y un espacio para refrescarse a la sombra o con aire acondicionado cuando las temperaturas superen un determinado umbral.

El 7 de septiembre, OSHA comenzó reuniones con propietarios de pequeñas empresas para discutir sus propuestas, incluidas las medidas que deberían adoptar las empresas cuando las temperaturas llegan a los 90 grados.

Como este verano se han batido récords de calor, la congresista Judy Chu (demócrata de California) y otros miembros del Congreso han impulsado una legislación que aceleraría el proceso de elaboración de normas de OSHA.

El proyecto de ley lleva el nombre de Asunción Valdivia, una trabajadora agrícola que se desmayó mientras recogía uvas en California en un día de 105 grados en 2004. Su hijo la recogió del campo y Valdivia murió de un golpe de calor en el trayecto a su casa.

“Ya sea en una granja, conduciendo un camión o trabajando en un almacén, los trabajadores como Asunción mantienen nuestro país en funcionamiento mientras soportan algunas de las condiciones más difíciles”, dijo Chu en declaraciones en julio en la que instaba al Congreso a aprobar el proyecto de ley.

Las organizaciones profesionales que representan a los empresarios se han opuesto a las normas, calificándolas de “exageradas”. También afirman que faltan datos que justifiquen regulaciones generales, dada la diversidad de trabajadores y lugares de trabajo, desde restaurantes de comida rápida hasta granjas.

La Cámara de Comercio de Estados Unidos, uno de los grupos de presión más poderosos de Washington, argumentó que tales medidas carecen de sentido “porque cada empleado experimenta el calor de forma diferente”. Además, según la Cámara, normas como los ciclos de trabajo-descanso “amenazan con perjudicar directa y sustancialmente… la productividad de los empleados y, por lo tanto, la viabilidad económica de su empleador”.

“Muchos de los problemas relacionados con el calor no son consecuencia del trabajo agrícola ni de la mala gestión del empresario, sino del moderno estilo de vida de los empleados”, escribió el Consejo Nacional del Algodón en su respuesta a la legislación propuesta.

Por ejemplo, el aire acondicionado hace más difícil que las personas se adapten a un ambiente caluroso después de haber estado en una vivienda o un vehículo fríos, y señaló que “los trabajadores más jóvenes, más acostumbrados a un estilo de vida más sedentario, no pueden aguantar un día trabajando al aire libre”.

La Asociación de Recursos Forestales, que representa a los propietarios de terrenos forestales, la industria maderera y los aserraderos, agregó que “las enfermedades y muertes relacionadas con el calor no figuran entre los riesgos laborales más graves a los que se enfrentan los trabajadores”. Citaron cifras de OSHA: la agencia documentó 789 hospitalizaciones y 54 muertes relacionadas con el calor a través de investigaciones e infracciones de 2018 a 2021.

OSHA admite que sus datos son cuestionables. Ha dicho que sus cifras “sobre enfermedades, accidentes y muertes relacionadas con el calor en el trabajo son probablemente grandes subestimaciones”.

Los accidentes y enfermedades no siempre se registran, las muertes provocadas por las altas temperaturas no siempre se atribuyen al calor, y los daños relacionados con el calor pueden ser acumulativos, provocando infartos, insuficiencia renal y otras dolencias después de que la persona haya abandonado su lugar de trabajo.

El efecto de la temperatura