U.S. Calls for Pause on Johnson & Johnson Vaccine, Complicating Rollout

New York, Connecticut and several other states will stop using the vaccine, which nearly seven million Americans have received. Here’s the latest.,

LiveUpdated April 13, 2021, 3:49 p.m. ETApril 13, 2021, 3:49 p.m. ET

Injections of Johnson & Johnson’s single-dose coronavirus vaccine came to a sudden halt in much of the United States on Tuesday after federal health agencies called for a pause in the vaccine’s use following the emergence of a rare blood clotting in six recipients within one to three weeks of vaccination. The virus is also surging in some parts of the U.S.

Nearly seven million people in the United States have received Johnson & Johnson shots so far.
Nearly seven million people in the United States have received Johnson & Johnson shots so far.Credit…Mary Altaffer/Associated Press

Injections of Johnson & Johnson’s single-dose coronavirus vaccine came to a sudden halt in much of the United States on Tuesday after federal health agencies called for a pause in the vaccine’s use following the emergence of a rare blood clotting in six recipients.

All six were women between the ages of 18 and 48 and all developed the illness within one to three weeks of vaccination. One woman died and a second woman in Nebraska has been hospitalized in critical condition.

As of Monday, nearly seven million people in the United States have received Johnson & Johnson shots so far without any other serious adverse reactions reported, and roughly nine million more doses have been shipped out to the states, according to data from the Centers for Disease Control and Prevention.

“We are recommending a pause in the use of this vaccine out of an abundance of caution,” Dr. Peter Marks, director of the Food and Drug Administration’s Center for Biologics Evaluation and Research, and Dr. Anne Schuchat, principal deputy director of the C.D.C., said in a joint statement. “Right now, these adverse events appear to be extremely rare.”

Dr. Marks said that the federal government was not issuing an order to suspend the vaccine, adding that health providers may decide that for a particular patient, the benefits of a shot outweigh the risks. “We’re not going to stop that provider from administering the vaccine because it could be right,” he said.

Scientists with the F.D.A. and C.D.C. will jointly examine possible links between the vaccine and the disorder and determine whether the F.D.A. should continue to authorize use of the vaccine for all adults or limit the authorization. Dr. Anthony S. Fauci, a White House medical adviser, suggested that the vaccine would likely be brought back into play. But “I can’t guarantee it,” he said.

The health agencies notified the White House Monday night about their decision to call for a pause in Johnson & Johnson vaccinations, and states were notified on Tuesday morning.

“The F.D.A. is the gold standard for ensuring the safety and effectiveness of the vaccines, and today’s action, I think, is clear evidence that they’re taking every step necessary to ensure the American people have clear and transparent information about the safety and effectiveness of these vaccines,” Jeffrey D. Zients, the White House Covid-19 response coordinator, said on Tuesday.

Experts have yet to determine to what extent, if any, the vaccine is responsible for the clots. It is common for regulators to investigate “safety signals” in new vaccines and other medical products. Very often, the signals prove not to be of concern. But the investigation follows actions by European regulators who concluded that a vaccine made by AstraZeneca may also be the cause of a similar, extremely rare clotting disorder. Johnson & Johnson on Tuesday said it would delay the rollout of its vaccine in Europe amid concerns over the rare blood clots found in the United States. And South Africa announced it would also pause its administration of the vaccine, even though it is currently the only one offered in the country.

U.S. and European public health experts have emphasized that for most people, the benefits of the Covid-19 vaccines far outweigh the risks. Fewer than one in a million Johnson & Johnson vaccinations in the United States are now under investigation. If there is indeed a risk of dangerous blood clots from the vaccine — which has yet to be determined — experts said that risk is extremely low. The risk of getting Covid-19 in the United States is far higher.

While the move was framed as a recommendation to health practitioners in the states, the impact was immediate.

The federal government temporarily halted administration of the Johnson & Johnson shots by the U.S. military, providers at federally-run sites and CVS and Walgreens, two pharmacy giants that participate in a federal vaccination program, officials said. Both companies said they were emailing customers whose appointments would be canceled and would reschedule appointments when able. More than 40 states quickly paused or recommend that providers pause administration of the dose.

Dr. Janet Woodcock, the acting commissioner of the F.D.A., said at a news conference Tuesday that the pause was only expected to last “a matter of days,” although she said the time frame depends on “what we learn in the next few days.” Dr. Schuchat said at the same briefing that the pause was enacted in part to “prepare the health care system to recognize and treat patients appropriately.”

Federal officials are concerned that doctors may not be trained to look for the rare disorder if recipients of the vaccine develop symptoms of it. Use of an anticoagulant drug called heparin– a standard treatment for blood clots — “can actually cause tremendous harm, or the outcome can be fatal,” Dr. Marks said.

In the United States, 300,000 to 600,000 people a year develop blood clots, according to C.D.C. data. But the particular blood clotting disorder that the vaccine recipients developed, known as cerebral venous sinus thrombosis, is extremely rare.

The C.D.C. and the F.D.A. recommended that people who have received the Johnson & Johnson vaccine within the past month should contact their doctors if they experience severe headaches, abdominal pain, leg pain or shortness of breath. Government experts said the most common symptom of the disorder was a moderate to severe, persistent headache that begins six days or later after the shot.

They said people should not be concerned about mild headaches and flu-like symptoms in the first few days after vaccination. Those are common, harmless side effects brought on by the immune system’s production of a defense against the coronavirus.

An emergency meeting of the C.D.C.’s outside advisory committee made up of independent experts has been scheduled for Wednesday to discuss how to handle the vaccine in the future. Officials also stressed that no serious safety problems have emerged with either of the other two federally authorized vaccines, developed by Pfizer-BioNTech and Moderna.

The move could substantially complicate the nation’s vaccination efforts at a time when many states are confronting a surge in new cases and are still trying to convince skeptical Americans that the inoculations are safe.

Regulators in Europe and elsewhere are concerned about a similar issue with another coronavirus vaccine, developed by AstraZeneca and Oxford University researchers, that has not been authorized for emergency use in the United States. At the news conference, Dr. Marks drew a connection between the two vaccines, saying the cases involving rare blood clots were very similar.

The Biden administration on Tuesday insisted that the pause would not disrupt vaccination efforts. Mr. Zients said the government would still have ample doses to cover every adult who wants to be vaccinated by the end of next month.

The vast majority of the nation’s vaccine supply comes from Pfizer-BioNTech and Moderna, and Mr. Zients said people with appointments for Johnson & Johnson shots would be switched to the other two vaccines. “We purchased excess supply so that we’d be ready for any contingency,” Mr. Zients said. He said the federal government shipped out 28 million doses of the two vaccines this week. As of Monday, the seven-day average of vaccinations was about 3.2 million a day, according to data reported by the C.D.C.

Still, if unresolved, the uncertainty about Johnson & Johnson’s shot could have long-term repercussions. Last month the Biden administration announced it had secured another 100 million doses of Johnson & Johnson vaccines after it helped to broker a manufacturing deal between the company and the pharmaceutical giant Merck & Co. At the time, the White House said the additional vaccines could help vaccinate children and supply booster doses.

Shipments of the Johnson & Johnson vaccine have been much more limited, but the Biden administration had still been counting on using hundreds of thousands of doses every week. In addition to requiring only a single dose, the vaccine is easier to ship and store than the other two.

In a news release, Johnson & Johnson said: “We are aware that thromboembolic events including those with thrombocytopenia have been reported with Covid-19 vaccines. At present, no clear causal relationship has been established between these rare events and the Janssen Covid-19 vaccine.” Janssen is the name of Johnson & Johnson’s division that developed the vaccine.

All of the women developed the illness within about one to three weeks of vaccination, with a median time of nine days. The Nebraska woman who is now hospitalized is in her late 40s and developed blood clots two weeks after her shot, state health officials said. Federal officials said there was broad agreement about the need to pause use of the vaccine while the cases are investigated.

The decision is a fresh blow to Johnson & Johnson. Late last month, the company discovered that workers at a Baltimore plant run by its subcontractor had accidentally contaminated a batch of vaccine, forcing the firm to throw out the equivalent of 13 million to 15 million doses. That plant was supposed to take over supply of the vaccine to the United States from Johnson & Johnson’s Dutch plants, which were certified by federal regulators earlier this year.

The Baltimore plant’s certification by the F.D.A. has now been delayed while inspectors investigate quality control issues, sharply reducing the supply of Johnson & Johnson vaccine. The sudden drop in available doses led to widespread complaints from governors and state health officials who had been expecting much bigger shipments of Johnson & Johnson’s vaccine this week than they got.

Eileen Sullivanand Lynsey Chutel contributed reporting.

A Kent State University student getting his Johnson & Johnson vaccination in Kent, Ohio, last week.
A Kent State University student getting his Johnson & Johnson vaccination in Kent, Ohio, last week.Credit…Phil Long/Associated Press

Following a call from federal health agencies, more than 40 states quickly paused or recommend that providers pause the administration of Johnson & Johnson’s vaccine after six women in the United States developed a rare disorder involving blood clots within one to three weeks of vaccination.

The states include: Alabama, California, Colorado, Connecticut, Delaware, Florida, Georgia, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, New Jersey, New Mexico, Nebraska, New York, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington State, West Virginia and Wisconsin.

CVS and Walgreens, the nation’s largest retail pharmacy chains, also said that they would immediately stop Johnson & Johnson vaccinations. Both companies said they were emailing customers whose appointments would be canceled and would reschedule appointments when able.

Publix and Wegmans, two sizable U.S. supermarket chains, likewise announced they would be suspending the use of that vaccine. Wegmans said it would cancel all appointments for the Johnson & Johnson vaccine, but would continue to offer the Moderna and Pfizer-BioNTech doses where available, and Publix said that customers could schedule a Moderna vaccine online.

Gov. Mike DeWine of Ohio and the state’s chief health official said they were advising all state vaccine providers to temporarily halt use of the single-dose vaccine. Connecticut health officials said they told vaccine providers to delay planned appointments or give an alternative option if they had the supply. New York’s health commissioner, Dr. Howard Zucker, said the state would stop using the Johnson & Johnson vaccine while the Food and Drug Administration and the Centers for Disease Control and Prevention evaluate the safety risks. Appointments for Johnson & Johnson’s shot on Tuesday at state mass sites would be honored with Pfizer doses, Dr. Zucker said.

California’s top epidemiologist, Dr. Erica Pan, said that the state would follow the federal guidance and was directing health care providers to pause the administration of the vaccine, “until we receive further direction from health and safety experts.”

The pause in California comes just a day before the state is set to expand eligibility to anyone age 16 and older — a move that some experts have worried will lead to frustration, as an explosion in demand for doses coincides with a decrease in supply and strains an already-confusing patchwork of appointment systems. Questions loomed about how long the pause would last, as well as whether the slowing of supply would affect the state’s reopening plans.

Gov. Gavin Newsom said on Twitter that the state is vaccinating more than 3 million people per week, and that the state is “still on track to fully reopen” on June 15–but the plan is dependent on widespread accessibility of vaccines.

The White House on Tuesday said that the pause will not have a significant effect on the country’s vaccination campaign, which has accelerated in recent weeks as a rise in new virus cases threatens a fourth possible surge. Many states have already opened vaccination eligibility to all adults and others plan to by next week.

“Over the last few weeks, we have made available more than 25 million doses of Pfizer and Moderna each week, and in fact this week we will make available 28 million doses of these vaccines,” Jeff Zients, the White House Covid-19 response coordinator, said on Tuesday. “This is more than enough supply to continue the current pace of vaccinations of 3 million shots per day.”

As of Monday, 36 percent of the country’s total population has received at least one shot of a vaccine, and 22 percent are fully vaccinated, according to data from the C.D.C.

Even though the reaction to the Johnson & Johnson shot is rare, any questions about the safety of the shots could bolster vaccine hesitancy.

Nearly seven million people in the United States have received Johnson & Johnson shots so far, and roughly nine million more doses have been shipped out to the states, according to data from the C.D.C. The six women who developed blood clots were between the ages of 18 and 48. One woman died and a second woman in Nebraska has been hospitalized in critical condition.

“We are recommending a pause in the use of this vaccine out of an abundance of caution,” Dr. Peter Marks, director of the F.D.A.’s Center for Biologics Evaluation and Research, and Dr. Anne Schuchat, principal deputy director of the C.D.C., said in a joint statement. “Right now, these adverse events appear to be extremely rare.”

At a news conference later on Tuesday morning, Dr. Marks said that “on an individual basis, a provider and patient can make a determination whether or not to receive the vaccine” manufactured by Johnson & Johnson.

The C.D.C.’s outside advisory committee of independent experts has scheduled an emergency meeting for Wednesday.

Experts have yet to determine to what extent, if any, the vaccine is responsible for the clots. But the investigation follows actions by European regulators who concluded that a vaccine made by AstraZeneca may also be the cause of a similar, extremely rare clotting disorder.

U.S. and European public health experts have emphasized that for most people, the benefits of the Covid-19 vaccines far outweigh the risks. Fewer than one in a million Johnson & Johnson vaccinations are now under investigation. If there is indeed a risk of blood clots from the vaccine — which has yet to be determined — that risk is extremely low. The risk of getting Covid-19 in the United States is far higher.

The F.D.A. recommends that people who have received the Johnson & Johnson vaccine within the past three weeks should contact their doctors if they experience severe headaches, abdominal pain, leg pain or shortness of breath. People should not be concerned about mild headaches and flu-like symptoms in the first few days after vaccination. Those are common, harmless side effects brought on by the immune system’s production of a defense against the coronavirus.

Federal officials are concerned that doctors may not be trained to look for the rare disorder if recipients of the vaccine develop symptoms of it. The federal health agencies said Tuesday morning that “treatment of this specific type of blood clot is different from the treatment that might typically be administered” for blood clots.

“Usually, an anticoagulant drug called heparin is used to treat blood clots. In this setting, administration of heparin may be dangerous, and alternative treatments need to be given,” the statement said.

Like many states, New York had already prepared for a significant drop in its supply of the Johnson & Johnson vaccine after federal officials said that supplies would be limited because of a production issue at a Baltimore manufacturing plant. On Friday, Gov. Andrew M. Cuomo said that New York expected to receive 34,900 Johnson & Johnson shots, a decrease of 88 percent from the previous week.

Dr. Zucker, New York’s health commissioner, said that the state would honor appointments made at state-run mass vaccination sites for the Johnson & Johnson vaccine by giving people the Pfizer-BioNTech vaccine instead. At a news conference, Mr. Cuomo said that the state had enough supply of the Pfizer and Moderna vaccines on hand to be able to adhere to its current vaccination pace.

Mayor Bill de Blasio of New York City said that the city would work with its vaccination sites to help people get appointments for the Pfizer or Moderna vaccine instead.

“Every site has been told this morning to stop giving the J&J shots,” he said at a news conference.

Both Mr. Cuomo and Mr. de Blasio received the Johnson & Johnson vaccine at separate appearances last month, which they framed as an effort to boost confidence in that vaccine’s efficacy rate and to address vaccine hesitancy.

The city’s health commissioner, Dr. Dave Chokshi, said that around 234,000 residents have received the Johnson & Johnson vaccine and none had reported any blood clots so far. The city had been relying on the vaccine to inoculate hard-to-reach New Yorkers, including people who are homebound.

Regulators in Europe and elsewhere are concerned about a similar issue with another coronavirus vaccine, developed by AstraZeneca and Oxford University researchers. That vaccine has not been authorized for emergency use in the United States.

Rebecca Robbins, Jill Cowan, Denise Grady, Carl Zimmer and Sharon Otterman contributed reporting.

A box of Johnson & Johnson Covid-19 vaccines shown by a pharmacist in Budapest, Hungary, on Tuesday.
A box of Johnson & Johnson Covid-19 vaccines shown by a pharmacist in Budapest, Hungary, on Tuesday.Credit…Szilard Koszticsak/EPA, via Shutterstock

Johnson & Johnson on Tuesday said it would delay the rollout of its vaccine in Europe amid concerns over rare blood clots, in another blow to the continent’s ambition to ramp up inoculation campaigns that have lagged behind other countries in the West.

Several countries of the bloc were poised to start administering the vaccine later this week, in what would have been a boost to efforts by the European Union to vaccinate 70 percent of adults by September.

“The safety and well-being of the people who use our products is our number one priority,” Johnson & Johnson said in a statement, adding that it had been reviewing the cases of blood clots detected in the United States with European health authorities.

The first signs of concern in Europe came last week. The European Medicines Agency, the bloc’s drug regulator, said it was investigating reports of four cases of blood clots in people who had received a shot of Johnson & Johnson’s Janssen vaccine in the United States, one of them being fatal. The regulator said it wasn’t clear if there was a link between the vaccine and the clots, adding that it treated the reports as “safety signal” that required further assessment.

Johnson & Johnson started delivering its one-shot vaccine to the bloc on Monday, with some member countries like Spain and Belgium already having received modest quantities of the shot, and preparing for the rollout later in the week. Fifty-five million doses of Johnson & Johnson’s vaccine are expected to be delivered to the European Union by the end of June, and another 120 million later in the year, according to Thierry Breton, the bloc’s top industry official.

On Tuesday, injections of Johnson & Johnson’s single-dose coronavirus vaccine came to a sudden halt in much of the United States on Tuesday after federal health agencies called for a pause in the vaccine’s use following the emergence of a rare blood clotting in six recipients.

All six were women between the ages of 18 and 48 and all developed symptoms within about two weeks of vaccination. One woman died and a second woman in Nebraska has been hospitalized in critical condition.

Nearly seven million people in the United States have received Johnson & Johnson shots so far, and about nine million more doses have been shipped out to the states, according to data from the Centers for Disease Control and Prevention.

Johnson & Johnson’s announcement comes as Europe has been embroiled in a regulatory back-and-forth over another vaccine, AstraZeneca’s. Several countries have restricted the use of the vaccine in younger people, after the European Medicines Agency said there was “a possible link” between blood clots and the vaccine earlier this month, and said it should be listed as a rare side effect.

Both Johnson & Johnson and AstraZeneca use the same technology, prompting concerns that the blood clots reported in recipients of both vaccines could be the same rare, yet sometimes fatal side effect.

The agency stopped short of advising to curb the use of the vaccine in 27 member countries, saying that it was up to the national authorities to decide who should receive which vaccine, which resulted in a patchwork of different national regulations.

France and Belgium have restricted its use for those older than 55, and Germany, Italy and Spain, for those over 60. Some other countries, such as Poland, which rely heavily on AstraZeneca in their national rollouts, decided to go ahead with AstraZeneca’s vaccine.

Registered nurse holding a Johnson & Johnson Covid-19 vaccine in Chicago last month.
Registered nurse holding a Johnson & Johnson Covid-19 vaccine in Chicago last month.Credit…Kamil Krzaczynski/Agence France-Presse — Getty Images

On Tuesday morning, U.S. federal health regulators recommended a pause in the use of Johnson & Johnson’s Covid-19 vaccine while they investigated six reports of blood clots in women ages 18 to 48. One has died, and a second is hospitalized in critical condition.

Experts have yet to determine to what extent, if any, the vaccine is responsible for the clots. But the investigation follows actions by European regulators who concluded that a vaccine made by AstraZeneca may also be the cause of a similar, extremely rare clotting disorder.

U.S. and European public health experts have emphasized that for most people, the benefits of the Covid vaccines far outweigh the risks.

Here are some of the common questions being asked and what we know so far.

Fewer than one in a million J&J vaccinations are now under investigation. If there is indeed a risk of blood clots from the vaccine — which has yet to be determined — that risk is extremely low. The risk of getting Covid-19 in the United States is far higher.

The F.D.A. recommends that people who have received the Johnson & Johnson vaccine within the past three weeks should contact their doctors if they experience severe headaches, abdominal pain, leg pain or shortness of breath.

Six women in the United States who received the Johnson & Johnson vaccine developed a rare disorder involving blood clots within about two weeks of vaccination. In the condition, called cerebral venous sinus thrombosis, clots form in veins that drain blood from the brain.

Researchers studying a very similar disorder in AstraZeneca recipients in Europe say it appears to be caused by an intense reaction to the vaccine by the immune system, which generates antibodies that activate platelets, a blood component that helps form normal clots to repair wounds. In addition to clots, abnormal bleeding occurs.

Dr. Peter Marks of the F.D.A. said it was the unusual combination of clotting and bleeding that set up a red flag for regulators as a possible safety signal.

At the news conference on Tuesday, Dr. Marks said the cases were “very, very similar.”

Both Johnson & Johnson and AstraZeneca use adenoviruses to carry DNA into human cells to begin the process of generating immunity to the coronavirus. It is not yet known whether that technology causes the problem.

German researchers have speculated that DNA from the vaccine may set off the immune reaction in some people. But the condition is so rare that the researchers say patients likely also have some individual biological trait — as yet unknown — that predisposes them to the immune overreaction.

Doctors in Germany and Norway have treated patients with blood-thinning drugs to try to stop the growth of the clots, and with intravenous immune globulin, which can help eliminate the misguided antibodies that are causing the problem.

Researchers there and U.S. federal health officials on Tuesday advised against using a common blood thinner, heparin, and choosing alternative medicines instead. The reason is that the disorder closely resembles a rare syndrome caused by heparin, and it is possible that heparin could make things worse in these patients.

The F.D.A. has not found any similar cases in people who have received the Moderna or Pfizer-BioNTech vaccines.

Benjamin Mueller contributed reporting.

Students line up for vaccines at Oakland University on Friday in Rochester, Mich. Coronavirus cases in the state have continued to rise in recent weeks.
Students line up for vaccines at Oakland University on Friday in Rochester, Mich. Coronavirus cases in the state have continued to rise in recent weeks.Credit…Emily Elconin for The New York Times

The virus is again surging in parts of the United States, but it’s a picture with dividing lines: ominous figures in the Northeast and Upper Midwest, but largely not in the South.

Experts are unsure what explains the split, which doesn’t correspond to vaccination levels. Some point to warmer weather in the Sun Belt, while others suspect that decreased testing is muddying the virus’s true footprint.

The contours of where the virus is resurgent can be drawn around one figure: states that are averaging about 15 new cases a day for every 100,000 people. The 23 states — including Alabama, Mississippi and Arkansas — that have averaged that or fewer over the past week seem to be keeping cases relatively low, according to a New York Times database. Nationally, the country is averaging 21 new cases per 100,000 people.

In the 27 states above that line, though, things have been trending for the worse. Michigan has the highest surge of all, reporting the most drastic increase in cases and hospitalizations in recent weeks. Illinois, Minnesota and others have also reported worrisome increases.

Nationally, reported cases in the United States are growing again after a steep fall from the post-holiday peak in January. In the past two weeks, new confirmed cases have jumped about 11 percent, even though vaccinations picked up considerably, with an average of 3.2 million doses given daily.

Some Southern states, like Alabama and Mississippi, are lagging in vaccinations. Only about 28 percent of people in each state have received at least one shot, according to a New York Times vaccine tracker. Still, case counts continue to drop in both states.

Health experts say cases are rising in the Northeast and Upper Midwest for several reasons, including pandemic fatigue, the reopening of schools and the resumption of youth sports.

Hospitalizations tend to follow the trend line in cases by a few weeks, and have been rising in some states, most notably in Michigan.

Officials are also concerned about the spread of more contagious virus variants, especially B.1.1.7, first identified in Britain. The variant is now the leading source of new coronavirus infections in the United States, the director of the Centers for Disease Control and Prevention said last week.

Just why those factors might affect some states more than others is hard to pinpoint, experts say.

Dr. David Rubin, the director of PolicyLab at the Children’s Hospital of Philadelphia, said warmer weather in Southern states and California was probably playing a role, because it allows people to gather outdoors, with less risk of transmission.

New case reports have fallen by about 11 percent in Georgia over the past two weeks. And in Alabama, new cases are down roughly 29 percent, with a 17 percent decline in hospitalizations.

Some experts say, though, that reduced testing in some states could be obscuring the true picture. Testing in Alabama, for instance, has started to dip, but the share of tests that come back positive has remained high, at 11.1 percent, compared with a nationwide average of 5.1 percent, according to data compiled by Johns Hopkins University.

“People who are symptomatic and go to their provider are going to get a test,” said Dr. Michael Saag, the associate dean for global health at the University of Alabama at Birmingham, but “the desire for people to go get tested just because they want to know what their status is has dropped off dramatically.”

Still, Dr. Saag said, there is probably not a hidden spike in cases in Alabama right now, since hospitalizations in the state remain low.

— Madeleine Ngo

People sitting near the Dome of the Rock at the Aqsa Mosque compound, Islam's third holiest site, in the old city of Jerusalem on Monday.
People sitting near the Dome of the Rock at the Aqsa Mosque compound, Islam’s third holiest site, in the old city of Jerusalem on Monday.Credit…Ahmad Gharabli/Agence France-Presse — Getty Images

Millions of Muslims on Tuesday began celebrating a second Ramadan in the middle of the pandemic, although in many countries the first day of the holy month offered the promise of a Ramadan with fewer restrictions than last year.

Mosques across the Middle East and other parts of the world were closed for prayer last year, and lockdowns prevented festive gatherings with friends and family. In Jerusalem, for instance, the Old City was largely empty and the Aqsa Mosque compound was closed to the public, as coronavirus cases were surging.

But a large degree of normalcy was back on Tuesday: The Old City’s narrow alleys were crowded, sweet shops were preparing Ramadan desserts, clothing stores were open and the Aqsa compound was welcoming worshipers.

“Last year, I felt depressed and I didn’t know how long the pandemic would last,” said Riyad Deis, a co-owner of a spice and dried fruit shop in the Old City, while selling whole pieces of turmeric and Medjool dates to a customer. “Now, I’m relaxed, I have enough money to provide for my family and people are purchasing goods from my shop — it’s a totally different reality.”

The enthusiasm of some didn’t mean the Ramadan would go as normal. Across several countries in the Middle East, the authorities imposed limitations on customs and festivities, requiring that mosques enforce social distancing and telling worshipers to bring their own prayer rugs and to wear face masks.

In Dubai, Saudi Arabia and Egypt, taraweeh, the optional extra prayers that worshipers can observe at night, were capped at half an hour. No one will also be allowed to spend the night in a mosque, as is common during the last 10 days of Ramadan.

Mosques around the region were also prohibited from serving the fast-breaking meal of iftar or the predawn meal of suhoor. Though Muslims could still gather for those meals with friends and family, the authorities asked them to limit those gatherings this year.

In Jerusalem, Omar Kiswani, the director of Al Aqsa Mosque, said he was overjoyed that the compound was open to worshipers, but still urged caution.

“These are times of great happiness — we hope the blessed Aqsa Mosque will return to its pre-pandemic glory — but these are also times of caution because the virus is still out there,” Mr. Kiswani said.

In Egypt, government officials and prominent television hosts linked to the authorities warned Egyptians of a third wave of infections as Ramadan approached, hinting that another curfew or other lockdown restrictions could be imposed if cases rose.

“If you want the houses of God to remain open,” Nouh Elesawy, an official who oversees mosques at the Egyptian Ministry of Endowments, said earlier this month, “adhere to the precautionary procedures and regulations.”

The Ramadan restrictions may hit the hardest in poor neighborhoods, where residents depend on iftar banquets usually sponsored by wealthy individuals or organizations. For those people, feasting and Ramadan gifts are likely to be rarer, with tourism still at a trickle and many small businesses still suffering from the economic effects of the pandemic.

In Lebanon and Syria, the pandemic has worsened economic crisis that will likely squeeze people’s ability to enjoy the holy month, more than the governments’ limited restrictions aimed at curbing the spread of the coronavirus.

In Syria, where experts say the official infection and death numbers for Covid-19 are far below the reality, the government has few restrictions in place. Worshipers will even be allowed to stand in line inside of mosques to pray together after breaking their fast, the Syrian Ministry of Religious Affairs said.

In Lebanon, which emerged recently from a strict lockdown, shops and restaurants can operate regularly during the day but must offer only delivery service during a nighttime curfew from 9:30 p.m. to 5 a.m.

Vivian Yee, Adam Rasgon and Asmaa al-Omar

Global Roundup

Administering a coronavirus vaccine to a frontline worker in New Delhi, last week.
Administering a coronavirus vaccine to a frontline worker in New Delhi, last week.Credit…Rebecca Conway for The New York Times

India said on Tuesday that it would fast-track the approval of vaccines in use in other countries, a move aimed at rapidly increasing the country’s vaccine supply as it battles what is currently the world’s biggest coronavirus outbreak.

The Indian government said that it would grant emergency authorization to any foreign-made vaccine that had been approved for use by regulators in the United States, the European Union, Britain or Japan, or by the World Health Organization. The move had been recommended by a panel of Indian scientists and eliminates a requirement for drug companies to conduct local clinical trials.

“The decision will facilitate quicker access to such foreign vaccines” and encourage imports of materials that would boost India’s vaccine manufacturing capacity, the government said in a statement.

Earlier on Tuesday, India’s top drug regulator granted emergency approval to Sputnik V, the Russian-made vaccine, adding a third vaccine to the country’s arsenal on the same day that health officials recorded 161,736 new coronavirus infections in 24 hours.

It was the seventh straight day that India has added more than 100,000 cases, according to a New York Times database. Only the United States has seen a faster rise in infections during the pandemic.

India has administered about 105 million domestically produced vaccine doses for a population of 1.3 billion, but it is widely believed that the country needs to scale up inoculations rapidly because other measures have failed to control the virus. Many states have reimposed partial lockdowns and weekend curfews. In the country’s financial hub, Mumbai, health officials are racing to erect field hospitals as facilities report shortages of oxygen, ventilators and coronavirus testing kits.

And there is the risk of a superspreading event with the gathering of millions of Hindu pilgrims for the annual Kumbh Mela festival on the banks of the Ganges River, where the authorities say they are powerless to enforce social distancing.

India’s outbreak is reverberating worldwide as its pharmaceutical industry — which was supposed to manufacture and export hundreds of millions of doses of the AstraZeneca vaccine — is keeping most supplies at home. The approval of the Sputnik vaccine, whose first doses are expected to be available for use in weeks, offers hope that India could speed up its inoculation drive.

But it is unclear at this stage whether India will be able to procure significant quantities of other vaccines, including the Pfizer, Moderna and Johnson & Johnson shots in use in the United States. Major Western nations have accumulated much of the global supply of those vaccines and manufacturers are struggling to meet the surging demand.

India will import millions of Sputnik doses from Russia and then begin manufacturing the vaccine domestically, officials said. More than 850 million doses will be made, with some intended for export, Kirill Dmitriev, chief executive of the Russian Direct Investment Fund, a sovereign wealth fund that has financed the vaccine’s development, said in an interview with India’s NDTV channel.

“India is a vaccine-manufacturing hub and our strategic partner for production of Sputnik V,” Mr. Dmitriev said.

India has more than 13.6 million confirmed coronavirus cases, the second most after the United States, and 171,058 deaths, the fourth highest toll.

In other news around the world:

  • Japan has begun vaccinating 36 million people over age 65, the first time shots have been made available to the public during the country’s slow vaccine rollout. Officials said that 1,139 people nationwide had received doses on Monday, and that doses to cover all Japanese above the age threshold would reach municipal health facilities by the end of June. Although Japan has weathered the pandemic better than most countries, the pace of its vaccination effort, which until now had only covered 1.1 million frontline medical workers, has sparked public criticism and raised questions about readiness for the Tokyo Summer Olympics in just over three months.

  • Scotland on Tuesday moved forward plans to loosen its coronavirus lockdown, a day after the British government eased many restrictions in England. New rules beginning Friday will permit Scots to meet outdoors in groups of up to six adults from six households. The current rules restrict travel and set the maximum group size at four, from two households. Restrictions on shops and outdoor service in pubs, now relaxed in England, are scheduled to remain in Scotland until April 26.

  • Austria‘s health minister resigned on Tuesday, citing personal health problems that he said have been exacerbated by the grueling job of helping lead the country’s response to the pandemic. “It feels like it has not been 15 months, but 15 years,” the minister, Rudolf Anschober, said in a statement. Mr. Anschober, 60, was appointed in January last year, as a Green party minister in a Conservative-led coalition, and has been one of the main faces of Austria’s coronavirus response. “In the worst health crisis in decades, the republic needs a health minister who is 100 percent fit. That is not currently me,” he said.

  • France will suspend all flights to and from Brazil, because of growing worries about the virus variant spreading there. “We see that the situation is getting worse” in Brazil, Prime Minister Jean Castex told lawmakers. The country previously permitted essential travel from Brazil, subject to testing and isolation requirements.

  • The World Health Organization on Monday evening called on governments to suspend the sale of live wild mammals in food markets to help prevent the emergence of new diseases. “Traditional markets, where live animals are held, slaughtered and dressed, pose a particular risk for pathogen transmission to workers and customers alike,” the agency said in a statement. Animals are the source of more than 70 percent of emerging infectious diseases in humans, it said. Early in the pandemic, Chinese officials suggested that the coronavirus outbreak might have started at a market. But W.H.O. experts said in a report last year that the role of animal markets in the story of the pandemic was still unclear.

Chancellor Angela Merkel, center, at a cabinet meeting in Berlin on Tuesday. Her government's proposal on coronavirus restrictions would place half the country over the threshold for lockdown.
Chancellor Angela Merkel, center, at a cabinet meeting in Berlin on Tuesday. Her government’s proposal on coronavirus restrictions would place half the country over the threshold for lockdown.Credit…Pool photo by Andreas Gora

BERLIN — Chancellor Angela Merkel’s government moved a step closer on Tuesday to securing the right to force restrictions on areas where the coronavirus is spreading rapidly, overriding state leaders reluctant to take action.

Ms. Merkel and her ministers approved a legislative proposal that would make it easier for the national government to enforce lockdowns and other limits on movement in regions where infection levels pass a set threshold. At current levels, it could lock down more than half of the country.

Under Germany’s decentralized leadership structures, the 16 state leaders have been meeting regularly with the chancellor to agree on nationwide coronavirus response policies. But with different regions experiencing different rates of infection, some state leaders have been reluctant to enforce the agreed limitations, leading to confusion and frustration among many Germans.

“I believe this amendment is as important as it is an urgent decision about how to proceed in the coronavirus pandemic,” the chancellor told reporters after meeting with her ministers.

Parliament still has to debate and approve the proposal, which would take the form of an amendment to the Protection Against Infection Act, and that process is expected to begin this week.

“We are in a situation where an emergency mechanism is necessary,” Ralph Brinkhaus, the leader of the Christian Democratic Union in Parliament, told reporters, before a meeting of his party lawmakers to discuss the amendment.

Under the proposed amendment, the federal government could force stores and cultural institutions to close and enforce limits on the number of people allowed to meet up in any region where infections surpass 100 new cases per 100,000 residents over a period of seven days.

More controversially, the law would also allow Ms. Merkel’s government to order that schools and day care centers close if the number of new infections reaches more than 200 per 100,000 inhabitants. Schools fall under the jurisdiction of the states, and local leaders are reluctant to relinquish that control.

Germany has registered more than three million infections and more than 78,700 deaths from Covid-19 since the virus began moving through the country last spring. It recorded 10,810 new cases of infection on Tuesday, bringing the national rate of infection to more than 140 per 100,000.

The number of patients in intensive care is expected to hit a record this month, as the country struggles to vaccinate enough people to get ahead of the spread of the highly contagious B.1.1.7 variant.

Vaccinations at a mosque in London earlier this month. Britain's program has reached over 32 million people, more than half the adult population.
Vaccinations at a mosque in London earlier this month. Britain’s program has reached over 32 million people, more than half the adult population.Credit…Andrew Testa for The New York Times

Britain has now offered vaccinations to everyone in the country age 50 and older, the government announced late on Monday, and is extending its program to another age group, the latest sign that the national rollout is continuing at pace.

On Tuesday, the authorities opened vaccinations to anyone 45 or older, yet the announcement came with a small hiccup: The website for the country’s National Health Service crashed for a short time after the younger cohort was invited to book appointments online.

The new step in the country’s vaccine rollout comes as the authorities eased several restrictions in England on Monday after months of stringent lockdowns, with pubs and restaurants opened for drinks and dining outside, and nonessential shops once again opening their doors.

Prime Minister Boris Johnson called the moment a “hugely significant milestone” and in a statement thanked those involved with the vaccine rollout. Mr. Johnson said the country was on track to offer all adults a vaccination by the end of July. More than 32 million people across Britain have received their first dose of one of the vaccines, according to government data.

The government said it had also already offered vaccinations to every health or care worker, and to everyone with a high-risk medical condition.

England has also began rolling out the Moderna vaccine, which will be offered as an alternative alongside the Pfizer BioNTech vaccine for those under 30, instead of AstraZeneca’s, which has been the mainstay of Britain’s program so far.

There have been concerns about a possible link between the AstraZeneca vaccine and very rare blood clots, and last week British regulators said an alternative should be provided for younger people. Potential infection still poses much greater risks than any vaccine side effect for all those over 30, they said, and could do so for younger people if cases surged again.

“The Moderna rollout marks another milestone in the vaccination program,” Stephen Powis, the medical director of the National Health Service, said in a statement. “We now have a third jab in our armory.”

The vaccination program, he added, “is our hope at the end of a year like no other” as he encouraged people to book their appointments.

But despite the hopeful vaccine news and the return to public life, the country is still battling new cases of the virus, and a cluster in two London neighborhoods of a worrisome variant first discovered in South Africa has prompted mass testing. Health workers have gone door to door to urge residents to get tested, even if they are not showing symptoms, as dozens of cases have emerged. Similar measures were carried out elsewhere in the city earlier this month.

Studies have shown that the variant contains a mutation that diminishes the vaccines’ effectiveness against it. Dr. Susan Hopkins, the chief medical adviser for the country’s test and trace campaign, said the cluster of cases in parts of South London was “significant.”

“It’s really important people in the local area play their part in stopping any further spread within the local community,” she said in a statement.

Pacific Palace, a dim sum restaurant on a commercial strip in the Sunset Park section of Brooklyn, has seen revenue plunge.
Pacific Palace, a dim sum restaurant on a commercial strip in the Sunset Park section of Brooklyn, has seen revenue plunge.Credit…Victor J. Blue for The New York Times

More than a year after the coronavirus first swept through New York, the streets of Sunset Park in southern Brooklyn reflect the pandemic’s deep and unhealed wounds intertwined with signs of a neighborhood trying to edge back to life.

The sidewalks are filling with shoppers and vendors. More businesses are welcoming customers. But owners still struggle to pay rent and keep their enterprises afloat, while many workers laid off after the city locked down last year remain without jobs.

And while the rate of vaccination in New York has increased significantly, the coronavirus still percolates through this densely packed neighborhood. The ZIP code that includes Sunset Park had the highest rate of positive cases in Brooklyn in early April, nearly double the citywide rate. Some residents have expressed skepticism about the vaccines, spooked by false information circulated over TikTok and other social media.

Adding to the stress is a spate of hate crimes and violence against people of Asian descent in New York and around the country, fed in some cases by racist claims that Asian-Americans are responsible for spreading the virus.

About a third of the residents in Sunset Park have received at least one dose of the vaccine, roughly the same level as the city overall, according to the city health data. But local leaders say they want to push that number much higher.

Kuan Neng, 49, the Buddhist monk who founded Xi Fang Temple on Eighth Avenue, said that people had come to him in recent weeks to express concerns over vaccines.

“Why do I need to do that?” is a common refrain, according to Mr. Kuan, followed by: “I’m healthy now. The hard times are over, more or less.”

“Many people want to delay and see,” Mr. Kuan said, himself included.

Firefighters at the site of COVID-19 hospital Matei Bals, after a fire broke out in one of its buildings in Bucharest, Romania, in January.
Firefighters at the site of COVID-19 hospital Matei Bals, after a fire broke out in one of its buildings in Bucharest, Romania, in January.Credit…Robert Ghement/EPA, via Shutterstock

Three people infected with the coronavirus died at a hospital in Bucharest on Monday evening after the oxygen supply stopped functioning, according to the authorities, the latest incident involving oxygen failure, which in many countries has driven up the virus death toll.

It was also another fatal setback for Romania’s ageing and overwhelmed health care system, which has suffered two fires in Covid-19 wards in recent months, killing at least 15 people.

Ventilators shut down at a mobile intensive care unit set up at the Victor Babes hospital in Bucharest after oxygen pressure reached too high a level, the country’s health authorities said in a statement, depriving patients of a vital supply. In addition to the three patients who died, five others were evacuated and moved to other facilities in the city.

Romania has recorded its highest rate of Covid-19 patients in intensive care units since the pandemic began, and on Sunday Prime Minister Florin Citu said that there were just six intensive care beds available across Romania, out of nearly 1,600.

Intensive care units in Hungary and Poland have also been at risk of being overwhelmed, as much of Eastern Europe has struggled to cope with a third wave of infections across the continent. Some Hungarian hospitals have sought medical students and volunteers to assist in Covid-19 wards, giving training to those without previous medical experience.

The mobile unit struck by the oxygen problem on Monday had only been in operation since Saturday, and it has epitomized long-running concerns over the country’s fragile health care system. In January, five patients died and a further 102 were evacuated from a different hospital in Bucharest after a fire broke out. In November, 10 patients hospitalized with the coronavirus died after a fire broke out in a hospital in the northeastern city of Piatra Neamt.

Romania’s spending on health care is among the lowest in the European Union, with just over five percent of gross domestic product allocated toward it, compared with 10 percent on average among other countries of the bloc.

More than 25,000 people who tested positive for the virus have died in Romania, and the authorities have closed schools and kindergartens throughout April as part of an extended Easter holiday.

The authorities have so far administered more than 3.5 million vaccine doses, in a population of about 19 million.

— Kit Gillet

Alisa Stephens, a biostatistician at the University of Pennsylvania in Philadelphia, had to manage work and taking care of her children after the city went into lockdown last year.
Alisa Stephens, a biostatistician at the University of Pennsylvania in Philadelphia, had to manage work and taking care of her children after the city went into lockdown last year.Credit…Hannah Yoon for The New York Times

Studies have found that women in academia have published fewer papers, led fewer clinical trials and received less recognition for their expertise during the pandemic.

Add to that the emotional upheaval of the pandemic, the protests over structural racism, worry about children’s mental health and education, and the lack of time to think or work, and an already unsustainable situation becomes unbearable.

Michelle Cardel, an obesity researcher at the University of Florida, worries that this confluence of factors could push some women to leave the sciences.

“My big fear is that we are going to have a secondary epidemic of loss, particularly of early career women in STEM,” she said.

Female scientists were struggling even before the pandemic. It was not unusual for them to hear that women were not as smart as men, or that a woman who was successful must have received a handout along the way, said Daniela Witten, a biostatistician at the University of Washington in Seattle.

Women in academia often have little recourse when confronted with discrimination. Their institutions sometimes lack the human resources structures common in the business world.

Compounding the frustration are outdated notions about how to help women in science. But social media has allowed women to share some of those concerns and find allies to organize and call out injustice when they see it, said Jessica Hamerman, an immunologist at the Benaroya Research Institute in Seattle.

In November, for example, a study on female scientists was published in the influential journal Nature Communications suggesting that having female mentors would hinder the career of young scientists and recommending that young women seek out male help.

The response was intense and unforgiving: Nearly 7,600 scientists signed a petition calling on the journal to retract the paper — which it did on Dec. 21.

The study arrived at a time when many female scientists were already worried about the pandemic’s effect on their careers, and already on edge and angry with a system that offered them little support.

Alisa Stephens found working from home to be a series of wearying challenges. Dr. Stephens is a biostatistician at the University of Pennsylvania, and carving out the time and mental space for that work with two young children at home was impossible.

Things eased once the family could safely bring in a nanny, but there was still little time for the deep thought Dr. Stephens had relied on each morning for her work.

Over time, she has adjusted her expectations of herself. “Maybe I’m at 80 percent as opposed to 100 percent,” she said, “but I can get things done at 80 percent to some extent.”

A woman administrating nasal swabs for the coronavirus test at a mobile testing site in Queens last week.
A woman administrating nasal swabs for the coronavirus test at a mobile testing site in Queens last week.Credit…Shannon Stapleton/Reuters

The number of new coronavirus cases in New York City has remained alarmingly, and stubbornly, high for weeks, even as tens of thousands of people are vaccinated daily.

A likely reason is that more contagious variants have displaced the original forms of the virus, public health officials have said, accounting for more than 75 percent of new cases, according to a recent analysis.

Until this week, the city had not said which variants were more common in which neighborhoods. But newly available ZIP code-level data provides some insight into the mix of variants circulating in the area.

The information serves as a vivid reminder that the dynamics of New York’s epidemic have changed over the past few months, and that the original forms of the virus are increasingly unusual across the city.

A variant first discovered in New York, B.1.526, has spread more widely in the city than all of the others so far. There has also been a significant increase in cases linked to the B.1.1.7 variant, which was first detected in Britain last year and now makes up nearly 30 percent of new cases sequenced in New York City.

This variant is now the main source of new infections across the United States and in Europe.

But not in New York City, where B.1.526 remains the most prevalent variant, comprising about 45 percent of cases sequenced from the fourth week of March.

As to which is more contagious — B.1.1.7 or B.1.526 — health officials are not yet sure. “We don’t have enough information to discern this at this moment,” said the city’s health commissioner, Dr. Dave Chokshi.

In a given week, about 1,000 to 2,000 coronavirus cases in New York City are sequenced — that is, the genetic material of the virus is examined for mutations. That represents roughly between 4 and 8 percent of New York City’s new cases. The majority of those cases are sequenced at a laboratory in Long Island City operated by Opentrons, a robotics company.

The city Health Department uses the sequences from this laboratory as the basis for its weekly sample gauging the prevalence of each variant.

But even with thousands of samples sequenced, the data still has significant limitations. Most of its coronavirus samples come from the city’s public hospital system and city sponsored testing sites. It receives lots of samples from some neighborhoods, but few from others.

“The limited number of variants sequenced up till now make it difficult to arrive at conclusions as to whether some neighborhoods are more severely affected than others,” Dr. El-Sadr said.

Each dot on the density maps above is placed in the ZIP code of a New Yorker whose coronavirus sample was sequenced at the lab. But neighborhoods with lots of dots do not necessarily correspond with coronavirus hot spots. The density of dots can often be explained by the presence of a city testing center nearby.

On the other hand, neighborhoods with few dots are not necessarily free of variants. It just means few coronavirus samples from there reached the lab.

There are blind spots across the Bronx, Queens and the southern half of Manhattan. In some ZIP codes too few samples have been sequenced to draw any solid conclusions. In Roosevelt Island, for example, only one case has been sequenced.

The city on Monday separately released a report based on ZIP-code level data that also showed the proportion of B.1.1.7 and B.1.526 cases growing rapidly.

The report said that B.1.526 cases have been detected in all five boroughs, but were slightly more common in the Bronx and parts of Queens. B.1.1.7 cases were also found citywide, but were slightly more common in southern Brooklyn, eastern Queens and Staten Island.

City officials said that the maps showed widespread transmission of the variants, and that they were an important reminder for people not to let their guards down in any neighborhood.

“The single best way we can address this threat is by vaccinating everyone as quickly as possible,” said Dr. Jay Varma, a senior adviser on public health in the mayor’s office. “The reality is you are at risk of any of these no matter where you are.”

Lauren Leatherby contributed research.

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