SAN FRANCISCO -- With so many states seeing a flood of coronavirus patients, U.S. hospitals are again worried about finding enough medical workers to meet demand just as infections from the holiday season threaten to add to the burden on American health care.
California, which is enduring by far its worst spike in cases and hospitalizations, is reaching out to places such as Australia and Taiwan to fill the need for 3,000 temporary medical workers, particularly nurses trained in critical care.
"We're now in a situation where we have surges all across the country, so nobody has many nurses to spare," said Dr. Janet Coffman, a professor of public policy at the University of California in San Francisco.
Hospitals in some states have enlisted retired nurses and students. In Alabama, more than 120 students and faculty members from the University of Alabama at Birmingham's nursing school began helping with care last week at the university hospital.
North Carolina Gov. Roy Cooper said Tuesday that "I know our biggest concern is staff. Even more concerned about that than physical beds and physical ICU units."
Health officials and elected leaders across the U.S. are asking people to stay home for the holidays while also trying to show the public that the covid-19 vaccines being delivered to health care workers and nursing home residents are safe.
A day after getting a vaccination on live television, President-elect Joe Biden said Tuesday that he has full confidence in the vaccine.
Dr. Anthony Fauci, the nation's top infectious disease expert, received the initial dose of the newest vaccine, produced by Moderna, alongside other federal health leaders who helped oversee its development.
Fauci said Tuesday on "Good Morning America" that he expects the U.S. will start vaccinating the general population in late March or early April and that most Americans will have access to the injections by mid-summer.
The medical worker staffing shortages are happening as some states report record numbers of deaths. Both Mississippi and West Virginia on Tuesday surpassed their previous highs for virus deaths reported in a single day, and Arizona saw its second-highest daily increase during the pandemic.
South Carolina Gov. Henry McMaster tested positive for the virus and was to receive outpatient antibody treatment for "mild symptoms," his office said Tuesday.
In Tennessee, which is seeing the nation's worst covid-19 infection surge per capita, the state health commissioner has warned that combining the Thanksgiving surge with another would "completely break our hospitals."
Deaths in Florida's nursing homes doubled during the Thanksgiving holiday, according to statistics gathered by the AARP. The rise drew concern from advocates who also worried about gatherings over Christmas and other year-end celebrations.
"There is nothing to celebrate. The national average is a catastrophe," said Dave Bruns, the spokesman for AARP Florida.
Much of California has exhausted its usual ability to staff intensive care beds. All of Southern California and the 12-county San Joaquin Valley to the north have been out of regular ICU capacity for days.
An emergency room physician in Los Angeles who helped set up a surge hospital in the spring said there are no plans to reopen it. "There would be no way to staff it," said Dr. Marc Futernick.
California hospitals typically turn to staffing agencies during flu season, when they rely on travel nurses to meet patient care needs.
But the pool of available travel nurses is drying up as demand for them has jumped 44% over the past month, with California, Texas, Florida, New York and Minnesota requesting the most extra staffers, according to the San Diego-based health care staffing firm Aya Healthcare.
Dr. Mark Ghaly, California's health and human services secretary, said the state is "lucky to get two-thirds" of its requests for travel nurses fulfilled right now.
Ghaly said entire areas of California may run out of room even in surge capacity units "by the end of the month and early in January." It's trying to avoid that by opening makeshift hospitals in places such as gymnasiums, tents and a vacant NBA arena, and by sending patients to parts of the state with empty beds.
The Trump administration and Pfizer are close to a deal under which the pharmaceutical company would bolster supply of its coronavirus vaccine for the United States by at least tens of millions of doses next year in exchange for a government directive giving it better access to manufacturing supplies, people familiar with the discussions said.
An agreement would help the United States at least partly offset a looming vaccine shortage that could leave as many as 110 million adult Americans uncovered in the first half of 2021.
So far, only two pharmaceutical companies -- Pfizer and Moderna -- have won federal authorization for emergency distribution of covid-19 vaccines, and most of what they are capable of producing for the next six months has already been allocated through contracts with the United States and other governments.
In the negotiations, the government is asking for 100 million additional doses from Pfizer from April through June. The company has signaled that it should be able to produce at least 70 million, and perhaps more, if it can get more access to supplies and raw materials.
To help Pfizer, the deal calls for the government to invoke the Defense Production Act to give the company better access to roughly nine specialized products it needs to make the vaccine. One person familiar with the list said it included lipids, the oily molecules in which the genetic material that is used in both the Moderna and Pfizer vaccines is encased.
Wealthy nations have gobbled up nearly all the global supply of the two leading covid-19 vaccines through the end of 2021, leaving many middle-income countries to turn to unproven drugs developed by China and Russia while poorer states face long waits for their first doses.
"Richer countries will be able to vaccinate ... their whole populations before vulnerable groups in many developing countries get covered," said Suerie Moon, co-director of the Global Health Center at the Graduate Institute of International and Development Studies in Geneva.
As a result, the pandemic may continue to kill people across much of the world for years, delay a global economic recovery and eventually resurge even in nations that manage to control it in the coming months through vaccination.
Experts say the inequities are the predictable result of a global health system in which money often counts more than the public good -- and where vaccines are costly commercial products developed and patented by a handful of huge drug companies.
The gap in access has sparked calls for emergency measures that would allow poorer countries to manufacture and import generic versions of covid-19 vaccines.
In October, India and South Africa asked the World Trade Organization to waive intellectual property protections for those drugs, just as it did for some medications used to treat HIV -- a move credited with saving millions of lives in Africa.
Humanitarian groups that support the plan -- which they have dubbed "the people's vaccine" -- warn that without it, 9 out of 10 people in dozens of poor countries will miss out on covid-19 vaccinations next year.
"If we do nothing, it's going to be well into late 2022 or early 2023 before even half of the low-income countries are vaccinated," said Niko Lusiani, a senior adviser with Oxfam America, the global health charity.
The proposal is opposed by the United States, the European Union and the United Kingdom -- wealthy WTO members that helped finance vaccine development and argue that such innovation would be impossible without patent protection.
The U.S. government provided the vast majority of funding for development of the vaccine made by Moderna. It also struck purchase agreements -- known as advance market commitments -- with the drugmaker and with Pfizer while their vaccines were still being tested. Those deals reduced risk for the companies and allowed the U.S. to secure 300 million shots.
In all, the U.S. government has confirmed deals to buy 1.1 billion doses of a half-dozen vaccines in various stages of development, according to the Global Health Innovation Center at Duke University. The United States is expected to end up with far more doses than what is needed to vaccinate every American.
Other wealthy countries have bought an additional 2.9 billion doses in deals with drugmakers.
For the poorest nations, the best chance to obtain significant quantities of vaccine in 2021 rests with an initiative called Covax.
Launched by the World Health Organization and several nonprofits, it aims to promote equitable distribution of vaccines by negotiating favorable pricing with drug companies and giving all countries -- rich or poor -- equal access.
Nearly every country in the world -- with the exception of the United States -- signed on, in many cases simply as an insurance policy in case bilateral deals with drugmakers fall short.
The poorest nations, though, are depending on aid from wealthier members, which have so far contributed $2.4 billion to the cause. Covax officials say they need to raise an additional $4.6 billion.
"While it is great that Covax may be able to access these vaccine doses, it will depend on whether the corporations agree to the right price and donors give them enough money to pay for it," Lusiani said.
Separately, scientists are raising concern, but not alarm, over new virus strains.
"There's zero evidence that there's any increase in severity" of covid-19 from the latest strain, Dr. Michael Ryan, the WHO's emergencies chief, said Monday.
"We don't want to overreact," Fauci said on CNN.
Worry has been growing since Saturday, when Britain's prime minister said a new strain, or variant, of the coronavirus seemed to spread more easily than earlier ones and was moving rapidly through England. Dozens of countries barred flights from the U.K., and southern England was placed under strict lockdown measures.
New variants have been seen almost since the virus was first detected in China nearly a year ago. Viruses often mutate, or develop small changes, as they reproduce and move through a population -- something "that's natural and expected," the WHO said in a statement Monday.
"Most of the mutations are trivial. It's the change of one or two letters in the genetic alphabet that doesn't make much difference in the ability to cause disease," said Dr. Philip Landrigan, a former Centers for Disease Control and Prevention scientist who directs a global health program at Boston College.
Moncef Slaoui, the chief science adviser for the U.S. government's covid-19 vaccine campaign, said the presumption is that current vaccines would still be effective against the variant, but that scientists are working to confirm that.
"My expectation is this will not be a problem," he said.
U.K. officials have said that "they don't believe there is impact on the vaccines," said WHO outbreak expert Maria Van Kerkhove.
Slaoui said scientists are still working to confirm whether the strain in England spreads more easily. He said it's also possible that "seeding" of hidden cases "happened in the shadows" before scientists started looking for it.
Information for this article was contributed by Daisy Nguyen, Marilynn Marchione, Christina Larson and Candice Choi of The Associated Press; by Sharon LaFraniere and Katie Thomas of The New York Times; and by Shashank Bengali and Kate Linthicum of the Los Angeles Times.