WASHINGTON -- Three-quarters of U.S. adults have received at least one dose of a covid-19 vaccine as of Tuesday, according to the White House, setting a milestone in the country's fight against the pandemic even as data shows that more than 40 million cases of the virus have been recorded in the country.
The count, more than the population of California, the nation's most populous state, is a testament to the spread of the coronavirus, especially lately with the highly contagious delta variant, and the U.S.' patchwork efforts to rein it in.
The delta variant has caused a continued surge of cases, hospitalizations and deaths, prompting President Joe Biden to plan a speech Thursday to outline a "six-pronged strategy" to "get the pandemic under control," press secretary Jen Psaki said.
The U.S. hit 70% of adults with at least one dose in early August, four weeks after Biden's July 4 target for the achievement. Despite wide availability of free shots, hesitancy among many Americans has left the U.S. well behind many other countries in inoculating its population.
A range of factors are now driving vaccinations, including the delta outbreak and more widespread employer mandates, which spiked after the Food and Drug Administration issued full approval for the Pfizer Inc.-BioNTech shot last month.
Psaki downplayed expectations for any fresh or expanded vaccine mandate in Biden's speech, and said the federal government does not believe it has the authority to require vaccines broadly at the national level.
Vaccines are effective in preventing severe disease and death, but 36% of American adults are not fully vaccinated, allowing the delta variant more than enough opportunity to inflict suffering and disrupt daily life. Health officials say that most of the patients who are being hospitalized and dying are not vaccinated and that it is those unvaccinated people who are driving the current surge and burdening the health care system.
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Over the past week, new virus cases have averaged more than 161,000 a day, as of Sunday. New deaths are up to 1,560 a day, and hospitalizations are averaging more than 102,000 a day. Those numbers, while high, remain lower than last winter's peaks.
The U.S. response to the pandemic remains a patchwork and a political battleground, with some prominent Republican governors downplaying the importance of vaccines and blocking public health measures such as mask mandates.
Cases have soared through the summer in the U.S. -- the country set a record for new cases on Aug. 27, exceeding the highs of last winter. Hospitalizations and deaths have also increased, including 3,911 deaths reported Thursday, the most in one day since January.
U.S. cases make up nearly one-fifth of the known global total, more than 221 million cases as of Tuesday, according to data from the Center for Systems Science and Engineering at Johns Hopkins University. That is likely to be an undercount because of factors like insufficient testing and reporting.
The news came at the end of the Labor Day weekend, not long after Dr. Rochelle P. Walensky, director of the Centers for Disease Control and Prevention, warned that unvaccinated Americans should avoid travel.
But data from the Transportation Security Administration suggested that people did not stay home in droves. Transportation Security Administration checkpoints recorded 2.13 million travelers through U.S. airports Friday, close to the number on the Friday before Labor Day two years ago.
IDAHO RATIONING
Not all Republicans have resisted the call for expanded vaccination. On Sept. 1, Gov. Brad Little of Idaho pleaded with people to get vaccinated.
"I wish everyone could have seen what I saw in the ICU last night," he said.
Idaho public health leaders announced Tuesday that they activated "crisis standards of care" allowing health care rationing for the state's northern hospitals because there are more coronavirus patients than the institutions can handle.
The Idaho Department of Health and Welfare quietly enacted the move Monday and publicly announced it in a statement Tuesday morning -- warning residents that they may not get the care they would normally expect if they need to be hospitalized.
The state health agency cited "a severe shortage of staffing and available beds in the northern area of the state caused by a massive increase in patients with covid-19 who require hospitalization."
The move allows hospitals to allot scarce resources like intensive care unit rooms to patients most likely to survive and make other dramatic changes to the way they treat patients. Other patients will still receive care, but they may be placed in hospital classrooms or conference rooms rather than traditional hospital rooms or go without some life-saving medical equipment.
Dave Jeppesen, director of the department, said, "This is a decision I was fervently hoping to avoid. The best tools we have to turn this around is for more people to get vaccinated and to wear masks indoors and in outdoor crowded public places. Please choose to get vaccinated as soon as possible -- it is your very best protection against being hospitalized from covid-19."
Idaho has one of the lowest vaccination rates in the U.S.
The designation includes 10 hospitals and health care systems in the Idaho panhandle and in north-central Idaho. The agency said its goal is to extend care to as many patients as possible and to save as many lives as possible.
On Monday, the Coeur d'Alene hospital started moving some coronavirus patients into its nearby conference center. A large classroom in the center was converted into a covid-19 ward, with temporary dividers separating the beds. Some emergency room patients are being treated in a converted portion of the emergency room lobby, and the hospital's entire third floor has also been designated for coronavirus patients.
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Urgent and elective surgeries are on hold, said Dr. Robert Scoggins, the chief of staff at Kootenai Health -- the largest hospital in northern Idaho -- which is struggling to accept any of the high-level trauma patients that would normally be transferred from the smaller hospitals in the region.
The designation will remain in effect until there are enough resources -- including staffing, hospital beds and equipment or a drop in the number of patients -- to provide normal levels of treatment to all.
Other states are preparing to take similar measures if needed. Hawaii Gov. David Ige quietly signed an order last week releasing hospitals and health care workers from liability if they have to ration health care.
BOOSTER PLANS
As Biden's administration presses to get shots into arms of the unvaccinated, its plan to launch a booster program for those already inoculated is already being forced to scale back expectations -- illustrating just how much important science still has to be worked out.
The initial plan was to offer Pfizer or Moderna boosters starting Sept. 20, contingent on authorization from U.S. regulators. But now administration officials acknowledge that Moderna boosters probably won't be ready by then -- the FDA needs more evidence to judge them. Adding to the complexity, Moderna wants its booster to be half the dose of the original shots.
As for Pfizer's booster, who really needs another dose right away isn't a simple decision either. What's ultimately recommended for an 80-year-old person vaccinated back in December may be different than for a 35-year-old immunized in the spring -- who likely would get a stronger immunity boost by waiting longer for another shot.
The administration announced its booster-shot plan in August based on indications that the immunity conferred by two shots can wane over time and isn't as effective against the delta variant -- data that some health experts outside the government say are inconclusive.
FDA's scientific advisers will publicly debate Pfizer's evidence on Sept. 17, just three days before the administration's target. If the FDA approves another dose, then advisers to the CDC will recommend who should get one.
That's tricky because while real-world data shows the vaccines used in the U.S. remain strongly protective against severe disease and death, the vaccines' ability to prevent milder infection is dropping. It's not clear how much of that is because of immunity waning or the extra-contagious delta variant -- or the fact that the delta variant struck just as much of the country dropped masks and other precautions.
When to jump to boosters "becomes a judgment," said Dr. Jesse Goodman of Georgetown University, a former FDA vaccine chief. "And is that urgent or do we have time for the data to come in?"
Anthony Fauci, Biden's chief medical adviser, told CNN on Sunday that it's likely that Pfizer boosters will begin Sept. 20 with Moderna boosters following a couple of weeks later. The administration has said it expects to give out approximately 100 million booster shots this fall.
Already the CDC is considering recommending the first boosters just for nursing home residents and older adults who'd be at highest risk of severe disease if their immunity wanes -- and to front-line health workers who can't go to work if they get even mild infections.
It's not yet clear what boosters will be given, or when, to those who received the Johnson & Johnson one-dose vaccine, which relies on different technology than the messenger RNA vaccines of Pfizer and Moderna.
EFFICACY QUESTIONS
The process of developing and approving vaccines and related booster doses has left many Americans with questions about the efficacy and timing of the third shot.
No one yet knows "the magic line" -- the antibody level known as the correlate of protection below which people are at risk for even mild infection, said immunologist Ali Ellebedy of Washington University at St. Louis.
But vaccines' main purpose is to prevent severe disease. "It's a very high bar to really go and say we can completely block infection," Ellebedy noted.
Plus, people's responses to their initial vaccinations vary. Younger people, for example, tend to produce more antibodies to begin with than older adults. That means months later when antibody levels have naturally declined, some people may still have enough to fend off infection while others don't.
Antibodies may wane, but many researchers are not fully sure how quickly and sharply the protection declines.
"We don't know the duration of protection following the boosters," said Dr. William Moss of Johns Hopkins University.
But antibodies are only one defense. If an infection sneaks past, white blood cells called T cells help prevent serious illness by killing virus-infected cells. Another type called memory B cells jump into action to make lots of new antibodies.
Those back-up systems help explain why protection against severe covid-19 is holding strong so far for most people.
For many other types of vaccines, waiting six months for a booster is the recommended timing. The Biden administration has been planning on eight months for covid-19 boosters.
The timing matters because the immune system gradually builds layers of protection over months. Give a booster too soon, before the immune response matures, and people can miss out on the optimal benefit, said Dr. Cameron Wolfe, an infectious disease specialist at Duke University.
"Sometimes waiting a little bit extra time is in fact appropriate to gain the strongest response," he said.
Information for this article was contributed by Josh Wingrove of Bloomberg News (TNS); by Daniel E. Slotnik and Adeel Hassan of The New York Times; and by Lauran Neergaard, Carla K. Johnson and Rebecca Boone of The Associated Press.