Just over a year ago, a cadre of doctors, nurses and other health care workers gathered under a canopy in the driving rain outside Hartford Hospital. They watched as Dr. Ajay Kumar, the chief clinical officer, became the first person in Connecticut to be inoculated against COVID-19.
Others stood in line for their turn. The day swelled with the promise of an eventual end to the pandemic, or at least a lighter immediate future.
“That’s it!” exclaimed Gov. Ned Lamont, who stood watching nearby. “A new day. Help is on the way.”
By the end of 2021, Connecticut’s eligible population would be more than 78% vaccinated, one of the highest rates in the country. But challenges have continued to mount.
At the end of 2020, there had been 185,708 cases of COVID-19 in Connecticut and nearly 6,000 deaths. By Dec. 21, 2021, there had been 471,141 cases and more than 9,000 deaths.
Plunging cases and hospitalizations in the spring gave way to another rise in infections in July, driven by the contagious delta variant.
Connecticut’s 27 acute care hospitals banded together over the summer and announced they would mandate that employees and people who contract with hospitals be vaccinated against COVID-19. By the fall, those requirements went into effect, and while many holdouts ultimately got immunized, others left or were fired.
Operators at nursing homes, which were battered during the pandemic, began imposing their own coronavirus vaccine requirements until the state declared in September that workers at all long-term care facilities would have to be inoculated.
Some facilities are still struggling with either vaccinating their staff or submitting verification: The state said it has handed out more than $19 million in fines to 101 long-term care centers that failed to report employee immunization rates.
In August, the state announced it was planning to roll out booster shots for people who were at least six months past their initial two-dose vaccine regimen. Federal guidance was puzzling: boosters were allowed for people 65 and older, those with underlying health conditions, those who work in long-term care settings and those who work or live in “high risk” environments. The categories were broad and vague, causing some people to avoid getting a booster out of confusion.
By November, with case rates steadily climbing, Lamont joined a handful of other states in encouraging residents to buck federal recommendations and get a booster shot regardless of occupation or condition. Everyone 18 and older who had gone six months or longer since their first two doses could get a booster (people who received the single-dose Johnson & Johnson are eligible two months after their initial shot).
Two days after Lamont’s announcement, the federal government opened boosters to everyone 18 and older.
Providers had been offering boosters to the wider public for precisely a week before news of a troubling new variant exploded. As Connecticut health officials look ahead to 2022, they are relying on vaccination and boosters in particular as defenses against omicron and so far have been reluctant to resurrect requirements that were common throughout 2020 – including mask mandates and limits on crowd sizes at indoor and outdoor venues.
A COVID-19 vaccine mandate for school-age children is up for debate, and the work around vaccine equity locally and globally continues.
“There was a lot of hope around what 2021 would look like, going forward,” said Dr. Manisha Juthani, the state’s public health commissioner. “What is humbling … which we’ve always known in theory, but we saw it play out with what happened with the delta wave this summer, is that, until the entire world has sufficient access to vaccines and we have thresholds of vaccinated people in each area to really reduce the amount of replication that’s happening in the world, the threat of variants will always loom.”
Vaccines for children
In early November, parents anxious to vaccinate their young children against the coronavirus received the news they had been waiting for: The Centers for Disease Control and Prevention and the Food and Drug Administration granted emergency authorization to Pfizer’s COVID-19 vaccine for children ages 5 to 11.
Some physicians are now advocating for the COVID-19 vaccine to be added to the list of the state’s mandatory immunizations for school-age children. The measles, mumps and rubella shot and the polio vaccine are among the immunizations already required for children to attend school.
“What I do know is that vaccines for children, if not mandated, would not be as effective,” said Dr. Juan Salazar, physician in chief at Connecticut Children’s Medical Center. “If we left it entirely up to our communities to decide whether to get measles vaccines or meningitis vaccines for either haemophilus influenza or meningicocus, our rates of vaccination would be much lower.”
As the pandemic continues, Salazar said, children “may actually be the reservoir where the virus continues to perpetuate itself, as we’ve seen with other viruses.”
“I’m guessing that at the beginning of next school year, we’ll have some form of mandate for kids who are beginning in elementary school early on,” he said. “Whether we extrapolate that to day care depends on the data and when that vaccine is approved for [children] six months and above.
“Ultimately, the only way we’re going to be able to solve this – at least for the pediatric age – is by providing some form of mandate that really requires the kids to be fully vaccinated before they get back to school.”
Even before the children’s vaccine won emergency approval, California Gov. Gavin Newsom announced he was imposing a mandate for kids in public and private schools.
California’s mandate will be phased in as the FDA grants full approval to the shot for children. Students who opt out of the requirement – and who don’t have a medical or personal belief exemption – would have to be homeschooled.
In Connecticut, health officials and politicians have begun to debate the prospect of a requirement or school-age children. So far, Lamont has said he has no plans to impose one.
But Juthani, the state health commissioner, has said she supports a mandate once the shot receives full federal approval.
“We have vaccine mandates for many other vaccines,” she told the CT Mirror. “This vaccine technology has been tested for many, many decades, and it is the way that our lives are going to be able to get back to some sort of normalcy.”
Others in the health community, including the Connecticut Chapter of the American Academy of Pediatrics, and education advocates have also said they support such an edict.
Some lawmakers said a bill could be raised during the upcoming legislative session to adopt a vaccine mandate for school kids. But they acknowledged the process would be politically difficult, and the 2022 session, which begins in February, only lasts three months.
“I wouldn’t rule out such a possibility, because if the data are sufficient and indicate that this would be a good thing to do given the high transmissibility of COVID, it’s quite possible [federal agencies] would recommend to us that it be added to the list” of mandatory shots, Rep. Jonathan Steinberg, a co-chair of the Public Health Committee, said.
Connecticut was an early leader in vaccine administration and continues to have one of the highest rates of vaccination in the country. But its vaccine rollout proceeded inequitably and exposed existing racial and socioeconomic disparities in access to health care, said Tekisha Everette, executive director of health equity solutions.
Pandemic control measures have assumed that all residents have access to the same resources, from the ability to work at home to the ability to access the internet.
“We have a system that is designed to produce outcomes that we are getting,” Everette said. “I’m really interested and excited about increasing community voice in our policymaking opportunities. If nothing else, we were taught during the pandemic and having to complete legislative sessions via Zoom that we can make policymaking much more accessible, much more equitable.”
The pandemic also highlighted the need to invest in public health infrastructure, particularly in the state’s cities, she added. The state’s efforts to find and empower trusted messengers have been imperfect, but investments in relationships with local community leaders are “a permanent solution. You don’t need to recreate the wheel next year to the new pandemic,” Everette said.
Even as Connecticut has made strides in increasing access to the vaccine, much of the rest of the world was left behind.
The omicron and delta variants have brought into sharp focus the need to vaccinate the entire world, “both for moral reasons but also for reasons of pure self-interest,” said Saad Omer, director of the Yale Institute for Global Health. “The success of the U.S. domestic response depends on what happens internationally.”
Globally, more people have died of COVID in 2021 than in 2020. To some degree, that statistic is a product of challenges in accurately counting COVID deaths as the pandemic hit last year, but it also reflects the difficulties that much of the world has had in accessing vaccinations against the disease.
COVAX, the World Health Organization’s initiative to distribute vaccines equitably, has lacked adequate supply to share doses with the rest of the world. The director-general of the World Health Organization called for a moratorium on boosters for the general population until the end of the year, but the Centers for Disease Control and Prevention threw open doors to near-universal booster eligibility last month.
Omer believes the United States can distribute boosters widely and that low- and middle- income countries can vaccinate their populations in tandem.
“Equity doesn’t have to be a zero-sum game. You can increase the size of the pie,” he said. “Very recently, the supply outlook has improved because COVAX has been able to get vaccine doses” after the Biden administration infused the program with more funding.
That said, the administration could do more to increase supply, Omer said, even though it surpasses its European counterparts in donating doses. “The U.S. announced the highest level of donation at 1.1 billion, but so far, only 25% of that has been delivered and another 25% has been allocated,” he said two weeks ago. “Press releases don’t save lives.”
But even with increased supply, much of the world still has challenges ahead in promoting vaccine acceptance. Earlier this year, Omer and his colleagues estimated that rates of vaccine hesitancy were lower among low- and middle-income countries when compared to high-income countries, but less wealthy countries were disincentivized to stoke demand for vaccines that they could not immediately provide.
“In that environment, vaccine hesitancy rose,” Omer said. After limited investment in education and outreach, many countries will now face an uphill battle in convincing their populations to embrace the vaccines as supply becomes available. “These delays did have an impact on the demand itself.”
Even as case rates have climbed this fall and winter, state leaders stood firm in refusing to revive some of the requirements that were common throughout 2020, including an indoor mask mandate and capacity limitations in restaurants, retail establishments and entertainment venues.
The Lamont administration has emphasized personal responsibility, such as getting vaccinated or seeking a booster shot and wearing a mask indoors when the vaccination status of those nearby is unclear.
“People in the state of Connecticut know what masks have done to help protect them in a community, and people are making that decision every day,” Juthani said.
Officials have said it is difficult to revive mandates once they have been taken away.
“One of the things that’s a challenge is when we have put policies in place and then we relax those policies, it’s very hard for people mentally to want to go back to an old policy,” Juthani has said.
“For every mandate, there’s enormous pushback, and you create some issues,” he said earlier this month on WNPR’s “Where We Live” radio show. “I do believe that fear is a great incentive. We have more people getting the booster today than we had two weeks ago without a mandate. They’re doing the right thing.”
But some physicians have begun to question whether additional requirements would serve the state well as the case rates go up and the omicron variant continues to spread.
“We all would love to live in a space where [people’s] personal responsibility leads them to an end goal that we all want. But if tomorrow Gov. Lamont made a decision that we’re going back to a mask mandate, I don’t think that would be the wrong thing,” said Dr. Keith Grant, Hartford HealthCare’s senior director of infection prevention. “I understand why the decision was made before to remove the mandate and to stick with the decision. I don’t know how far he is from changing that decision. I wouldn’t be surprised if it’s changed very soon.”
“Government still has a significant role to play,” he added. “Government intervention may not be … very welcome. But it worked.”
The state may want to consider requiring proof of vaccination for indoor dining and entertainment locations, Omer said. “Vaccines do not completely prevent transmission, but they do reduce it.”
“I can go to New York and go to ‘Hamilton’ [on Broadway], and they make me wear a mask and check my vaccine requirement,” he said. “But when I go to my local theater, movie theater, there’s no requirements. That’s dangerous, and that’s bad for business as well. A lot of people are sick and tired of feeling vulnerable outside, and being able to celebrate the holidays, to go out for a movie, for example, to an indoor venue and feel safe is important.”
The state has released a digital card that would allow establishments to verify the vaccination status of their patrons. The governor has stressed that using the card is voluntary for both businesses and customers and that the card is not a precursor to a state-wide mandate that would require its use to access goods and services.
Lamont has yet to decide if towns and cities will be able to mandate its use within their jurisdictions. Currently, municipalities can only require proof of vaccination for their own employees or as a condition of entry to their buildings.
Hopes, concerns for the new year
As the cold weather sets in, hospitals are experiencing an influx of COVID-19 patients. Hospitals are also dealing with patients who put off medical care in 2020 amid fears about catching the coronavirus.
“In our health system, it’s being able to accommodate an ongoing surge of patients for COVID, while at the same time taking care of patients who are presenting to our institution sicker, and in later stages of their medical conditions, requiring more care and longer-length stay,” said Dr. Tom Balcezak, chief clinical officer at Yale New Haven Health. “That means all of our already tired, overburdened, sometimes smaller staff are having to do more work. So staffing is a challenge; taking care of the crush of patients is going to be a challenge.”
Nathan Grubaugh, associate professor of epidemiology at the Yale School of Public Health, tweeted that he expects omicron to be dominant in the state in the next few days, though the possibility remains that it could co-circulate with the delta variant.
Researchers are still trying to understand the omicron variant, but the strain is considered to be highly transmissible. Preliminary evidence suggests that omicron has a lower hospitalization rate than delta, partly due to its biological composition and partly due to prior immunity in the populations studied, the New York Times reported.
But though the variant may turn out to be milder, “I do worry about a large proportion of the population having this long-term disability as a result of getting the virus,” said Akiko Iwasaki, professor of immunobiology and epidemiology at the Yale School of Medicine.
There are challenges in defining “long COVID,” and the United States does not presently have a national surveillance system equipped to track it, so estimating prevalence can be tricky.
“If you look at the hospitalized cohort that are discharged, anywhere between 50% to 75% of that population is still having long-term symptoms for weeks and months. And people who have milder disease who are never hospitalized, or people with a very mild disease that didn’t even realize they had it, they also go on to develop long COVID. And that’s estimated to be between 10% to 30%,” Iwasaki said. “I’m hoping that there will be … [a] universal diagnosis for long COVID, and that way we can start to have more numbers and epidemiology and demographics and risk factors.”
At present, treatments for long COVID help patients manage symptoms but don’t address the root cause, because researchers don’t yet understand the condition.
“There are a couple of hypotheses that we’re pursuing. One is that there may be a viral reservoir that’s established that could be chronically inducing inflammatory response. The other possibility is autoimmune disease,” Iwasaki said, adding that she remains optimistic that 2022 will bring insights that will help in the creation of new therapies.
“I do have hope, and without hope, we can’t do this. Because science is hard. And most of the time we’re wrong, but cumulatively we will discover things that can help people.”
Looking back over 2021, Grant, Hartford HealthCare’s senior director of infection prevention, said he appreciates all of the strides that have been made – the quick development and rollout of the coronavirus vaccine; physicians, nurses and other health providers working hard despite being overstretched; and agencies working together that normally wouldn’t.
But the nation still hasn’t taken stock of the impact that COVID-19 has had on children and families, he said.
“Hopefully at some point in 2022, we’ll be able to appreciate the life that’s been lost in this and the impact that it has had,” he said. “Kids have lost two years of socializing and developing; it’s had an impact on mental health. So I’m hoping we will have time in 2022 … to appreciate and just to remember and reminisce on the impact of this disease.”