Pregnancy and the COVID Vaccine

COVID-19 Vaccines and Pregnancy

The ethics and safety of COVID vaccines for pregnant people

Q&A WITH RUTH FADEN, ELANA JAFFE, CARLEIGH KRUBINER, AND CHIZOBA WONODI | MARCH 29, 2021

This article originally appeared on the Johns Hopkins University Coronavirus Resource Center.

Globally, over 200 million people are pregnant each year. Whether they should be offered the new COVID vaccines as they become available is an important public health policy decision. Whether pregnant people should seek vaccination is a deeply personal decision.

Are pregnant people at higher risk of developing severe COVID?

Evidence to date suggests that people who are pregnant face a higher risk of severe disease and death from COVID compared to people who are not pregnant. For instance, pregnant people are three times more likely to require admission to intensive care and to need invasive ventilation. The overall risk of death among pregnant people is low, but it is elevated compared to similar people who are not pregnant. Some studies suggest that COVID in pregnancy might be associated with increased rates of preterm birth.

Our understanding of the probability and severity of harms from SARS-CoV-2 infection in pregnancy is evolving. The pandemic has been ongoing for just over a year, which limits what can currently be known about the health risks of COVID for pregnant people, and especially their offspring. Whether SARS-CoV-2 infection in pregnancy poses risks to the developing fetus remains underdetermined. Current evidence suggests that transmission of SARS-CoV-2 to the fetus is rare. However, severe maternal illness can have serious implications for the fetus. For example, fevers during early pregnancy have in some studies been associated with increased risk for certain birth defects. Since the pandemic has only been with us for just over a year, there are no data yet on long-term childhood outcomes for offspring exposed in utero.

There are still significant unknowns: How do risks vary by trimester? What are the risks of asymptomatic infection? Further, most current information about COVID and pregnancy comes from high-income countries, limiting its global generalizability

Do we know if COVID vaccines are safe in pregnancy?

At this point, tens of thousands of pregnant people have received COVID vaccines globally, including in the U.S., Canada, the U.K., and Israel. Thus far, there have been no reports suggestive of concern. Additionally, none of the vaccines that have thus far been authorized for use in the U.S.—the Pfizer-BioNtech, Moderna, and Johnson & Johnson/Janssen vaccines, as well as the Oxford-AstraZeneca vaccine authorized in other countries—contain live or replication-competent viruses. Therefore, it is extremely unlikely that a vaccine virus could replicate, cross the placenta, and infect the fetus. However, more research is needed in order to better characterize the safety profile of each COVID vaccine in pregnancy.

Although there is not yet pregnancy-specific data about COVID vaccines from clinical trials, the vaccines have been studied in pregnant laboratory animals. Called developmental and reproductive toxicity (DART) studies, research with pregnant animals can provide reassurance about moving forward with vaccine research in pregnant people. There are no concerning signals from DART study data for the Pfizer-BioNtech, Moderna, Johnson & Johnson/Janssen, and preliminary DART data for the Oxford-AstraZeneca vaccines. Small numbers of participants in the research trials for these vaccines have become pregnant. No concerning risk signals in those pregnancies have been reported.

All three of these vaccines offer a very high level of protection against severe COVID. There is little reason to believe these vaccines will be less effective in pregnant people than they are in people of comparable age who are not pregnant.

What positions have different national and global authorities taken on pregnant people and COVID vaccines that are authorized for use?

The absence of pregnancy-specific data for COVID vaccines has made regulatory and public health decision-making complicated. Largely due to the absence of evidence, most public health agencies have held back on making explicit recommendations on COVID vaccine administration in pregnancy. In the U.S., Canada, the U.K., and several other countries, the position of the relevant public health authority is that pregnant people who otherwise qualify for an authorized vaccine—such as pregnant people who are health care workers or members of other prioritized essential workforces—should be permitted to make their own decisions about vaccination, based on their assessment of whether the prospect of benefit to them and their offspring outweighs the risks. This is also the position of the World Health Organization for the vaccines they have thus far evaluated. In Israel, the Ministry of Health and Vaccines Prioritization Committee recommended vaccination for pregnant people in their second or third trimester. Most jurisdictions in the U.S. are already offering the vaccine to pregnant people given higher COVID risk in pregnancy, including the District of Columbia, Pennsylvania, and Mississippi.

What do obstetricians say about COVID vaccines and pregnancy?

Professional societies, such as the American College of Obstetricians and Gynecologists, the Society for Maternal-Fetal-Medicine, and the Royal College of Obstetricians and Gynaecologists, all support COVID vaccination in pregnancy when the benefits outweigh the risks.

How should pregnant people think about the benefits and risks?

The major benefit of the Pfizer-BioNtech, Moderna, Johnson & Johnson/Janssen, and Oxford-AstraZeneca vaccines to all people, pregnant or not, is that being vaccinated provides a high level of protection against serious illness from COVID.

How important the protective benefit of COVID vaccination is to any individual pregnant person depends on how likely they are to get infected, and how likely they are to get seriously ill, if infected. Pregnant people differ in how likely they are to get infected. A person’s risk of becoming infected depends on at least three things: 1) whether their job puts them at risk of infection; 2) the rate of transmission in their community; and 3) who they live with, especially whether they live with people who are at increased risk because of their jobs, or in a crowded home or densely populated neighborhood. For example, people whose jobs require them to be in regular contact with many people are at higher risk of infection than people who can work from home. Similarly, people who live with other people who also work outside the home are at greater risk than people who live alone or only with others who also work or attend school from home.

Pregnant people also differ in how likely they are to get seriously ill with COVID, if they become infected. While pregnancy by itself is a risk factor for serious illness, some medical conditions like diabetes, heart disease, or being very overweight are even greater risk factors. People who are pregnant and also have high-risk medical conditions are more likely to develop severe COVID if they become infected than pregnant people who do not have those medical conditions.

Pregnant people should also consider whether they have access to alternative modes of protection from infection. Questions to ask include: Can they take a leave from work or be temporarily transferred to a lower-risk job; do they have access to high quality personal protective equipment; and, if someone in their household gets infected or exposed, is there a way for that person to safely isolate away from others?

Resources, including provider information sheets, conversation guides, and decision aids, have been developed to facilitate the values-driven and context-dependent calculations that pregnant people face in the coming months.

When are we likely to get data from pregnant people?

Some people prioritized for vaccination have received COVID vaccines while pregnant, and data about their pregnancies are being collected by public health agencies. Registries are being established in multiple countries to capture the experiences of pregnant people who are receiving COVID vaccines. At least one developer, Pfizer-BioNTech, has begun a pregnancy-specific trial for their vaccine, which will enroll 4,000 pregnant people across nine countries.

What is wrong with this picture?

The absence of pregnancy-specific data around COVID vaccines continues an unfair pattern in which evidence about safety of new vaccines for pregnant people lags behind. This unfairness is ethically problematic in at least two important ways.

First, people may be denied vaccine, or may face barriers in accessing vaccine, because they are pregnant. Public health agencies globally have struggled to determine the most ethical position regarding whether to allow pregnant people to receive COVID vaccines in the absence of pregnancy-specific data. While there is still limited evidence on the safety of currently authorized vaccines in pregnancy, with high vaccine efficacy, no risk signals from studies in pregnant animals, and few biologically plausible risks, the permissive approach that most health authorities have taken enabling individuals to decide for themselves is ethically appropriate.

However, in some settings—whether by policy guidance, local guidelines, or even individual provider reticence—a lack of evidence may mean that pregnant people will face unfair denial of highly effective vaccines from which they stand to benefit.

Second, even when pregnant people are eligible for vaccination, because public health authorities have not explicitly recommended COVID vaccines in pregnancy, the burden of making decisions about vaccination has shifted to pregnant people. Evidence gaps shift the responsibility for associated risk more squarely to pregnant people, where their nonpregnant peers have an evidence base and a public health recommendation to back up their vaccination decision. While endorsement from medical professional societies is helpful, without pregnancy-specific evidence or explicit pregnancy recommendations, there is also the risk that pregnant people’s decisions will be biased by the strong risk distortions that are known to be present in the context of pregnancy.

Hopefully, the evidence necessary for public health agencies to make clear, full-throated recommendations about the use of at least some COVID vaccines in pregnancy will be forthcoming in the coming months. Efforts are underway to encourage developers of vaccines not yet approved for use to move more quickly to conduct studies with pregnant people and otherwise undertake efforts to systematically generate evidence on the safety of their products in pregnancy. We will continue to update this brief, as new data and new policies become available, both for the vaccines discussed here and for additional vaccines that will shortly be evaluated for use in public health programs.

Ruth Faden, PhD, MPH, is the founder of the Johns Hopkins Berman Institute of Bioethics and was its director from 1995 until 2016. She is a professor in Health Policy and Management.

Carleigh Krubiner, PhD, is an associate faculty member at the Johns Hopkins Berman Institute of Bioethics. 

Chizoba Wonodi, DrPh ’09, MPH ’04, is an associate scientist in International Health and the Nigeria Country Director for the International Vaccine Access Center.

A Primer on Herd Immunity

What is Herd Immunity and How Can We Achieve It With COVID-19?

Stopping SARS-CoV-2 will require a substantial percentage of the population to be immune.

BY GYPSYAMBER D’SOUZA AND DAVID DOWDY | UPDATED APRIL 6, 2021

When the coronavirus that causes COVID-19 first started to spread, virtually nobody was immune. Meeting no resistance, the virus spread quickly across communities. Stopping it will require a significant percentage of people to be immune. But how can we get to that point?

In this Q&A, Gypsyamber D’Souza, PhD ’07, MPH, MS, and David Dowdy, MD, PhD ’08, ScM ’02, explain how the race is on to get people immune by vaccinating them before they get infected.

What is herd immunity?

When most of a population is immune to an infectious disease, this provides indirect protection—or population immunity (also called herd immunity or herd protection)—to those who are not immune to the disease.

For example, if 80% of a population is immune to a virus, four out of every five people who encounter someone with the disease won’t get sick (and won’t spread the disease any further). In this way, the spread of infectious diseases is kept under control. Depending how contagious an infection is, usually 50% to 90% of a population needs immunity before infection rates start to decline. But this percentage isn’t a “magic threshold” that we need to cross—especially for a novel virus. Both viral evolution and changes in how people interact with each other can bring this number up or down. Below any “herd immunity threshold,” immunity in the population (for example, from vaccination) can still have a positive effect. And above the threshold, infections can still occur.

The higher the level of immunity, the larger the benefit. This is why it is important to get as many people as possible vaccinated.

How have we achieved herd immunity for other infectious diseases?

Measles, mumps, polio, and chickenpox are examples of infectious diseases that were once very common but are now rare in the U.S. because vaccines helped to establish herd immunity. We sometimes see outbreaks of vaccine-preventable diseases in communities with lower vaccine coverage because they don’t have herd protection. (The 2019 measles outbreak at Disneyland is an example.)

For infections without a vaccine, even if many adults have developed immunity because of prior infection, the disease can still circulate among children and can still infect those with weakened immune systems. This was seen for many of the aforementioned diseases before vaccines were developed.

Other viruses (like the flu) mutate over time, so antibodies from a previous infection provide protection for only a short period of time. For the flu, this is less than a year. If SARS-CoV-2, the virus that causes COVID-19, is like other coronaviruses that currently infect humans, we can expect that people who get infected will be immune for months to years. For example, population-based studies in places like Denmark have shown that an initial infection by SARS-CoV-2 is protective against repeat infection for more than six months. But this level of immunity may be lower among people with weaker immune systems (such as people who are older), and it is unlikely to be lifelong. This is why we need vaccines for SARS-CoV-2 as well.

What will it take to achieve herd immunity with SARS-CoV-2?

As with any other infection, there are two ways to achieve herd immunity: A large proportion of the population either gets infected or gets a protective vaccine. What we know about coronavirus so far suggests that, if we were really to go back to a pre-pandemic lifestyle, we would need at least 70% of the population to be immune to keep the rate of infection down (“achieve herd immunity”) without restrictions on activities. But this level depends on many factors, including the infectiousness of the virus (variants can evolve that are more infectious) and how people interact with each other.

For example, when the population reduces their level of interaction (through distancing, wearing masks, etc.), infection rates slow down. But as society opens up more broadly and the virus mutates to become more contagious, infection rates will go up again. Since we are not currently at a level of protection that can allow life to return to normal without seeing another spike in cases and deaths, it is now a race between infection and injection.

What are the possibilities for how herd immunity could play out?

In the worst case (for example, if we stop distancing and mask wearing and remove limits on crowded indoor gatherings), we will continue to see additional waves of surging infection. The virus will infect—and kill—many more people before our vaccination program reaches everyone. And deaths aren’t the only problem. The more people the virus infects, the more chances it has to mutate. This can increase transmission risk, decrease the effectiveness of vaccines, and make the pandemic harder to control in the long run.

In the best case, we vaccinate people as quickly as possible while maintaining distancing and other prevention measures to keep infection levels low. This will take concerted effort on everyone’s part. But if we continue vaccinating the population at the current rate, in the U.S. we should see meaningful effects on transmission by the end of the summer of 2021. While there is not going to be a “herd immunity day” where life immediately goes back to normal, this approach gives us the best long-term chance of beating the pandemic.

The most likely outcome is somewhere in the middle of these extremes. During the spring and early summer (or longer, if efforts to vaccinate the population stall), we will likely continue to see infection rates rise and fall. When infection rates fall, we may relax distancing measures—but this can lead to a rebound in infections as people interact with each other more closely. We then may need to re-implement these measures to bring infections down again.

Will we ever get to herd immunity?

Yes—and hopefully sooner rather than later, as vaccine manufacturing and distribution are rapidly being scaled up. In the United States, current projections are that we can get more than half of all American adults fully vaccinated by the end of Summer 2021—which would take us a long way toward herd immunity, in only a few months. By the time winter comes around, hopefully enough of the population will be vaccinated to prevent another large surge like what we have seen this year. But this optimistic scenario is not guaranteed. It requires widespread vaccine uptake among all parts of the population—including all ages and races, in all cities, suburbs, and countrysides. Because the human population is so interconnected, an outbreak anywhere can lead to a resurgence everywhere.

This is a global concern as well. As long as there are unvaccinated populations in the world, SARS-CoV-2 will continue to spread and mutate, and additional variants will emerge. In the U.S. and elsewhere, booster vaccination may become necessary if variants arise that can evade the immune response provoked by current vaccines.

Prolonged effort will be required to prevent major outbreaks until vaccination is widespread. Even then, it is very unlikely that SARS-CoV-2 will be eradicated; it will still likely infect children and others who have not been vaccinated, and we will likely need to update the vaccine and provide booster doses on some regular basis. But it is also likely that the continuing waves of explosive spread that we are seeing right now will eventually die down—because in the future, enough of the population will be immune to provide herd protection.

What should we expect in the coming months?

We now have multiple effective vaccines, and the race is on to get people vaccinated before they get infected (and have the chance to spread infection to others). It is difficult to predict the future because many factors are at play—including new variants with the potential for increased transmission, changes in our own behavior as the pandemic drags on, and seasonal effects that may help to reduce transmission in the summer months. But one thing is certain: The more people who are vaccinated, the less opportunity the virus will have to spread in the population, and the closer we will be to herd immunity.

We have seen that the restrictions needed over time have varied as preventive measures have worked to drive infection rates down, but we have also seen these rates resurge as our responses have relaxed. Once we get enough people vaccinated to drive down infection rates more consistently, we should be able to gradually lift these restrictions. But until the vaccine is widely distributed and a large majority of the population is vaccinated, there will still be a risk of infection and outbreaks—and we will need to take some precautions.

In the end, though, we will build up immunity to this virus; life will be able to return to “normal” eventually. The fastest way to get to that point is for each of us to do our part in the coming months to reduce the spread of the virus—continue to wear masks, maintain distance, avoid high-risk indoor gatherings, and get vaccinated as soon as a vaccine becomes available to us.

Gypsyamber D’Souza is a professor and David Dowdy an associate professor in Epidemiology at the Bloomberg School.https://www.youtube.com/embed/HfRN-UjEeZo?enablejsapi=1&rel=0&origin=https://www.jhsph.edu&showinfo=0

COVID in Bangladesh; Not Much Compassion

In Bangladesh, Plenty of Vaccines but Few Takers

April 5, 2021

Photo of Brian Simpson

BRIAN W. SIMPSONEDITOR-IN-CHIEF   

West Dhanmondi, Dhaka, March 31, 2021. Image:Taufique Joarder

Image creditWest Dhanmondi, Dhaka, March 31, 2021. Image:Taufique Joarder

A speedy vaccine rollout is Bangladesh’s shining victory during the pandemic, but there aren’t enough takers for the shots, says Taufique Joarder, MBBS, DrPH, MPH, executive director of the Public Health Foundation, Bangladesh. Even as the country negotiated quick access to vaccines, it didn’t prioritize distribution planning and communications.

The paradox is one of many for the country’s COVID-19 response, including a lockdown that was called a “general holiday” as well as doctors locked out of their apartments by fearful landlords.

Joarder, who lives in Dhaka, shares insights on Bangladesh’s surging case numbers and other issues for Global Health NOW’s COVID Countries series.

Bangladesh

Cases: 611,295

Deaths: 9,046

Source: Johns Hopkins (as of April 1, 2021)

The Big Picture

In the past couple of weeks, suddenly, the numbers increased. I guess a couple of weeks ago, we had perhaps 100 or so cases per day, but today [March 26] it was 3,587 cases and 34 deaths. We don’t have a very reliable data. In the absence of a way to really verify, we just rely on what the government says. It can be an artifact of increased testing.

I heard from people working in government, medical, primary health care centers and rural areas that whenever there was a surge in cases, they received informal government directives that said, don’t send your patients for testing, give them some medications. Because when it is tested, it’s kind of difficult to hide the numbers.

The Mood in Bangladesh

If you go outside, I mean, you won’t see any difference with from the like, pre-COVID situation. People are all around everywhere.

There was no good information like what can happen, what you can do, what you cannot do. Nothing was there. As a result, we read news articles like children deserting their elderly parents who had coughing, for example. They just deserted them in a jungle so that they can’t return home. That happened.

I heard from so many of my doctor colleagues, physician colleagues, that they were actually driven out of their homes and they did not have any place to go because their landlord said, “Oh, you will bring in the coronavirus in our apartment.”

Government Response

Bangladesh does not have a very effective public health system. So firstly, the response was very clinical centric, all hospital centric. There was no effective communication. Secondly, the response was very much administrative rather than scientific.

During Eid [the Muslim religious holiday], traditionally, the Eid prayer is held in open places. [The government] gave us another directive to say your prayer in a mosque rather than in open places. Their directive was totally opposed to the scientific knowledge we had at that time [May 2020]. We were surprised. The scientific leadership was not really there.

Lockdown

They started lockdown on 26th of March and said it would last for one week. They just kept on increasing the time of the lockdown every week. People were not prepared to stay home for a longer time. And as a result, there had never been an effective lockdown in Bangladesh.

The government also did not use the term “lockdown.” They used “general holiday.” Some of my acquaintances used this general holiday as an opportunity to go to vacations to tourist places. A few got married. And when there is a wedding ceremony in Bangladesh, you have like thousands of people coming. And that’s what exactly happened.

Vaccine Situation

The one good thing is that Bangladesh procured the vaccine quite early. They started vaccination on January 27. And they started vaccinating people in a larger scale from 7  February.

Interestingly, instead of like government procurement or going to COVAX, the government engaged a private pharmaceutical company to procure it for them. And it did not follow any, any transparent procedures.

Nobody really knew how this vaccine is going to be distributed, who is going to get the vaccine, or anything like that. When they started rolling out, they found that there was not many recipients, and they decreased the age bar from 55 to 40 years. Enthusiasts rushed in, and government was happy to call it a success. But after a few weeks, vaccination centers became almost empty again. My wife went to get vaccine just 2 days ago. And she reported that nobody was there in the vaccine center.

Expatriate Workers

In the beginning, it was termed a disease of the expatriates. Bangladesh has a lot of expatriate workers working in Middle East and Southeast Asian countries, Europe. So, when they returned, [the government] should have actually arranged good quarantine facilities. Instead, the government raised a red flag over the houses of the people who came from abroad. This stigmatized them and their family.

Worst Time

I would say the worst time was actually the early days. We were all confused. The whole city was like a ghost city. Nobody knew what’s happening. Nobody knew who is in charge. So it was actually a terrible time.

Positive Moment

A positive moment is actually the vaccination. That was the only time we praised the government for taking very rapid actions. I got the vaccine. My friends are living in different countries, most of them said they need to wait at least four or five months before they get the vaccine, but we got the vaccine.

What’s happening in your country? To be part of GHN’s COVID Countries series, email Brian at bsimpso1 [at] jhu.edu.

Join the 50,000+ subscribers in 170+ countries who rely on Global Health NOW summaries and exclusive articles for the latest public health news. Sign up for our free weekday enewsletter, and please share the link with friends and colleagues: https://www.globalhealthnow.org/subscribe

Is it Worth it to Get More of Tom Gore?

$19.95 for a California Cabernet Sauvignon? I think its possible if you stay away from Napa, Sonoma and the Russian River Valley. I this case the Tom Gore label says it is a California Cabernet Sauvignon which means all the grapes can come from all over California. So it pays for Mr. Gore to know the product of his growers. There are savvy buyers of grapes In California like Phillip Zorn who have in my past produced some amazing inexpensive wines knowing the growers so well.

How about Tom Gore? Do you buy some more or snore? Decently focused aroma of blueberry, black cherry and blackberry with faint wafts of smoke. On the palate smooth with minimal tannins like a wine you can bring open, let it settle down for a few hours, uncork and enjoy immediately. Gentle notes of blueberry and blackberry in a relaxed finish. Very appropriate for your week-end barbeque both before the food is served and for your meal. I think lamb burgers might match the essential softness of the wine. As for grilled steak it is too dainty. It could suit the cult beer can chicken. Assuming if we have real live football great for a tail gate party.

So get more Tom Gore and forget the snore.

(Tom Gore Vineyards 2019 California Cabernet Sauvignon, Tom Gore Vineyards, Acampo, California, $19.95, Liquor Control Board of Ontario # 451336, 750 mL, 13.5%, Robert K. Stephen A Little Birdie Told Me So Rating 89/100).

Poetry Corner: “Casino Covid In Canada”

Casino Covid in Canada

Caught in the slot machine blur
Anti vaxxers be prepared for a nasty slur
hoping for the jackpot of herd immunity
the saviour of the community
the three cherries of untested vaccines in the long term
which could be worse than the germ
as the RNA composition of Pfizer and Moderna messes with our genes
Holy Shit where were the simpler days of Captain Kangaroo and Mr. Green Jeans
displaced by the politico-medico teams
desperately trying the placate the panicked screams
opening and closing duplicating and replicating surges and waves
killing and maiming more
turning science as their excuse and weapon
misjudged again and again
ruining the economy and the health of all
crazy focus on a virus
but in a casino you know who wins
it is always the house
which will be voting about your performance in the next election
and according to the latest polls means you’ll be delivered a nasty blow to your midsection
and today’s brilliant observation by Ontario Premier Doug Ford
That we are going to get through this
of course we are
just a question of when and what will be the economic and social carnage
and who will be put to blame
for starters Canada’s dismal vaccination rate
must be an embarrassing state for all
will we ever be told the truth ?
Perhaps we know it already?
you know politics is a dirty game
perhaps the political and medico elite did their best but some will get the blame

Robert K. Stephen

Jon Kabat-Zinn’s “Full Catastrophe Living”; a second way of practicing mindfulness

“The second way of practicing using the breath is to be mindful of it from time to time during the day, or even all day long, wherever you are and whatever you are doing. In this way the thread of meditative awareness, including the physical relaxation, the emotional calm, and the insight that come with, is woven into every aspect of your daily life. We call this informal meditation practice, but is easily neglected and loses much of its ability to stabilize the mind if it is not combined with regular meditation practice.”

Susan Cain’s “Quiet”; introverts vs. extroverts

“Introverts think before they act, digest information thoroughly, stay on task longer, give up less easily, and work more accurately. Introverts and extroverts also direct their attention differently: if you leave them to their own devices, the introverts tend to sit around wondering about things, imagining things, recalling events from their past, and making plans for the future. The extroverts are more likely to focus on what’s happening around them. It’s as if extroverts are seeing “what is” while their introverted peers are asking “what if”.”

Passage of the Day :Marguerite de Navarre: “The Heptameron”: Love

“I’ll do just as you ask, because the story I have in mind is about a woman who was wanton and a woman who was wise. You may please yourselves which example you follow. You will see that love makes bad people do bad things, and virtuous people do things we should respect. For in itself, love is good, but if the individual is bad, then you might wish to call it something else – foolish, fickle, cruel or deprived. What you will see, then, from the story I am about to tell you. It is that love doesn’t change the heart but shows the heart as it really is – wanton in women who are wanton, wise in women that are wise.”

Marguerite de Navarre (1492-1549)

“Mutantism on the March” :Chapter 37 “Green Cross Public Relations vs. Reality”

Nicaragua was embroiled in a fiendish mess. Detroit manufactured Cadillac’s whizzed by the begging hordes occasionally tossing a few worthless coins not for charitable purposes but rather for a laugh at these dirty and rank smelling masses. Charity was big business for Hartford Connecticut based Green Cross. A leaked report by a team of investigative Nicaraguan journalists, later found dead outside Managua with their severed heads attached to poles, exposed a salacious little fact that Green Cross was selling Nicaraguan blood for a tidy profit in the United States. It was also suggested more information was to be released concerning the Green Cross acting as an organ broker in Europe. So in fact Nicaragua was being bled dry in many ways. The poverty was augmenting weekly and surpassing dismal Central American averages. A fair comment could be made the nation was in the hands of greedy profit mongers with a goal of squeezing out every sellable commodity from Nicaragua.

Squid was well in tune with the squalor of Nicaragua being briefed by Santa Claus and through the reading of reports of gringo charities operating in Nicaragua “explaining” the miserable conditions. This poverty, filth and disease was all the more appalling given that across the street were gated and guarded mansions. Green Cross was the dominant charitable organization operating in the country. Squid’s contacts told him Green Cross was expanding from blood selling and organ brokering to child abduction to placate the demand of the northern infertiles. Green Cross was nothing but another gringo “corporation” operating in the middle of a stinking moral and economic cesspool. The Green Cross in many eyes were nothing but apologists for the real gringo culprits. It was time something was done.

With some volunteers Squid researched the goings on of Green Cross, It wasn’t long before the secret police discovered what Squid was up to and in a surprising move the government praised his efforts to make Nicaragua a stronger country and a kinder one to its citizens. They also gave him some friendly advice that he was wasting his time as the junta had formed an investigative committee to “investigate” Green Cross charitable work so he would be their guest at a luxurious government villa (under house arrest) for a week after which he would be flown to New Delhi. Squid escaped house arrest and undercover finished his research some three weeks later culminating in a devastating report.

Rufus Moonhead was the brains behind the Green Cross in Nicaragua operating under the name Booker T. Whilmot. Yes Moonhead, as you may remember, was chased out of the United States for numerous criminal activities including bribery, fraud and smuggling much exposed by Squid himself. Moonhead had fled to Nicaragua initially drinking vast quantities of beer and becoming acquainted with every prostitute both male and female in Nicaragua.

Some friendly United States senators with links to the CIA, advised Moza of the whereabouts of Moonhead and his potential for protecting a country surrounded by communism. Moza’s agents found Moonhead dead drunk at the Intercontinental Hotel in Managua. After sobering him up they escorted him to the presidential place to Moza who was impressed with a jewel of a find. A gringo that had swindled fellow gringos out of millions! Moonhead resigned his position at the Green Cross after being offered a consultancy position on the Nicaraguan Public Advertising Commission. Thinking he would lead a life of languishing drunkenness and attempting to avoid STDs  he was brought back to life with a license to swindle. His first task was to solicit the ears and sympathies of several large United States corporations such as Unifoods, Murky Express and Green Cross. Big plans were afoot.

Testimonial to Failure in Strategy: Yet Another Yo-Yo Move Stay at Home Order in Ontario

COVID-19: enhanced public health and workplace safety measures

Learn about the state of emergency and provincewide stay-at-home order to interrupt transmission of COVID-19covid 19.

Stay-at-home order

A province-wide declaration of emergency and a stay-at-home order are in effect as of April 8 at 12:01 a.m. The COVID-19covid 19 Response Framework (colour-coded zones) is paused during this time.

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  1. About the state of emergency and provincewide stay-at-home order
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About the state of emergency and provincewide stay-at-home order

As COVID-19covid 19 cases continue to rise at an alarming rate, a state of emergency and provincewide stay-at-home order are in effect as of Thursday, April 8, at 12:01 a.m.

This puts in place shutdown measures that:

  • are the most stringent, to address rapidly escalating conditions, including the spread of variants of concern
  • include business closures in higher risk sectors (for example, fitness activities, personal care service establishments, indoor and outdoor dining)

Read O. Reg. 82/20 for details.

General public health and workplace safety measures

For businesses, organizations and facilities

Refer to O. Reg. 82/20 for details.

Public health advice, recommendations and instructions

Businesses or organizations must comply with the advice, recommendations and instructions of public health officials. This includes advice, recommendations or instructions on:

  • physical distancing
  • cleaning or disinfecting
  • working remotely

Check with your local public health unit for any additional advice, recommendations or instructions.

Work from home except where necessary

Each person responsible for a business or organization that is open shall ensure that any person who performs work for the business or organization conducts their work remotely, with limited exception, for instance, where the nature of their work requires them to be on-site at the workplace.

Physical distancing and line management

Businesses must not permit patrons to line up inside, or to line up or congregate outside, unless they:

  • maintain a physical distance of at least two metres from others
  • wear a mask or face covering (with some exceptions)

Screening

Businesses or organizations must operate in compliance with the advice, recommendations instructions issued by the Office of the Chief Medical Officer of Health on screening individuals.

For patrons

Businesses must implement passive screening for patrons by posting signs at all entrances informing people to screen themselves for COVID-19covid 19 before entry.

Active screening is required in accordance with instructions by the Office of the Chief Medical Officer of Health. Where this is required, it is noted in the sections below.

For workers

Workplaces must screen all workers or visitors entering the work environment. See the COVID-19covid 19 Screening Tool for Workplaces for more information.

Personal protective equipment including eye protection

Everyone must wear a mask or face covering that covers their mouth, nose and chin inside any business or place that is open (with some exceptions).

Workers must wear appropriate personal protective equipment (PPE) that protects their eyes, nose and mouth, if in the course of providing services they are:

  • required to come within 2 metres of another person who is not wearing a mask or face covering
  • in an indoor area and are not separated by plexiglass or some other impermeable barrier

Capacity limits

As of April 8 at 12:01 a.m., the majority of non-essential stores (including malls) will only be open for curbside pick-up and delivery by appointment, and additional capacity limits may apply.

In person shopping permitted for all retail, subject to ability to maintain two metres of physical distancing and capacity limits of:

  • 50% for supermarkets and other stores that primarily sell groceries, convenience stores and pharmacies
  • 25% for all other retail, including discount and big box retailers, liquor stores, cannabis stores, hardware stores and garden centres

All businesses or facilities that engage in retail sales to the public must post a sign in a location visible to the public that states the maximum capacity they are permitted to operate under.

To calculate maximum capacity:

  • for 50% capacity: divide the total square metres of floor space accessible to the public (not including shelving and store fixtures) by 8 and round down to the nearest whole number
  • for 25% capacity: divide the total square metres of floor space accessible to the public (not including shelving and store fixtures) by 16 and round down to the nearest whole number

Cleaning and disinfection

Open businesses must ensure that equipment, washrooms, locker rooms, change rooms and showers that are accessible to the public are cleaned and disinfected as frequently as is necessary to maintain a sanitary condition.

Face coverings

Businesses or organizations must ensure that patrons and workers wear masks or face coverings indoors, with limited exceptions.

Safety plans

Open businesses must prepare and make available a COVID-19covid 19 safety plan. A copy of the plan must be made available to any person for review upon request, and be posted where it would come to the attention of individuals working in or attending the business.

For individuals

Physical distancing

Everyone must maintain a physical distance of at least two metres from others (except for caregivers or other members of their household) in a place of business or facility that is open to the public.

Face coverings

Everyone must wear a mask or face covering that covers their mouth, nose and chin in indoor public spaces (with limited exceptions).

Accessing closed indoor and outdoor recreational amenities

Accessing closed indoor and outdoor recreational amenities is not allowed.

Organized public events and social gatherings

Events and gatherings

Indoor organized public events and social gatherings are not allowed, except with members of the same household (the people you live with).

Individuals who live alone and single parents may consider having exclusive, close contact with another household to help reduce the negative impacts of social isolation.

Outdoor organized public events and social gatherings must comply with public health advice on physical distancing and have no more than 5 people.

Weddings, funerals and other religious services, rites or ceremonies

For weddings, funerals and other religious services, rites or ceremonies:

  • physical distancing must be maintained
  • guests must wear masks or face coverings
  • capacity limits:
    • indoors: 15% capacity of the room
    • outside: the number of people that can maintain two metres physical distance from each other

Drive-in services, rites or ceremonies permitted, subject to certain conditions.

Virtual services permitted.

Businesses that can open and relevant restrictions

Refer to O. Reg. 82/20 for details.

Supply chain

Businesses allowed to open if they supply essential:

  • support
  • products
  • supplies
  • systems
  • services, including processing, packaging, warehousing, distribution, delivery and maintenance

Meeting or event spaces

Only permitted to open for:

  • child care centres and authorized recreational and skill building programs (as described in the Child Care and Early Years Act, 2014)
  • court services
  • government services
  • mental health and addictions support services (for example, Alcoholics Anonymous), permitted to a maximum of 10 people
  • social services
  • collective bargaining, so long as more than ten people are permitted to occupy the rented space

Contact information recording required, with the exception of court services.

Restaurants, bars, and other food or drink establishments

Take out, drive through, and delivery permitted only (includes the sale of alcohol).

Night clubs and strip clubs only permitted to open if they operate as a food or drink establishment.

Retailers

Supermarkets, convenience stores, indoor farmer’s markets and other stores that primarily sell food

Open for:

  • in-person retail (50% capacity where two metres physical distancing can be maintained)
  • curbside pick-up
  • delivery

Pharmacies

Open for:

  • in-person retail (50% capacity, where two metres physical distancing can be maintained)
  • curbside pick-up
  • delivery

All other retail (including liquor, cannabis, hardware and pet stores)

As of April 8 at 12:01 a.m., the majority of non-essential stores will only be open for curbside pick-up and delivery, by appointment, with some exceptions. Discount and big box stores will only be open for in-person shopping for groceries, household cleaning supplies, personal care items, pharmacy items and pet supplies.

Currently open for:

  • in-person retail (25% capacity, where two metres physical distancing can be maintained)
  • curbside pick-up
  • delivery

Shopping malls

As of April 8 at 12:01 a.m., access to shopping malls will be limited to curbside pick-up and delivery only, by appointment.

Currently open, with the following conditions:

  • maximum capacity 25% per store, where two metres physical distancing can be maintained
  • inside dining spaces closed (includes food courts)
  • music must be low enough for normal conversation to be possible
  • indoor shopping malls must actively screen patrons in accordance with the advice, recommendations and instructions of the Office of the Chief Medical Officer of Health before they enter

Motor vehicle sales

As of April 8 at 12:01 a.m., in-person shopping for motor vehicles will be available by appointment only.

  • Includes cars, trucks and motorcycles; recreational vehicles including motor homes; trailers and travel trailers; boats and other watercraft; and other motorized vehicles, including power-assisted bicycles, golf carts, scooters, snowmobiles and all-terrain vehicles
  • Members of the public must not be permitted where products are neither sold nor displayed for sale
  • Subject to certain conditions related to test drives, including:
    • limited to no more than 10 minutes
    • a maximum of two people, including up to one sales representative permitted
    • windows must be opened at all times unless if two people who are not members of the same household are present in the vehicle

Services

Permitted services include:

  • rental and leasing services, including automobile, commercial and light industrial machinery and equipment rental
  • gas stations and other fuel suppliers
  • automated and self-service car washes
  • laundromats and drycleaners
  • snow clearing and landscaping services
  • security services for residences, businesses and other properties
  • domestic services to support children, seniors or vulnerable persons, including:
    • housekeeping
    • cooking
    • indoor and outdoor cleaning and maintenance services
  • vehicle and equipment repair and essential maintenance and vehicle and equipment rental services
  • courier, postal, shipping, moving and delivery services
  • funeral and related services
  • staffing services including providing temporary help
  • veterinary services and other businesses that provide pet services and for the health and welfare of animals, including:
    • farms
    • boarding kennels
    • stables
    • animal shelters
    • research facilities
    • pet groomers
    • pet sitters
    • pet walkers
    • pet trainers (including for service animals)

Rental accommodations

Hotels, motels, lodges, cabins, cottages, resorts student residences and other shared rental accommodations

  • Indoor pools, fitness centres or other recreational facilities closed.

Short-term rentals

Short-term rentals (for example, cottages, cabins) are only to be provided to individuals who are in need of housing.

With the exception of exercising an Aboriginal or treaty right, ice fishing huts may:

  • only be used by to members of the same household
  • not be used overnight

Seasonal campgrounds

Campsites must be made available only for trailers and recreational vehicles that are:

  • used by individuals who are in need of housing
  • permitted to be there by the terms of a full season contract

Only campsites with electricity, water services and facilities for sewage disposal may be provided.

All recreational facilities in the campground and all other shared facilities in the campground, other than washrooms and showers, must be closed.

Other areas of the campground must be closed to the genera public (may only be opened for preparing the seasonal campground for reopening).

Post-secondary institutions

Post-secondary institutions open for virtual instruction, with limited exceptions where in-person instruction is required (e.g., clinical training, trades). Subject to physical distancing with limited exceptions.

In-person teaching (each instructional space at the institution at one time) and in-person examinations cannot exceed 10 persons, with limited exemptions for:

  • diagnostic cardiac sonography and diagnostic medical sonography
  • diagnostic ultrasound
  • medical imaging
  • medical laboratory assistant and Medical laboratory technician
  • medical radiation technology
  • medicine
  • mental health and addictions services, including psychology services, social work services and counselling services
  • nursing
  • paramedic
  • personal support worker, supportive care worker, home care worker or a similar occupation
  • pharmacy/pharmacy technician
  • public health inspector, if the program is accredited by the Canadian Institute of Public Health Inspectors
  • rehabilitation sciences (nutrition, speech language pathology, occupational science, and physiotherapy)
  • respiratory therapy

Additional requirements for in-person teaching that involves singing or the playing of brass or wind instruments.

Financial services

Financial services that are permitted include:

  • capital markets and related securities trading and advisory services
  • banking/credit union activities including credit intermediation
  • insurance
  • land registration services
  • pension and benefits payment services
  • financial services including payroll and payment processing and accounting and tax services

Real estate (including pre-sale construction)

No open houses – showing a property permitted by appointment only.

Telecommunications and IT infrastructure/service providers

Permitted businesses include:

  • information technology (IT) services, including online services, software products and the facilities necessary for their operation and delivery
  • telecommunications providers and services (phone, internet, radio, cell phones etc.) and facilities necessary for their operation and delivery
  • newspapers, radio and television broadcasting

Maintenance

Maintenance, repair and property management services that manage and maintain the safety, security, sanitation and operation of institutional, commercial, industrial and residential properties and buildings are allowed.

Transportation services

Permitted services include:

  • transportation services provided by air, water, road, and rail, including taxis and other private transportation providers
  • support services for transportation services, including:
    • logistical support, distribution services, warehousing and storage, truck stops and tow operators, and
    • services that support the operations and safety of transportation systems including maintenance and repairs
  • marinas, boating clubs and other organizations that maintain docking facilities (with conditions)
  • businesses that provide and support online retail, including by providing warehousing, storage and distribution of goods that are ordered online

In-person driving instruction

In-person driving instruction only permitted for:

  • instruction for drivers of commercial motor vehicles
  • the Ontario Driver Certification Program (administered by the Ministry of Transportation), for motor vehicles for which:
    • a class of driver’s licence other than Class G, G1, G2, M, M1 or M2 is required
    • an air brake endorsement is required
  • students at private career colleges, in accordance with certain conditions

Manufacturing

Businesses are permitted if they:

  • extract, manufacture, process and distribute goods, products, equipment and materials, including businesses that manufacture inputs to other manufacturers (for example primary metal/steel, blow molding, component manufacturers and chemicals that feed the end-product manufacturer), regardless of whether those other manufacturers are inside or outside of Ontario
  • support and facilitate the movement of goods within integrated North American and global supply chains

Agriculture and food production

Businesses are allowed if they:

  • produce food and beverages, agricultural products (including plants), including by farming, harvesting, aquaculture, hunting and fishing
  • process, manufacture or distribute:
    • food
    • beverages
    • crops
    • agricultural products
    • animal products and by-products
  • support the food or agricultural products supply chains and the health and safety of food, animals and plants

Construction

Construction activities or projects and related supporting services, including demolition and land surveying, are allowed.

Resources and energy

Businesses that provide and ensure the domestic and global continuity of supply of resources are allowed, including:

  • resource exploration
  • mining
  • forestry
  • aggregates
  • petroleum and petroleum by-products
  • chemicals

Also allowed are:

  • electricity generation, transmission, distribution and storage
  • natural gas distribution, transmission and storage

Community services

Businesses that deliver or support the delivery of community services are allowed, including:

  • sewage treatment and disposal
  • waste collection, transport, storage, processing, disposal or recycling
  • potable drinking water
  • critical infrastructure repair and maintenance including roads, dams, bridges
  • environmental rehabilitation, management and monitoring, and spill clean-up and response
  • administrative authorities that regulate and inspect businesses
  • professional and social services that support the legal and justice system
  • government services, including:
    • policing and law enforcement
    • fire and emergency services
    • paramedics
    • coroner and pathology services
    • corrections and court services
    • licences and permits
  • allotment gardens or community gardens

Facilities for sports and recreational fitness activities

Only open for:

  • identified high-performance athletes, including parasport athletes training and competing for the next Olympics/Paralympics, and specified professional leagues (for example, NHL and AHL
  • child care, mental health and addiction support services, social services or other specified purposes (includes community centres and multi-purpose facilities, such as YMCA) – 10 people maximum
  • access to physical therapy for a person with a disability (as defined in the Accessibility for Ontarians with Disabilities Act, 2005)

Outdoor recreational amenities

Outdoor recreational amenities permitted to open, subject to conditions, include:

  • parks and recreational areas
  • baseball diamonds
  • batting cages
  • soccer, football and sports fields
  • tennis, platform tennis, table tennis and pickleball courts
  • basketball courts
  • BMX parks
  • skate parks
  • frisbee golf locations
  • cycling tracks and bike trails
  • horse riding facilities
  • shooting ranges, including those operated by rod and gun clubs
  • ice rinks
  • tobogganing hills
  • snowmobile, cross country, dogsledding, ice-skating and snow-shoe trails
  • playgrounds
  • portions of parks or recreational areas containing outdoor fitness equipment
  • golf courses and driving ranges

A permitted outdoor recreational amenity may only open if:

  • physical distance of at least two metres can be maintained
  • team sports, or other sports or games where people may come within two metres of each other, are not practiced or played
  • locker rooms, change rooms, showers and clubhouses remain closed (except for access to equipment storage, washrooms or first aid)

Research

Businesses and organizations that maintain research facilities and engage in research, including medical research and other research and development activities, are permitted.

Health care and social services

Permitted:

  • organizations and providers that deliver home care services or personal support services to seniors and persons with disabilities
  • regulated health professionals
  • professionals or organizations that provide in-person counselling services
  • organizations that provide health care, including:
    • retirement homes
    • hospitals
    • clinics
    • long-term care facilities
    • independent health facilities
    • mental health and addictions counselling supports
  • laboratories and specimen collection centres
  • manufacturers, wholesalers, distributors and retailers of pharmaceutical products and medical supplies, including:
    • medications
    • medical isotopes
    • vaccines and antivirals
    • medical devices
    • medical supplies
  • manufacturers, distributors and businesses that provide logistical support for products and services that support the delivery of health care
  • organizations that provide critical personal support services in home or residential services for individuals with physical disabilities
  • organizations that support the provision of food, shelter, safety or protection or social services and other necessities of life to economically disadvantaged and other vulnerable individuals
  • businesses that are primarily engaged in the provision of health and safety training (with conditions)

Media industries

Permitted:

  • sound recording, production, publishing and distribution businesses
  • commercial film and television production, including all supporting activities such as hair, makeup and wardrobe – with the following conditions:
    • no studio audiences permitted to be on the film or television set
    • no more than 50 performers may be on the film or television set
    • the film or television set may be located in any business or place, including any business or place that is otherwise required to be closed
    • set must be configured and operated in such a way as to enable persons on the set to maintain a physical distance of at least two metres from other persons, except where necessary for the filming of the film or television production
    • hair or makeup services providers must wear appropriate personal protective equipment
    • singers and players of brass or wind instruments must be separated from any other performers by plexiglass or some other impermeable barrier
    • the person responsible for the film or television production must ensure that the production operates in accordance with the guidance document titled “Film and television industry health and safety during COVID-19covid 19” issued by the Film and Television Health and Safety Advisory Committee of the Ministry of Labour, Training and Skills Development, as amended from time to time.
  • film and television postproduction, visual effects and animation studios
  • book and periodical production, publishing and distribution businesses
  • commercial and industrial photography
  • interactive digital media businesses, including:
    • computer system software or application developers and publishers
    • video game developers and publishers

Libraries

Circulating materials must be reserved over the telephone or online for contactless curbside, delivery or pick-up.

Patrons must only be permitted to enter the premises to facilitate the contactless drop-off and pick-up or access computers, photocopiers or similar services.

Patrons must not:

  • be in the book stacks
  • handle circulating materials that are shelved or in other areas of library storage

Circulating materials returned to the library must be disinfected or quarantined before they are recirculated.

Other permitted services include:

  • child care services
  • mental health and addiction support services, to a limit of 10 people
  • social services

Businesses not permitted to open

  • Amusement parks, water parks
  • Bathhouses and sex clubs
  • Casinos, bingo halls and gaming establishments
  • Concert venues, theatres and cinemas (includes drive in or drive through events)
  • Day camps
  • Horse racing (open for training only, no races or spectators)
  • Motorsports
  • Museums and cultural amenities
  • Personal care services
  • Tour and guide services
  • Zoos and aquariums (permitted to operate for the care of animals)