Throughout the pandemic, wrenching scenes have played out across the United States as doctors found themselves in the unfamiliar position of overtly rationing a treatment. But it was not ventilators, as initially feared: Concerted action largely headed off those shortages. Instead, it was the limited availability of ECMO — which requires expensive equipment similar in concept to a heart-lung machine and specially trained staff who can provide constant monitoring and one-on-one nursing — that forced stark choices among patients.
“Patients died because they could not get ECMO,” said Dr. Lena M. Napolitano, co-director of the Surgical Critical Care Unit at the University of Michigan. This spring, she was overwhelmed with requests to accept patients considered good candidates for ECMO. “We could not accommodate all of them,” she said.
Doctors tried to select individuals most likely to benefit from ECMO, a last-resort treatment that can mechanically substitute for badly damaged lungs. But dozens of interviews with medical staff and patients across the country, and reporting inside five hospitals that provide ECMO, revealed that in the absence of regional sharing systems to ensure fairness and match resources to needs, hospitals and clinicians were left to apply differing criteria, with insurance coverage, geography and even personal appeals having an influence.
“It’s unsettling to have to make those kinds of decisions,” said Dr. Ryan Barbaro, a critical care physician in Michigan and head of an international registry of Covid-19 patients who have received ECMO — short for extracorporeal membrane oxygenation — about half of whom survived hospitalization.
Close to 8,000 patients worldwide have received ECMO to date, including nearly 5,000 in North America. Despite the progress the United States has made against the coronavirus, some doctors are still having to ration ECMO, which is offered in less than 10 percent of hospitals.
“It’s something we’re balancing every day,” said Dr. Erik Eddie Suarez, a cardiovascular surgeon at Houston Methodist. If the hospital accepts too many Covid patients for ECMO, he said, “we can’t do cardiac surgery,” because some of those patients also need the treatment.
Dr. Anthony S. Fauci made the rounds of the morning TV news shows on Sunday, trying to quell confusion over the latest federal pandemic guidance for the start of school in the fall as well as growing questions about the necessity of booster shots.
On Sunday, Israel’s health ministry announced that it would begin offering boosters to adults with weakened immune systems who already had two doses of the Pfizer-BioNTech vaccine, in light of the rising number of cases there caused by the Delta variant of the coronavirus. The news was first reported by Reuters.
Asked about the development on CNN’s “State of the Union,” Dr. Fauci emphasized that the Centers for Disease Control and Prevention was committed to following the science and said that boosters were not recommended “right now,” given that more than 90 percent of new Covid-related hospitalizations were in unvaccinated patients.
But he did not rule out the possibility that boosters might eventually be advisable for certain populations.
Pfizer and BioNTech announced last week that they were developing a vaccine targeted to the Delta variant and also had promising results from studies of people who received a booster shot. With a third shot, “you get five to 10 times the number of antibodies that you had from the second dose,” Dr. Scott Gottlieb, the former head of the Food and Drug Administration who is now on Pfizer’s board, said on the CBS program “Face the Nation.”
But while Dr. Gottlieb noted that Pfizer and federal agencies would be meeting early in the week to discuss the data on boosters, Dr. Fauci said that additional studies were necessary.
“What the pharmaceutical company Pfizer did, they did their own study and said, ‘You know, we think you’re going to need a boost,’” he said on “Face the Nation.” Federal agencies, he added, were doing their own independent research on the booster question.
Dr. Fauci’s answers, well over a year into the pandemic, reflected his dual role: officially, as President Biden’s chief medical adviser, and unofficially, as the public’s chief medical assuager.
On Friday, the C.D.C. released new guidelines for preventing coronavirus transmission in schools, with face masks, social distancing and ventilation recommended as key strategies. But the agency emphasized that the top priority should be a return to in-person classroom education, saying that not every item had to be fulfilled and that local jurisdictions should issue their own guidance.
Dr. Fauci deflected criticism that the C.D.C. appeared to be flip-flopping with its successive guidelines. He noted that the agency responded to data at large but that local districts had to be nimble in responding to their own situations.
“If you can’t implement them, you should still do everything you can with testing, with guidelines that would allow people, for example, in lunchrooms when you gather, when you’re sick don’t come to school, do everything you can to keep the in-person classes going,” he said on the ABC program “This Week.”
Treasury Secretary Janet L. Yellen said on Sunday that she was concerned that coronavirus variants could derail the global economic recovery and called for an urgent push to vaccinate more people around the world.
Her comments, made at the conclusion of a gathering of the finance ministers of the Group of 20 nations, came as the highly contagious Delta variant of the coronavirus was driving outbreaks among unvaccinated populations in countries such as Australia, Indonesia, Malaysia and Portugal.
“We are very concerned about the Delta variant and other variants that could emerge and threaten recovery,” Ms. Yellen said. “We are a connected global economy. What happens in any part of the world affects all other countries.”
Many cities and countries have started to declare victory against the pandemic, easing restrictions and returning to normal life. But Ms. Yellen warned that the public health crisis was not over.
She said that the world’s top economic officials had spent much of the weekend in Venice discussing how they could improve vaccine distribution, with the goal of getting 70 percent of the world inoculated by next year. Ms. Yellen noted that many countries had been successful in financing the purchase of vaccines, but that the logistics of getting them into people’s arms were falling short.
“We need to do something more and to be more effective,” she said.
The spread of variants has started to dampen optimism about the trajectory of the recovery. Analysts at Capital Economics said last week that they planned to lower their economic growth outlook for the year to below 6 percent.
“The divergence across economies is intensifying,” Kristalina Georgieva, the managing director of the I.M.F., said on Saturday. “Essentially, the world is facing a two-track recovery.”
The I.M.F. executive board approved a plan last week to issue $650 billion worth of reserve funds that countries could use to buy vaccines and to finance health care initiatives.
The pandemic has been a cruel blow for thousands of migrant workers in South Asia who are out of work or unable to return to their jobs abroad.
Countries like Bangladesh, India and Nepal rely heavily on migrant workers, who send billions of dollars home each year. But over the past year, many have lost their jobs and been forced to return to their native countries. Others still have jobs or have found new ones, but are struggling to make travel arrangements to take up the posts.
The lack of Covid-19 vaccines has compounded the problem, with many countries requiring migrant workers to be inoculated to avoid quarantine or sometimes to enter at all.
Ajay Sodari, a migrant worker in Kathmandu, Nepal, who needs to be vaccinated before he can start his job in South Korea, said, “I spent four years studying the Korean language, to get selected as a qualified worker in language tests and sign a labor agreement with the company.” He said that he had spent thousands of dollars to meet the employment requirements but that the pandemic had “shattered my dream.”
The lack of vaccines has been most acute in Bangladesh and Nepal, both of which planned to source most of their doses from neighboring India until New Delhi stopped vaccine exports this spring to prioritize its own citizens. In Bangladesh and Nepal, only about 3 percent of the population is fully vaccinated, according to a New York Times database.
In Nepal, where inward remittances account for a quarter of gross domestic product, migrant workers were not among the priority groups in initial phases of the vaccination campaign, which favored older adults, frontline health workers, security personnel and government officials. As many as 35,000 migrant workers are stuck in Nepal despite obtaining final work permit approval from the country’s government, according to the Nepal Association of Foreign Employment Agencies. The group says that most countries have stopped recruiting workers from Nepal because they are not vaccinated.
In Bangladesh, there are at least 90,000 migrant workers waiting to get vaccinated before they can start their jobs abroad, said Shahidul Alam, director general at the Bureau of Manpower Employment and Training, a government agency. Mr. Alam said that Bangladesh was stepping up its vaccination efforts among migrant workers, including with the introduction of an app.
“In the last seven days, at least 45,000 workers registered in the app, and the vaccination for them is already started,” he said on Thursday.
The workers’ situation is complicated by the fact that their destination countries sometimes require certain vaccines. Neither Saudi Arabia nor Kuwait, two of the most common destinations for Bangladeshi migrant workers, recognize the Chinese-made Sinopharm vaccine, which Bangladesh now largely relies upon for mass inoculation.
To help the stranded workers, the government in Bangladesh is giving them the Pfizer vaccine at seven health facilities in Dhaka, the capital, using some of the 106,000 doses received through the Covax global vaccine-sharing program. Mr. Alam said that the workers would also receive some of the 2.5 million doses of the Moderna vaccine received from the United States this month in partnership with Covax.
In India, which has the world’s largest migrant population at nearly 18 million, vaccine shortages are worse in some states than others. The southern state of Kerala is home to the greatest number of migrants in India, with nearly four million Keralites living abroad. Though the state has recently prioritized vaccination for migrants, many said they had been stranded in India for months, unable to return to their jobs and worried their visas would expire.
Hanees Babu, 52, has been waiting in Kerala for nearly nine months to return to Kuwait, where he owns a business selling automotive lubricants. He has received both doses of the AstraZeneca vaccine, but that is not necessarily the end of his problems. His vaccine certificate lists the name of the vaccine as Covishield, as it is known in India, which can cause confusion in other countries. The Delhi High Court recently directed the central government to consider including the AstraZeneca name on vaccination certificates to make it easier for people to travel abroad.
The Kerala state government is already issuing vaccination certificates that say AstraZeneca, but they have to be applied for separately. Several people seeking to travel abroad said that having two different vaccination certificates made the process more difficult and had led some countries to stop processing visa applications from India completely.
Shalini Venugopal Bhagat reported from Goa, India; Bhadra Sharma from Kathmandu, Nepal; and Saif Hasnat from Dhaka, Bangladesh.
Malta will ban visitors over the age of 12 from entering the country starting Wednesday unless they are fully vaccinated against the coronavirus, the first country in the European Union to impose such restrictions.
The small archipelago between Sicily and Libya, with a population of half a million, has the world’s highest proportion of fully vaccinated residents at about 70 percent, and about 74 percent have received one dose, according to data compiled by The New York Times.
But as the highly contagious Delta variant spreads rapidly across Europe, coronavirus infections are increasing in Malta, with an average of 58 new cases a day, according to the Times data.
Chris Fearne, the Maltese health minister, announced the latest measures at a news conference on Friday after new virus cases had doubled every day since the previous Monday, according to Reuters.
“We will be the first E.U. country to do so, but we need to protect our society,” he said of the introduction of the restrictions.
Starting Wednesday, the Maltese authorities will require vaccination certificates issued 14 days after the final dose. Documents issued by Malta, the European Union or Britain will be recognized.
Children ages 5 to 12 must have a negative PCR test for Covid-19, while children under 5 are exempt. All children must be accompanied by a fully vaccinated adult with an authorized vaccine certificate.
The government said on Friday that the rise in coronavirus infections showed very clearly that the country’s vaccination efforts were working, as most of the people who tested positive were foreign nationals who had not been inoculated.
The restrictions were implemented to err on the side of caution to protect the country’s unvaccinated population, the government said.
BioNTech on Monday announced a deal to provide 10 million doses of its coronavirus vaccine to Taiwan, easing a serious shortage there and ending months of deadlock stemming from the self-ruling island’s complicated relationship with China, which considers Taiwan part of its territory.
The deal is a convoluted one, reflecting the delicate needle that had to be threaded.
The vaccines will be purchased, then donated to Taiwan’s government, by two of the island’s most prominent corporate titans — Foxconn, a major assembler of Apple’s iPhones; and TSMC, which makes the cutting-edge chips in Apple’s latest devices — in conjunction with the YongLin Foundation, a charity set up by Foxconn’s founder, Terry Gou.
The shots will be sold by Fosun Pharma, the Shanghai company that is BioNTech’s manufacturing and distribution partner for mainland China, Hong Kong, Macau and Taiwan. (BioNTech’s partner in other parts of the world, including the United States, is Pfizer.)
And officially, the buyer will be Zuellig Pharma, a Swiss-owned company entrusted with the task by Foxconn, TSMC and YongLin. The New York Times reported last month that discussions had taken place about a deal that would include Zuellig, which is already working with Moderna to supply that company’s coronavirus vaccine in Southeast Asia, Hong Kong, Macau and Taiwan.
For much of this year, it looked as if Taiwan’s efforts to acquire vaccines from BioNTech, a German company, had fallen victim to political tensions with China. Taiwanese officials said that they had negotiated with BioNTech for months before unspecified “Chinese intervention” caused the talks to run aground. Officials in Beijing denied this and said that, given BioNTech’s partnership with Fosun, Taiwan should not have been dealing directly with the German drugmaker in the first place.
Chinese officials have offered to donate vaccines made by Chinese companies and said that Taiwanese people were welcome to get inoculated in China. But Taiwanese law bars the import of Chinese-made vaccines, and opinion polls show that many people in Taiwan distrust them. So far, the island has administered first vaccine doses to around 15 percent of its 23.5 million residents. Many of those shots were donated by Japan or the United States.
Foxconn, TSMC and YongLin sought to reassure the Taiwanese public in a joint statement on Monday, saying that the BioNTech vaccines they were buying would be imported directly from factories in the European Union and would bear the original labeling. The shots are expected to arrive at the end of September at the earliest, the statement said.
Mr. Gou of Foxconn wrote on his Facebook page that the government in Beijing had not steered the purchase or interfered in it at all.
Taiwanese health officials expressed their gratitude for the deal on Monday. A spokesman for China’s Taiwan Affairs Office also praised the agreement, though he added that if the island’s government “had considered the life, health and well-being of Taiwan compatriots, this issue could have been resolved sooner.”
Thailand said on Monday that health care workers who had received the coronavirus vaccine made by Sinovac of China would also be inoculated with the Oxford-AstraZeneca or Pfizer-BioNTech shots to give them greater protection as concerns grow about more transmissible variants as well as about the waning immunity provided by Sinovac.
Anutin Charnvirakul, Thailand’s health minister, said that people vaccinated with one dose of Sinovac should be given the AstraZeneca shot as the second dose three to four weeks later. Those who have already received both shots of the Sinovac vaccine, he said, should receive a booster shot “right away.”
“This will build immunity against the virus to a high level more quickly,” Mr. Anutin said at a news conference.
Thailand is the latest foreign government to indicate doubts about the immunity provided by the Sinovac vaccine. On Friday, Indonesia said it would offer the Moderna vaccine as a booster to health care workers who had received two doses of the Sinovac shot.
Both countries are facing their most serious coronavirus outbreaks of the pandemic, driven by the highly contagious Delta variant that was first detected in India. On Sunday, Thailand reported a record 9,418 new coronavirus infections, a day after it reported a record 91 coronavirus-related deaths. For at least two weeks starting Monday, the capital, Bangkok, and surrounding provinces will be under tight restrictions aimed at curbing the spread of the virus, including a curfew and a five-person limit on gatherings.
Most medical workers in Thailand were inoculated with the Sinovac vaccine after it was approved in February, with the AstraZeneca vaccine becoming available only recently. Trial results have shown that the Sinovac shot is at least 51 percent effective at preventing symptomatic disease, above the threshold set by the World Health Organization, and even more effective at preventing hospitalization and death.
But several countries that were among the earliest recipients of the Sinovac vaccine have reported that their health care workers have fallen ill with Covid-19 despite being fully vaccinated. On Sunday, the Thai Health Ministry said that out of the 677,348 medical personnel who had received two doses of Sinovac, 618 had become infected, citing data from April to July. One nurse has died and another medical worker is in critical condition.
“Breakthrough infections” — infections that happen even in individuals who are fully vaccinated — can happen with any vaccine. But governments are especially concerned when it happens to health care workers, especially at a time when their hospitals are already under strain.
On Sunday, Prof. Thiravat Hemachudha, a specialist in clinical, virological, and immunological studies at Chulalongkorn University in Bangkok, said that a study of people who had received two doses of the Sinovac vaccine showed that their level of antibodies, at 70 percent, was “barely efficacious” against the Alpha variant first detected in Britain or against the Delta variant.
Professor Thiravat said it was imperative that the Thai government gave frontline medical workers booster shots because they faced higher risks of infection. Thailand is producing the AstraZeneca shots locally, the only country in Southeast Asia to do so. It does not have any Pfizer vaccines on hand but expects to receive a donation of 1.5 million doses from the United States this month.
While studies suggest that most Covid-19 vaccines are effective against the Delta variant, which the W.H.O. says is likely to become the dominant form of the virus worldwide in coming months, less is known about the Sinovac vaccine. One of China’s top epidemiologists, Zhong Nanshan, has said that a study of 160 people infected with the Delta variant in the southern city of Guangzhou showed that China’s vaccines, developed by Sinovac and another company, called Sinopharm, were 69 percent effective in preventing infection among close contacts, according to Xinhua, the state-run news agency. Sinovac has not provided any data.
Elsie Chen contributed research.
Thousands of Iranians frustrated with the government’s chaotic vaccine rollout and desperate for protection after enduring wave after wave of the coronavirus are flocking by air and land to neighboring Armenia to be vaccinated against Covid-19.
Iran is enduring a fifth wave of the pandemic, with Tehran and 143 cities declared high-risk “red” zones and the highly contagious Delta variant of the virus spreading quickly. Over the past two weeks, Iran’s average daily caseload has risen by 63 percent, to nearly 17,000, according to a New York Times database.
Only about 2 percent of Iran’s 84 million people have been fully vaccinated, according to the Our World in Data project at the University of Oxford. With U.S.- and British-made vaccines banned by Ayatollah Ali Khamenei, Iran’s top leader, the country is waiting for shipments of vaccines made by China and Russia.
Across the border in Armenia, a country of three million, there are more vaccine doses than people willing to take them, largely because of widespread conspiracy theories and misinformation. Officials there announced in May that they would provide free vaccines to foreigners without registration. Mobile clinics were set up in the streets to make them easily accessible to tourists and visitors. Iranians don’t need a visa to travel to Armenia, and the drive from the border to the capital, Yerevan, is about seven hours.
Based on Iran’s vaccine eligibility chart, Parvin Chamanpira, 53, and her husband calculated that it would be months before they qualified, so they traveled from Tehran to Yerevan last week and received their shots from an ambulance parked on the side of the road. She said it took about five minutes, requiring only a blood pressure check and no paperwork. They will return in a few weeks for their second shots.
“This is not an ideal choice for Iranians to be forced to travel and spend a lot of money and be stressed out for getting a vaccine,” Ms. Chamanpira said. “We would not do it if we didn’t have to.”
Armenian officials have not said how many foreign nationals have received vaccinations, but the number of flights between Tehran and Yerevan has been increased to meet the demand. Tickets are sold out until late August, travel agents said. Bus tours centered around vaccinations are also booked. Some Iranians are chartering their own buses and vans or driving their own cars across the border, according to several people organizing the trips.
In a social media group dedicated to planning vaccination trips to Armenia, Iranians at the border posted videos on Friday showing lines of cars and people stretching for miles, saying the wait was at least 13 hours.
Among ordinary Iranians and medical workers facing the surge in cases, anger at the government is mounting. Some prominent physicians have called for the health minister to be prosecuted for his mishandling of the pandemic and the vaccine rollout.
“Our only weapon is immediate and fast vaccination of the public,” Dr. Saeedreza Mehrpour, the head of Shariati Hospital in Tehran, said on his Instagram page on Thursday, criticizing the country’s leaders for putting defiant ideology over public health. “I wish we had better relations with the worlds.”
President Hassan Rouhani said this month that Iran would expand its vaccine distribution effort in the coming weeks by importing more foreign vaccines and producing domestic ones. So far it has received more than 2.1 million doses of the AstraZeneca vaccine through Covax, the global vaccine-sharing program.
In the meantime, Iranians seeking vaccination have been largely left on their own, including those in higher-risk groups. Fahimeh Hosseini, 72, a retired banker, said she recently waited for four hours with dozens of other older people outside a clinic in Tehran for a second dose of the vaccine, only to be told there were no more. The clinic told them appointments for a second dose could not be scheduled because there was no predicting when the vaccine would be in stock.
“They told us to keep coming back until you get lucky,” she said.