C.D.C. Panel Recommends Restarting J.&J. Vaccine

The U.S. is likely to permit the Johnson & Johnson shot if the panel says the benefits outweigh any blood clot risk. Here’s the latest on Covid-19.,

LiveUpdated April 23, 2021, 5:52 p.m. ETApril 23, 2021, 5:52 p.m. ET

The U.S. government is likely to follow the panel’s recommendation and end the pause. In India, which recorded more than 330,000 cases in 24 hours, the second consecutive global record, hospitals plead for oxygen.

A vial containing doses of the Johnson & Johnson Covid-19 vaccine.
A vial containing doses of the Johnson & Johnson Covid-19 vaccine.Credit…Bryan Anselm for The New York Times

A panel of advisers to the Centers for Disease Control and Prevention on Friday voted to recommend lifting the pause on the Johnson & Johnson Covid-19 vaccine for all adults and adding a label about an exceedingly uncommon, but potentially dangerous, blood clotting disorder.

The vote came after a C.D.C. scientist presented nine new confirmed cases of the disorder, bringing the total to 15. All the cases have been in women, and 13 have been in women between 18 and 49 years old.

Federal health officials are expected to respond quickly and formally recommend that states lift the pause. Several states, including Texas, Alabama, Utah and Wisconsin, said they expected to follow that recommendation.

Administration of the vaccine ground to a halt last week after reports emerged of a rare blood clotting disorder in six women who had received the vaccine. The disorder combines blood clots, often in the brain, and a low level of platelets, blood cells that typically promote clotting.

“This pause was essential to our ability to inform the public,” Dr. Jose R. Romero, the chair of the advisory panel, said at the meeting.

The overall risk of developing the clotting disorder is extremely low. Women between 30 and 39 appear to be at greatest risk, with 11.8 cases per million doses given. There have been 7 cases per million doses among women between 18 and 49.

Three women have died from the rare clots and seven remain hospitalized, four of whom are in the intensive care unit, a C.D.C. scientist said at Friday’s meeting.

“These cases are not just numbers to any of us, and we take them very seriously,” Dr. Joanne Waldstreicher, the chief medical officer of Johnson & Johnson, said at the meeting. “These are people.”

The company supported adding a warning label to the vaccine, and has agreed upon language for a potential label with the F.D.A., she said. The label she presented notes that “most cases” of the clotting disorder have occurred in women between 18 and 49 years old.

Nearly 8 million doses of the Johnson & Johnson vaccine have now been administered. Among men and women who are 50 or over, there has been less than one case per million doses.

The clotting disorder is “rare but clinically serious,” Dr. Tom Shimabukuro, the deputy director of the C.D.C.’s immunization safety office, said at the meeting.

Roughly 10 million doses or more of the Johnson & Johnson vaccine, produced at the company’s factory in the Netherlands, are sitting on shelves across the United States and could be deployed immediately.

The vaccine has immense potential benefits for the population. If vaccinations resume for all adults, 26 to 45 cases of the clotting disorder would be expected over the next six months, according to a model presented by Dr. Sara Oliver, a C.D.C. scientist. However, 600 to 1,400 fewer Covid-19 related deaths would be expected over the same time period.

The vaccine, which is easy to store and requires just one shot, is also especially well-suited for use in hard-to-reach populations, including people who are homebound, homeless, or incarcerated.

Additional potential cases of the clotting disorder, including some in men, are currently being reviewed. The C.D.C. scientist also mentioned one case that developed in a 25-year-old man who participated in a clinical trial of the vaccine.

Twelve of the 15 women in the confirmed cases developed blood clots in the brain. Many also had clots elsewhere. Initial symptoms, which include headaches, typically begin six or more days after vaccination, Dr. Shimabukuro said. As the disorder develops, it can cause more severe headaches, nausea and vomiting, abdominal pain, weakness on one side of the body, speech difficulties, loss of consciousness and seizures.

Dr. Shimabukuro noted that seven of the women were obese, two had hypothyroidism, two had high blood pressure, and two were using oral contraceptives. It is not yet clear whether any of these factors might increase the risk of developing the clotting disorder after vaccination.

The patients’ symptoms closely resemble a rare syndrome that can be caused by heparin, a widely used blood thinner, Dr. Michael Streiff, a hematologist at Johns Hopkins University, told the panel. Heparin, which might typically be used to treat blood clots, should not be used to treat these patients, he said.

Doctors should consider the rare clotting disorder in patients who present with blood clots and low levels of platelets within three weeks of receiving the Johnson & Johnson vaccine, Dr. Streiff said.

“Recognition that this syndrome exists is helping to improve outcomes,” he said.

The meeting comes as the federal government is also investigating problems at a Baltimore factory that was slated to help satisfy the country’s vaccine demand. Emergent BioSolutions, the plant’s operator, has produced tens of millions of doses of Johnson & Johnson’s vaccine, but they cannot be distributed until regulators certify the plant.

After Emergent had to discard up to 15 million possibly contaminated doses of the vaccine last month, federal regulators conducted an inspection that found a series of problems, including the risk that other batches could have been contaminated.

United States > United StatesOn Apr. 22 14-day change
New cases 66,362 -6%
New deaths 911 -2%
World > WorldOn Apr. 22 14-day change
New cases 882,803 +27%
New deaths 13,011 +12%

U.S. vaccinations >

Where states are reporting vaccines given

Fully vaccinated

At least one dose

Other trackers:

Medical students and physician assistants from Touro University Nevada waiting to screen people in Las Vegas last month.
Medical students and physician assistants from Touro University Nevada waiting to screen people in Las Vegas last month.Credit…Steve Marcus/Reuters

Some county health departments that a month ago couldn’t keep up with vaccine demand have now started closing some of their mass vaccination sites for lack of customers, and some counties are declining vaccine shipments.

Now that more than half of adults in the United States have received at least one Covid-19 vaccine dose and the country has surpassed 200 million administered doses, demand for shots appears to be slowing in many areas.

White House and health officials are comparing the next phase of the vaccination campaign to a get-out-the-vote effort. Officials in many states are looking past mass vaccination sites and toward having patients get vaccinated by their own doctors, where people are most at ease — a shift that will require the Biden administration to ship vaccine in much smaller quantities.

The seven-day average of vaccinations has declined somewhat in recent days, to 2.86 million doses a day as of Friday, from a high point of 3.38 million last week, according to a New York Times analysis of data from the Centers for Disease Control and Prevention.

At a news conference on Friday, Jeffrey D. Zients, the White House’s Covid-19 response coordinator, acknowledged that the pace of vaccinations nationally would ebb. “We expect daily vaccination rates will moderate and fluctuate. We’ve gotten vaccinations to the most at risk and those most eager to get vaccinated as quickly as possible,” he said. “And we will continue those efforts, but we know reaching other populations will take time and focus.”

Mr. Zients said two new federally-run vaccination sites would open Friday in Kentucky, with a combined capacity of 7,000 shots each week.

Even with persistent vaccine hesitancy, the reasons for the dip in vaccination rates are still not entirely clear. Injections of Johnson & Johnson’s vaccine were halted last week as federal health officials investigated a potential rare side effect may have had some effect on daily tallies, with millions of doses now sitting on shelves and yet-to-be-allocated. A drop in interest has been especially acute in some regions of the country, with significant declines in the South. On Friday, a panel of advisers to the C.D.C. voted to recommend lifting the pause on the vaccine for all adults and adding a label about an exceedingly uncommon, but potentially dangerous, blood clotting disorder.

While every person 16 and older in the country became eligible for a coronavirus vaccination on Monday, dropping demand has pushed Mercer County, Ohio — where 27 percent of adults have at least one dose — to announce the closing of its mass vaccination site on May 7.

“It wasn’t fair to ask our volunteers to keep showing up there when they weren’t being fully utilized — they like to keep busy,” Jason Menchhofer, county health administrator, said in an interview on Thursday about the site on the local fairgrounds.

In the first few months of the year, the site in the county of 41,000, which borders Indiana, would fill up its 400 appointments in an hour or two, he said. “We could even reach down into those who were not age-eligible to get it to come in at the end of the day to come out quickly and get it into someone’s arm,” he said.

But demand has fallen precipitously in the last several weeks, and last week the county ended up wasting two doses, which was a first. “We no longer have a reserve of people who want to be vaccinated to reach into to show up and take those doses,” he added.

The largest vaccination site in Las Vegas, the Cashman Center, will close on May 5 as the list of open appointments grow and the lines to be inoculated have dwindled. The tens of thousands of open appointments at sites across the nation are forcing officials to pivot their outreach strategies and zero in on smaller events.

Palm Beach County in Florida said on Tuesday that it would shut its three mass vaccination sites, which are operating at about half capacity, by the end of May. Of 16,000 appointment slots available this week, only 6,000 were filled, according to health officials. Instead, three mobile units will each aim to give 500 doses a day.

In Galveston County, Texas, a mass drive-through clinic at a county park won’t operate after May 1. The park has been administering 5,000 doses per day, including on Thursday. But demand for appointments has dampened in the last three weeks, according to the county’s chief public health officer. He also asked the state to pause vaccine shipments.

“We’re concerned that some of it may expire before we use it, if we keep getting it,” said Dr. Philip Keiser. “We are trying to figure out how to balance out supply and demand, yet also have enough on hand so that when school kids are able to get back, we can do them.”

There will be much more targeted outreach, down to the Census tract level, Dr. Keiser said, and there might be 100 or 200 injections per day rather than thousands.

“We got about 50 percent of our people vaccinated,” he said, “and we recognize that next 25 percent is going to be a lot harder than the first.”

A paramedic checking the oxygen level of a patient inside an ambulance in Ahmedabad, India, on Thursday.
A paramedic checking the oxygen level of a patient inside an ambulance in Ahmedabad, India, on Thursday.Credit…Amit Dave/Reuters

The Times’s Emily Schmall reports from New Delhi on the desperate situation in India. The following is an excerpt from her article.

NEW DELHI — A catastrophic second wave of the coronavirus is battering India, which is reporting the world’s highest number of new infections as hospitals and patients beg for fast-diminishing oxygen supplies and other emergency aid.

India recorded more than 330,000 coronavirus cases in 24 hours, the health ministry said on Friday, the second consecutive day that the country has set a global record for daily infections.

Canada has joined Britain, Hong Kong, Singapore and New Zealand in barring travelers coming from India. And the U.S. State Department advised people against going to India after the Centers for Disease Control raised the risk level to its highest measure.

Even as cases have climbed, Prime Minister Narendra Modi’s governing Bharatiya Janata Party and other parties have continued to hold mass rallies with thousands of people unmasked. The government has also allowed an enormous Hindu festival to draw millions of pilgrims despite signs that it has become a superspreader event.

The catastrophe in India is playing out vividly on social media, with Twitter feeds and WhatsApp groups broadcasting hospitals’ pleas for oxygen and medicines, and families’ desperate searches for beds in overwhelmed Covid-19 wards. With many hospitals short of ventilators, television reports have shown patients lying inside ambulances parked outside emergency rooms, struggling to breathe.

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Mayor Bill de Blasio of New York announced on Friday that all eligible residents could now get vaccinated for Covid-19 at any city-run site without an appointment.CreditCredit…James Estrin/The New York Times

New York City is now allowing any eligible New Yorker to get vaccinated at city-run sites without an appointment, an attempt to simplify the inoculation process and expand access, Mayor Bill de Blasio said on Friday.

“We want to make it simple,” Mr. de Blasio said at a news conference. “We want to encourage people. And let’s face it, convenience matters to New Yorkers.”

The city had begun allowing walk-in vaccinations for people older than 50 last week. Friday’s expansion to all eligible New Yorkers is limited to sites run by the city’s health department and its public hospital system, but as of Friday, New York State has also begun allowing walk-in vaccinations to anyone older than 60 at 16 of its vaccination sites, including five in New York City.

Being able to walk into a vaccine site will simplify a process that had confounded many New Yorkers desperately seeking vaccines. Appointments at all vaccination sites, including those run by the city, were elusive for months. New Yorkers often had to check dozens of websites, each with different sign-up protocol. In some cases, appointments seemed to disappear as residents were trying to book them.

Officials had long worried that navigating the complex system was a major barrier to the equitable distribution of the vaccines in New York.

As the supply of vaccines increased, appointments became far less scarce. Mr. de Blasio said that the city was now confident enough in its continued supply to eliminate the need for appointments.

Mr. de Blasio also said that the city was eliminating rules that restricted appointments to residents of neighborhoods surrounding certain sites.

The requirements were initially meant to address inequitable distribution of the vaccine and ensure that residents in harder-hit neighborhoods or boroughs had access to inoculations.

As of Friday, more than six million doses of Covid vaccines have been administered in New York City. According to the city’s data, 50 percent of residents over 18 have received at least one dose.

But inequity remains: 60 percent of eligible adults have received one dose of the vaccine in Manhattan, compared to 41 percent in the Bronx and 45 percent in Brooklyn.

Black and Latino residents are also being vaccinated at a slower pace than white residents. Of the city residents who received one dose and whose race was recorded, about 34 percent were white, 21 percent were Asian, 20 percent were Latino and 13 percent were Black. The city’s population is roughly 29 percent Latino and 24 percent Black.

The new walk-in policy does not expand eligibility requirements for the vaccine: Only those ages 16 and older can receive the Pfizer-BioNTech vaccine, and only those 18 and older can receive the Moderna vaccine.

Mr. de Blasio said the city was pressing community health centers to adopt similar policies. Officials were also urging private doctors to call their patients and urge them to get vaccinated.

An inoculation at a union hall in Chicago on April 6. Coronavirus cases in Illinois are starting to recede.
An inoculation at a union hall in Chicago on April 6. Coronavirus cases in Illinois are starting to recede.Credit…Kamil Krzaczynski/Agence France-Presse — Getty Images

For weeks, Illinois has been beset by a stubbornly high daily load of reported coronavirus cases, leading to climbing hospitalizations and deaths. But new data is signaling that the virus might be on the verge of retreat.

Illinois is reporting an average of about 2,900 new cases a day, down nearly 13 percent from a week ago. Central Illinois, which saw major growth in cases earlier this month, is now improving, according to a New York Times database — especially in Peoria, one of the metropolitan areas where the virus had been spreading the fastest.

“It is great we have seen some abatement in local hot spots,” said Dr. Emily Landon, the chief epidemiologist at the University of Chicago, who has been advising Gov. J.B. Pritzker on the state’s pandemic response. Dr. Landon cautioned that there were other pockets of the state, though, especially those with low vaccine rates, that remain ripe for “a fiery outbreak.”

“I wouldn’t say everybody is out of the woods,” she added.

Illinois’s latest surge in cases followed the rising trends in other Midwest states like Michigan and Minnesota beginning in late February and March. The situation grew particularly worrisome in Michigan, which continues to lead the nation in cases per 100,000 per people, but has seen a 15 percent decline over the past two weeks.

The case counts surged at a time when variants were starting to spread widely, and states have been racing to vaccinate as many people as possible, in part to head off the variants. About a quarter of Illinois’s population is now fully vaccinated, and 43 percent of residents have received as least one shot. Officials said the recent surge may be burning itself out in part because of the growing number of people who are protected.

“We have seen a beginning, of maybe a lessening of the rise of cases,” Governor Pritzker said last week. “I don’t want to predict anything, because this virus is unpredictable. But I think at least in the short term, that seems to be good news.”

In Central Illinois, Peoria County reported new-case declines of about 23 percent from two weeks ago. Local officials said that when vaccinations first became widely available, people started taking fewer precautions, even though highly contagious variants were spreading.

“It led to the perfect storm,” said Monica Hendrickson, public health administrator for the Peoria City/County Health Department.

Hospitalizations and Covid deaths remain high in Illinois, putting mounting pressure on the health care system. Hospitalizations are up by about 29 percent over the past two weeks, and deaths have risen by 15 percent during that period, according to Times data.

Dr. Michael Cruz, chief operating officer at OSF HealthCare, said on Thursday that about a half-dozen of the hospital system’s medical centers in Illinois are at more than 90 percent of capacity. He said it was too early to say whether the recent decline in new case reports was a “true inflection point.”

“The virus does what the virus does,” Dr. Cruz said. “Let it hang around long enough, it will start mutating.”

The heavily-touristed area of Condado, in San Juan, the Puerto Rican capital,  on Wednesday.
The heavily-touristed area of Condado, in San Juan, the Puerto Rican capital, on Wednesday.Credit…Erika P. Rodriguez for The New York Times

SAN JUAN, P.R. — Throughout the pandemic, Dr. Victor Ramos, a pediatrician, had not seen more than two Covid-19 patients hospitalized at the same time at San Jorge Children & Women’s Hospital in San Juan, the Puerto Rican capital, where he works nights. When he left after one of his shifts a few days ago, the hospital’s pediatric patient count had grown to 10.

“We had never seen that,” he said.

Puerto Rico has experienced its worst coronavirus outbreak of the pandemic over the past five weeks, with an explosive growth in cases exceeding records that had been set in December. Only this week did the numbers stop rising, giving the territory its first respite since the surge began in mid-March.

Behind the rise, experts say, was a confluence of factors, including the arrival of variants that probably made the virus more contagious right when people weary of staying home and hopeful about vaccines began to let their guard down, returning to work in person and shopping and dining indoors. Tourists poured in for Spring Break season. People gathered to celebrate Holy Week, a time when many are off work.

“The government relaxed restrictions around January and February — it opened the economy completely,” said Mayor Luis Javier Hernandez Ortiz of Villalba, a town in south-central Puerto Rico. “This gave the virus opportunities to spread that it didn’t have a year ago.”

In early April, the island went from averaging about 200 new cases a day to about 800, according to a New York Times database. In the week leading up to April 13, more than 7,100 cases were identified, a record. A two-week period this month saw cases grow by 151 percent.

The Emergent BioSolutions plant in Baltimore.
The Emergent BioSolutions plant in Baltimore.Credit…Jim Lo Scalzo/EPA, via Shutterstock

AstraZeneca, which shipped millions of doses of its coronavirus vaccine to Mexico and Canada last month at the direction of the Biden administration, said on Thursday that the doses had been made at a Baltimore plant where production was halted because of serious manufacturing flaws.

AstraZeneca’s vaccine, made until recently by Emergent BioSolutions in Baltimore, is not authoized for use in the United States, and tens of millions of doses have been sitting idly at manufacturing plants. But the White House said last month that the federal government, which committed last year to buying 300 million doses from the company, intended to “loan” 2.5 million doses to Mexico and 1.5 million doses to Canada.

Whether regulators from those countries inspected the Emergent plant before accepting the AstraZeneca doses, and whether American officials warned them of the ongoing issues at the site, is unclear.

The New York Times reported this month that from early October to January, Emergent discarded five lots of AstraZeneca vaccine — each the equivalent of two million to three million doses — because of contamination or suspected contamination, according to internal logs, a government official and a former company supervisor.

Officials from the Biden administration declined to comment. The Canadian government has said that the AstraZeneca doses were received and distributed, and that it reserved several thousand for quality testing. The status of the doses sent to Mexico is unclear.

In a statement on Thursday, AstraZeneca said that the doses delivered to Mexico and Canada “met the stringent requirements we are required to follow,” and that “required safety tests and quality control measures” were conducted at each step of the production process and before the batches were released.

Last month, The Times reported that an ingredient mix-up at the Emergent Baltimore plant had ruined up to 15 million doses of a coronavirus vaccine developed by Johnson & Johnson. Workers at the plant had conflated ingredients from the two vaccines.

Federal officials ordered major changes to the plant after those revelations.

The Biden administration ordered Emergent to stop making the AstraZeneca vaccine, and put Johnson & Johnson in charge of running the Baltimore plant. A report by Food and Drug Administration inspectors, made public on Wednesday, concluded that Emergent may have contaminated additional doses. It also spotlighted numerous other problems with training and cleanliness at the plant.

The disclosure that the vaccine doses sent to Mexico and Canada came from the Emergent plant raises questions about the Biden administration’s role in arranging for the shipments. Reporting in The Times has shown that federal health officials — and the F.D.A. — were aware of problems at the Emergent plant long before the recent disclosures.

The F.D.A. has not cleared the Emergent plant to release any doses in the United States and has not indicated when, or whether, it will do so. If a drug or biologic made in the United States is shipped to another country, it is up to that country’s regulators to certify whether it is safe.

In its statement on Thursday, which was issued first to CBS News, AstraZeneca said, “The quality information from the manufacturing plants involved was properly submitted to the relevant regulatory agencies in each country to support authorization and approval of shipments from this supply chain.”

Members of the Frutos do Senhor evangelical church performing baptisms and serving breakfast to homeless people in Sao Paulo, Brazil, this month.
Members of the Frutos do Senhor evangelical church performing baptisms and serving breakfast to homeless people in Sao Paulo, Brazil, this month.Credit…Victor Moriyama for The New York Times

Rail-thin teenagers holding placards at traffic stops with fome — the word for hunger — in large print. Children begging for food outside supermarkets. Families huddling in flimsy encampments on sidewalks, asking for baby formula, crackers, anything.

The scenes of hunger in Brazil are stark evidence that President Jair Bolsonaro’s bet that he could protect the country’s economy by resisting public health policies intended to curb the virus has failed. From the start of the pandemic, he scorned the guidance of health experts, arguing that the economic damage wrought by lockdowns would be a bigger threat to the economy than the coronavirus itself.

That trade-off led to one of the world’s highest death tolls, but it has not kept the country afloat.

About 19 million people have gone hungry over the past year, and about 117 million people — more than half the country — faced food insecurity, with uncertain access to enough nutrition, in 2020, according to estimates. One expert says: “The way the government has handled the virus has deepened poverty and inequality. Hunger is a serious and intractable problem in Brazil.”

A mobile Covid-19 walk-up testing site in Los Angeles. A new study says that many adults who have mild cases of Covid-19 can, months later, receive diagnoses of new ailments.
A mobile Covid-19 walk-up testing site in Los Angeles. A new study says that many adults who have mild cases of Covid-19 can, months later, receive diagnoses of new ailments. Credit…Philip Cheung for The New York Times

Most adults who test positive for the virus that causes Covid-19 don’t require hospital care, but they tend to seek medical care in the following months, and two-thirds of those who do seek care receive a diagnosis of a new health condition they did not have previously, a new study reports.

The study, conducted by investigators from the Centers for Disease Control and Prevention and Kaiser Permanente, included some 3,171 members of the Kaiser Permanente Georgia integrated health care system. More than half were Black.

The message for patients is that even for those who have had only mild Covid-19, “it’s possible you may experience new or persistent symptoms months after the initial diagnosis,” said Dr. Alfonso C. Hernandez-Romieu, an infectious disease specialist with the C.D.C. who was the study’s lead author. “And it’s important for people to make sure they’re going to their clinicians,” he said, to express their concerns.

“It’s equally important,” he added, “for clinicians to acknowledge that there may be these long-term effects, and to really make sure they’re validating patients, treating them with empathy, and trying to help them in the best way possible.”

Clinicians need to monitor patients for Covid-19-related complications that are potentially very serious, like blood clots, he said.

The study did not compare patients who tested positive for the coronavirus to patients who did not test positive, so the authors were unable to say whether people who had recovered from mild Covid-19 disease made more doctors’ visits than those who never had the virus.

But two-thirds of the patients who had mild disease sought medical care a month to six months after their Covid-19 diagnoses, and about two-thirds of those who sought care were found to have an entirely new condition. The new diagnoses included cough, shortness of breath, heart rate abnormalities, chest or throat pain, and fatigue, “which likely represent ongoing Covid-19 symptoms,” the study said.

Among those more likely to seek medical care were adults 50 and older, women and those with underlying health conditions. Black adults were also slightly more likely than others to seek care. But over all, the authors noted, the number of visits declined over time.

The potential for long-term complications, even after a mild course of disease, underscores the need for prevention measures and vaccination, Dr. Hernandez-Romieu said.

“There is a lot we don’t know about post-Covid conditions,” he said. “Even though a majority of people don’t end up with severe Covid, or end up in the hospital, the potential for long-term health effects is really important.”

The Centers for Disease Control and Prevention is recommending lifting the pause on the Johnson & Johnson Covid-19 vaccine for all adults while adding a warning label.
The Centers for Disease Control and Prevention is recommending lifting the pause on the Johnson & Johnson Covid-19 vaccine for all adults while adding a warning label.Credit…Alessandro Grassani for The New York Times

A panel of advisers to the Centers for Disease Control and Prevention has recommended lifting the pause on the Johnson & Johnson Covid-19 vaccine for all adults while adding a warning label about a rare but dangerous blood clots disorder. But a central mystery persists: How might a vaccine that has been given to nearly eight million people cause the side effect in just a few of them?

There’s no clear answer yet, but Dr. Andreas Greinacher, a researcher at University Medicine Greifswald in Germany is leading one effort to find out. At a news conference on Tuesday, he said that he had reached an agreement with Johnson & Johnson to inspect the components of the vaccine to see if it can disrupt the normal blood clotting process under certain rare conditions.

“We just agreed that we would like to work together,” he said.

It’s possible, Dr. Greinacher said, that the Johnson & Johnson vaccine can cause rare side effects by the same process that he suspects is responsible for similar side effects from the AstraZeneca vaccine. The main ingredient in both vaccines are harmless viruses known as adenoviruses, which slip into human cells and deliver a coronavirus gene that will later trigger an immune response.

On Tuesday, Dr. Greinacher and his colleagues released a report on how the AstraZeneca vaccines may trigger the side effect. The study has not yet been published in a scientific journal.

The scientists found that components in the AstraZeneca vaccine can stick to a protein that platelets release during the formation of blood clots. These clumps of molecules could be seen by the body as foreign invaders, the scientists speculated, triggering a cascade of reactions that cause platelets to turn into dangerous clots.

Dr. Paul A. Offit, a vaccine expert at Children’s Hospital of Philadelphia who was not involved in the study, found Dr. Greinacher’s study intriguing but far from the final word. “He throws out a lot of possibilities,” he said.

Dr. Offit said it was not clear which of the many factors the researchers studied might explain the rare blood clots in people vaccinated with AstraZeneca’s doses. “It’s like sipping from a fire hose,” he said.

At a news conference on Tuesday, Dr. Greinacher said that the research might point to ways, in the AstraZeneca vaccine, of lowering the risk of the clots or of treating the side effects. But he emphasized that the small risk of those side effects was strongly outweighed by the protection that vaccines such as AstraZeneca provide against Covid-19.

“Not being vaccinated is far more dangerous than being vaccinated and at risk for this adverse drug reaction,” he said.

Antonia Laraki, 75, applied for a homebound vaccine visit from the city in March and waited weeks to hear back.
Antonia Laraki, 75, applied for a homebound vaccine visit from the city in March and waited weeks to hear back.Credit…James Estrin/The New York Times

Antonia Laraki has a leg badly swollen from lymphedema and a son with autism at home who relies on her. After applying for a citywide program in mid-March that vaccinates homebound people, she waited weeks just to hear when the city might be able to send someone to her apartment.

Finally, on Tuesday, she got the news: Vaccinators would be able to make it to her apartment the next day, with the Moderna shot. The city had been using Johnson & Johnson for the program, but after a pause in administering that vaccine because of a rare blood clot disorder, some of its partners were able to pivot.

Still, the pause caused the cancellation of over 1,000 appointments for homebound people, adding yet another hurdle to a program that has moved slowly.

“I feel relieved,” said Mrs. Laraki, 75, on Friday, from her apartment in a Manhattan housing project.

While more than two million people are now fully vaccinated in New York City, the city’s effort to vaccinate homebound seniors has lagged. Though there are an estimated 23,000 homebound adults who need shots, city teams had made only 3,600 vaccination visits as of last week.

The city did not begin its main homebound vaccine effort until March 1, in large part out of a desire to wait for the Johnson & Johnson vaccine, which is logistically easier to use because it requires one dose. Now, the unexpected pause, and lingering fear generated by it, could be a major setback to the program, which had finally ramped up and was reaching about 1,200 people per week.

A committee of health experts is meeting on Friday and is expected to issue a recommendation to federal officials about whether to lift the pause.

“We are in a time frame here that is frightening,” said Gale Brewer, the Manhattan borough president and leader of a weekly task force meeting focused on the vaccine rollout. “We are all trying to beat the variants, and with the home health aides going in and out, there is risk.”

In Venice Beach, Calif., in December.
In Venice Beach, Calif., in December.Credit…Jessica Pons for The New York Times

After a year in which many people have learned to dutifully wear masks and look askance at anyone who does not, it’s understandable that people remain fearful when they cross paths with the unmasked. So how to decide about when to wear a mask outside?

Many experts in viruses and public health say the guidance hasn’t changed: Spending time with others outside during the pandemic has always been safer than indoors. But whether a mask is needed outdoors depends on the circumstances, including local public health rules and whether people are vaccinated.

On Thursday, Dr. Rochelle Walensky, director of the Centers for Disease Control and Prevention, said on the “Today” show that the agency is considering revising its mask guidance for outdoor activities as more and more people get vaccinated against the coronavirus.

“We will be looking at the outdoor masking question,” she said. “But it’s also in the context of the fact that we still have people who are dying of Covid.”

She added that if “we can get our caseloads down, then we’ll be in really good shape in the country.”

While new cases, hospitalizations and new deaths have declined from their peaks in January, they have stayed at a relatively stagnant level in recent weeks, according to a New York Times database. The average of new cases is more than 61,000 a day, as of Thursday, with high concentrations in Michigan and the Northeast. And new deaths remain near an average of more than 715 a day.

Currently, the C.D.C. says masks “may not be necessary” when you are outside by yourself away from others, or with people in your household, but it does not explicitly say there is no longer a need to mask up while outdoors.

Brief encounters with an unmasked person on a sidewalk or a hiking trail are very low risk, said Linsey Marr, a professor of civil and environmental engineering at Virginia Tech who is one of the world’s leading experts on viral transmission.

Even if a person coughs or sneezes outside, the odds of someone nearby getting a large enough dose of virus to become infected remain low, she said.

Dr. Marr uses a two-out-of-three rule for deciding when to wear a mask in public spaces or when she doesn’t know others’ vaccination status. In these situations, she makes sure to meet two out of three conditions: outdoors, distanced and masked.

“If you’re outdoors, you either need to be distanced or masked,” she said. “If you’re not outdoors, you need to be distanced and masked. This is how I’ve been living for the past year.”

The Iowa State Penitentiary in Fort Madison, Iowa.
The Iowa State Penitentiary in Fort Madison, Iowa.Credit…Ben Roberts/The Hawk Eye, via Associated Press

Dozens of inmates at an Iowa prison were sickened this week after the prison’s nurses inadvertently administered overdoses of the Pfizer coronavirus vaccine, an error medical experts fear could erode trust among a population already wary of vaccinations.

At least 77 inmates at the Iowa State Penitentiary in Fort Madison received shots on Tuesday that contained six times the recommended dosage. The Iowa Department of Corrections said it had temporarily halted administration of the vaccine at the facility and two nurses had been placed on administrative leave pending an investigation.

Cord Overton, a prison spokesman, said none of the inmates had been hospitalized, but that they were suffering from ailments consistent with people who have had adverse reactions to the vaccine, including body aches and low-grade fever.

While prison inmates in most states have begun to receive vaccinations, the hesitancy rate among both incarcerated people and prison guards is a concern for public health officials. In Pennsylvania, for example, as many as 75 percent of correctional staff and 45 percent of inmates have not yet been inoculated, despite the availability of the vaccine.

Public health experts fear that given the reluctance to get inoculated, outbreaks in correctional facilities might continue well after much of the rest of society has been vaccinated, creating islands of infection.

Jaimie Meyer, an associate professor at the Yale School of Medicine, said dosing errors involving the Pfizer vaccine had been “rare.” She said that medical care at prisons presented particular problems because of inadequate staffing.

“When there’s a single nurse practitioner who’s meant to take care of a thousand patients, they often don’t have the same levels of support that you would elsewhere,” said Dr. Meyer.

In Iowa, the Corrections Department said its nurses had been told to follow the instructions on the medication when preparing the doses and to consult a statement on proper procedures from the manufacturer.

— Ann Hinga Klein

Arriving at a campus Covid testing site at U.C. Davis in January. All universities in the U.C. and C.S.U. systems are planning to require Covid vaccinations for students, faculty and staff returning in the fall.
Arriving at a campus Covid testing site at U.C. Davis in January. All universities in the U.C. and C.S.U. systems are planning to require Covid vaccinations for students, faculty and staff returning in the fall.Credit…Max Whittaker for The New York Times

In a sweeping move likely to be followed by campuses across the nation, the University of California and California State University systems — two of the nation’s largest public university systems — are planning to require Covid-19 vaccinations by the start of the fall semester for all students, faculty and staff.

The proposed mandate, contingent on full approval of one or more vaccines by the Food and Drug Administration, comes as a growing number of private universities — including Stanford, Duke, Brown, Cornell, Syracuse and Rutgers — have announced similar conditions for returning to campus or attending in-person classes.

The decision in California, however, will impact roughly one million people in college towns and campus environments that served as hotbeds for the spread of the virus last year. The 10 U.C. and 23 Cal State campuses collectively enroll more than 764,000 students and are among the largest local employers in many parts of the state.

In recent months, California has brought its rate of new Covid-19 cases down from one of the nation’s highest to one of the lowest. University officials said they were making the announcement now so that students and employees could plan, and that students who opt out will be required to obtain medical exemptions and could be denied campus housing.

“Receiving a vaccine for the virus that causes Covid-19 is a key step people can take to protect themselves, their friends and family, and our campus communities while helping bring the pandemic to an end,” the University of California President Michael V. Drake, who is also a physician, said in a statement.

The California announcement was quickly followed by similar mandates from the University of Massachusetts-Amherst and from Maryland’s public university system. And on Friday, the University of Michigan said it would require all students who choose to live on its Ann Arbor campus during the fall to be fully vaccinated for the coronavirus.

“We know that widespread vaccination will be the only way to facilitate a return to normal and robust campus life,” Martino Harmon, the University of Michigan vice president for student life, said in an announcement. “This is not a mandate to be vaccinated, but rather a choice to live in communal living and therefore make the choice to get vaccinated.”

Vaccine requirements for communicable diseases such as polio, diphtheria and whooping cough are already in place at most colleges and universities.

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