Health

(LONDON, HONG KONG and JAKARTA) — A perfect storm with the coronavirus appears to be brewing across the Asia-Pacific region: surges in the highly contagious delta variant combined with slow vaccination uptake.

Tight vaccine supplies are a major factor and experts caution that unless most of the global population is vaccinated, and richer countries share more of their vaccines, the world will face a far longer bout with the coronavirus than anticipated.

The issue extends from countries at the center of the current surge, like Indonesia, to those that fared relatively well with the disease early on in the pandemic, like South Korea.

Even as countries like the U.S. and U.K. face rising cases despite their largely vaccinated populations, hospitalizations and deaths have not yet risen to the same levels as 2020 due to the success of vaccination efforts, public health experts say. Yet the vast majority of the global population remains unvaccinated (just 3.7 billion out of 10-12 billion recommended doses have been distributed).

More people have died of COVID-19 since Jan. 4, 2021 than the whole of last year, according to an ABC analysis of WHO data.

The pandemic is not just far from over — it is in a “critical moment where we are all under threat,” due to rising new variants and vaccine inequality, according to WHO spokesperson Dr. Margaret Harris. The course of the virus, she said, is that it is likely to become “endemic” — meaning it will not disappear, but eventually could become manageable like the other coronaviruses in circulation.

But a true end to the pandemic will likely only happen with the artificial immunity conferred by mass vaccination, according to Yanzhong Huang, a senior fellow for global health at the Council on Foreign Relations.

“You have countries that are making good progress toward building an immunity shield,” he told ABC News. “When you look at the rest of the world, a very small percentage of the population [is] being vaccinated.”

The stark vaccine disparity is far from lost on people in Indonesia, who in the last few months have seen the delta variant rip through their communities, overrunning hospitals, filling graveyards and leaving family and friends who’ve lost loved ones in anguish.

In scenes reminiscent of when India was at its devastating peak earlier this year, there is a clamor for oxygen canisters in Indonesia — now the coronavirus epicenter of the region. Afflicted families, turned away from hospital wards, are taking treatment into their own hands. For two weeks, Defitio Pratama, 27, a marketing salesman based just outside Jakarta, took care of his sick mother at home.

“We had no idea what to do at that time since we did not have oxygen tank at hand,” he told ABC News in Jakarta, where there are long lines for scarce oxygen cylinders. “I started contacting friends and families for oxygen tank, I even went all the way to other city when I found my mother’s friend offering to lend theirs. We could not take my mother to hospital because they kept rejecting us, we had no choice but to treat her at home.”

While Pratama has received one dose of the AstraZeneca vaccine, his mother, who is asthmatic, remains unvaccinated. In the week ending July 19, 9,696 deaths were recorded, an increase of 36% from the week before, according to the WHO. Just under 16% of the population has received at least one dose of vaccine.

In Indonesia, a combination of a lack of supply, vaccine hesitancy and concerns over the Chinese manufactured Sinovac have contributed to the slow rollout, but the country is by no means alone in the region.

Thailand, Australia, Vietnam and South Korea — all countries that were praised last year for their swift containment strategies — have reintroduced restrictions to deal with outbreaks of the Delta variant, which is estimated to be 60% more transmissible than the alpha variant, in recent months. According to Harris, the world’s richest countries are “basically holding the rest of the world hostage by not insisting that their manufacturers share.”

“This is why you’ve got massive outbreaks going on around the world,” she told ABC News. “But people don’t seem to hear it. What they’re hearing is possibly what they want to hear is ‘I’m vaccinated, now, I can go back to normal.’ You can’t. Not until you sort it out in the rest of the world.”

The Biden administration has pledged to donate more than 80 million doses to countries in need, with 23 million going to Asia. Some 3 million doses of Moderna arrived in Indonesia from the U.S. on July 11 — but the rollout needs to significantly increase in order to meet the WHO’s target to vaccinate at least 10% of every country in the world by the end of September.

For the pandemic to end and the virus to become manageable on a global level and COVID-19 to become manageable as with other coronaviruses, between 10 and 12 billion doses need to be administered around the world, Huang said, ideally with high effectiveness. That number currently stands at around 3.7 billion, according to the WHO.

“The best case scenario is that through these vaccination efforts that by the end of next year we have produced enough vaccines that can vaccinate a majority of the population worldwide, and that vaccination is effective in terms of preventing severe cases of death,” Huang said. “Previously I was more optimistic about how and when the pandemic is going to end. “But now, with that divide in terms of vaccine access, in terms of the strategies adopted by countries, in terms of the continued emergence of the new variants, I’m not that optimistic anymore.”

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(NEW YORK) — As contentious debates over vaccine mandates continue with new coronavirus cases on the rise among the unvaccinated, elected officials are starting to fine-tune the idea of a new incentive by requiring public employees to get a coronavirus test until they get their shots.

Barun Mathema, an assistant professor of epidemiology at Columbia University’s Mailman School of Public Health, told ABC News that the plan is a very effective incentive on paper, and it will have a bigger impact outside of the public sector when it comes to confidence in the vaccines.

“This is saying the government, unambiguously, supports vaccination. One can try things like lotteries to entice individuals, but to me, this is a serious and thoughtful approach,” he told ABC News.

New York City Mayor Bill de Blasio announced last week that employees of the city’s public hospital system, which included medical centers like Elmhurst Hospital, the epicenter of the first wave of hospitalizations in 2020, would have to show proof of vaccination or submit a weekly test until they got their shot. Exemptions are allowed for religious medical reasons.

De Blasio expanded that order on Monday to all city public employees, which included police officers, firefighters and teachers. Even though 59% of the city’s entire population and 70% of its adult population has at least one dose of the vaccine as of Tuesday, the numbers were lagging among the ranks of some New York agencies, city data showed.

The NYPD had a 43% vaccination rate, the Department of Correction had a 42% vaccination rate, the FDNY had a 55% vaccination rate, and public school employees and city hospital employees each had a 60% vaccination rate, according to data from city officials. Nationally, 56% of all residents and 69% of all adults have at least one shot, according to the U.S. Centers for Disease Control and Prevention.

The testing mandate will go into effect for unvaccinated public hospital workers next week, and goes into effect on Sept. 13, the first day of schools in New York, for other public employees.

De Blasio stressed that the delta variant is causing cases to rise in unvaccinated neighborhoods in the city and he wanted to ensure New Yorkers that their public employees were vaccinated or proven safe.

“We’re going to keep climbing this ladder and adding additional measures as needed mandates and strong measures, whenever needed to fight the delta variant,” the mayor said during a news conference Monday.

A few hours later, California Gov. Gavin Newsom announced that he would place a similar testing mandate for any state employee who can’t provide proof of vaccination. The mandate affects 249,000 employees and also provides exemptions for religious or medical reasons.

“California has committed to vaccination verification and or testing on a weekly basis,” Newsom said at a news conference.

California’s policy will take effect on Aug. 9.

Mathema said the policy will be most effective at swaying unvaccinated employees who were on the fence about getting the shot and needed an incentive to do so.

In this case, time spent on taking a COVID-19 test, submitting the paperwork to a boss and getting their OK week after week would take its toll, Mathema said.

“There will certainly be some people who find the constant testing inconvenient,” he said.

Dr. John Brownstein, an epidemiologist at Boston Children’s Hospital and an ABC News contributor, said the testing requirement will put extra pressure on an unvaccinated employee to get their shot.

“They’ll have to quarantine and put themselves out of two weeks of work,” he said.

Brownstein predicted that more states will follow New York City and California’s lead and there appears to be momentum at the federal level. President Joe Biden is expected to announce Thursday that all federal employees show proof of vaccination or submit to regular testing, ABC News has learned.

Brownstein added that some businesses have begun to implement rules that provide more benefits for customers. Some cruise ships, he noted, restrict their non-vaccinated passengers from the more popular dining areas and attractions.

“It’s a hybrid carrot and stick situation. You’re giving benefits to people who are vaccinated and punishing people who aren’t,” he said.

Mathema warned that there are likely to be a number of public employees who will submit to the weekly testing rather than get their shots. He reiterated that elected officials and businesses that implement a testing mandate for the unvaccinated needed to supplement their policy with a focused educational plan.

“I do believe this needs to be met with outreach, strong outreach and consistent outreach,” Mathema said. “We do need to be tactful, show empathy and address real issues that are out there: people’s concerns over the vaccine.”

Anyone who needs help scheduling a free vaccine appointment can log onto vaccines.gov.

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(WASHINGTON) — The Centers for Disease Control and Prevention on Tuesday reversed its mask guidance to specifically target areas of the country with the highest levels of the coronavirus and recommended that everyone in those areas, vaccinated or not, wear a mask as the delta variant continues to spread rapidly across the U.S.

The public health agency also recommended schools embrace universal masks, departing from guidance released earlier this month that suggested vaccinated students and staff were safe to go without.

“CDC recommends localities encourage universal indoor masking for all teachers, staff, students, and visitors to schools, regardless of vaccination status,” the CDC wrote in a summary of the new guidance. “Children should return to full-time in-person learning in the fall with proper prevention strategies are in place.”

CDC Director Rochelle Walensky cited new scientific data from a recent outbreak investigation, as well as data from other countries, to defend the agency’s decision to urge vaccinated people to return to wearing a mask in some parts of the country.

She said the data show the delta variant “behaves uniquely” from past strains of the virus.

The data indicate that on “rare occasions, some vaccinated people with the delta variant … may be contagious and spread the virus to others. This new science is worrisome and unfortunately warrants an update to our recommendations,” she said.

Last May, the CDC took the country by surprise when it announced guidance that all vaccinated Americans were safe to go without a mask indoors or in a crowd. Its guidance for schools followed that principle.

The CDC recommendations noted that individuals and schools could still opt to wear a mask even if fully vaccinated, but said the risk of illness and transmission was low.

On Tuesday, two months after the initial guidance was released, the agency told reporters that the risk of severe illness from COVID still remains low for Americans who are fully vaccinated and the vast majority of people hospitalized with COVID-19 are still unvaccinated.

But the delta variant, which has taken root in the U.S. over the last month and now represents 83% of all infections, is different than past mutations of the virus, the CDC said.

“In rare occasions, some vaccinated people can get delta in a breakthrough infection and may be contagious,” the CDC said.

Ahead of the CDC’s announcement, ABC News White House correspondent Karen Travers asked press secretary Jen Psaki what the White House’s message is to Americans who may now rethink even getting a vaccine with these conflicting recommendations.

“We continue to be at war with a virus, an evolving pandemic,” Psaki said in response. “Our responsibility here is to always lead with the science, and always lead with the advice of health and medical experts and we’re going to continue to provide information to all of you about how to protect yourself and save your lives. We’re not saying that wearing a mask is convenient, or people feel like it, but we are telling you that that is the way to protect yourself protect your loved ones and that’s why the CDC is issuing this guidance.”

ABC News’ Justin Gomez contributed to this report.

This is a developing story. Please check back for updates.

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(NEW YORK) — In the last decade, the popularity of traditional cigarettes — particularly among teenagers — has declined tremendously, while the use of electronic cigarettes has been on the rise.

But now a new smoke-free alternative called heated tobacco is slowly gaining a foothold in the U.S. market. Also known as heat-not-burn tobacco products, the devices heat up a cigarette without using an open flame.

The heated cigarette produces an aerosol that contains the nicotine as well as other chemicals and additives. The device is more similar to a traditional cigarettes than an e-cigarette or a vape device, which don’t contain tobacco, because the nicotine is coming directly from the cigarette.

Tobacco companies are attempting to glamorize these products, experts told ABC News.

“They’re attempting to make the packaging and the marketing look white and clear and clean and very modern,” said Erika Sward, assistant vice president for advocacy at the American Lung Association. “But we can’t afford to be fooled again on another tobacco product.”

“The tobacco industry is always looking for new ways to get new people to smoke and use nicotine products and be hooked for life,” said Dr. Maria Rahmandar, medical director of the Substance Use and Prevention Program at Lurie Children’s Hospital in Chicago.

So far, only one such device — made by one of the world’s largest tobacco companies, Philip Morris — has been approved by the U.S. Food and Drug Administration. Dr. Moira Gilchrist, vice president of strategic and scientific communications at Philip Morris, told ABC News that the company’s heated tobacco product “is not for youth at all.”

“We place a really high emphasis on making sure we’re selling a product only to the right people, and that we’re not attracting the wrong audience,” Gilchrist added.

Despite this sentiment, teens are still curious — and at risk.

While heated tobacco products only became legal in the United States in 2019, the device have already started to catch the attention of high school students. Nearly one in 10 of California’s 10th and 12th graders have heard of heated tobacco products, with the vast majority saying they first learned about them from the internet or social media, according to a study published in Pediatrics, the official peer-reviewed journal of the American Academy of Pediatrics.

Although the survey found that less than 1% of California teens have actually used heated tobacco products, researchers are worried.

“Our concern is that this is a new product and the design is kind of slick,” the study’s co-author, Dr. Shu-Hong Zhu, who is also the director of the Center for Research and Intervention in Tobacco Control at the University of California, San Diego, told ABC News. “Our goal was to raise the alarm. We fear this might be like the new e-cigarettes.”

Almost one in five students surveyed said they would try heated tobacco products if offered to them by a friend. This number doubled for students who have already used e-cigarettes or vape devices, according to the study.

Heated tobacco products have been marketed as a better alternative to smoking, but the American Academy of Pediatrics warns the devices contain about the same amount of nicotine as traditional cigarettes and give off secondhand aerosol that is unsafe to breath.

“If someone is interested in quitting smoking there are ways that are safe and effective,” Sward said. “This is a product that is aimed at continuing someone’s addiction.”

Moreover, the devices also contain chemicals like carbon monoxide (a poisonous gas), acetone (the active ingredient in nail polish remover), ammonia (commonly used in household cleaners) and benzene (a component of gasoline).

“Any time [parents] or their children are inhaling these kinds or any type of chemicals into their lungs, they’re putting their health at risk,” Sward warned.

As teens head back to school this fall, experts are urging families to be aware of these new, dangerous products.

“Nicotine is just so powerful,” Rahmandar said. “There is no safe tobacco product. There is no safe nicotine product. These products are certainly not safe and harmless — especially to the developing brain.”

Chidimma J. Acholonu, M.D. M.P.H. is a pediatric resident physician at the University of Chicago and a contributor for the ABC News Medical Unit.

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(NEW YORK) — Kayley Reese first noticed what seemed like a growing bump in her stomach over a year ago.

“The reason I really noticed it was because I own a clothing store and am in all the photos and it got to a point where I could see it in every single photo,” Reese, of Richmond, Virginia, told Good Morning America. “It looked like I was pregnant.”

Reese, 23, said she did not notice any other physical symptoms, so she did not do anything about it.

“On social media I would see some things like it’s your uterus protruding or everyone has it, it’s a protective layer,” she said. “So I kind of made it normal in my head.”

It was not until June when Reese flew home to Orlando, Florida, that she began to feel symptoms and sought treatment.

“I was nauseous and dizzy and my appetite wasn’t normal and I had shortness of breath, painful urination, all that,” said Reese. “My mom asked to feel the spot that I was complaining about and said, ‘That is not normal.'”

Reese went to a local emergency department, where she underwent testing that found a large cyst near her left ovary.

“The [doctors] weren’t sure how long it had been there but they said the symptoms I was having were from that,” she said. “At 23, I had no idea this could ever happen to me.”

Reese underwent a two-hour surgery to remove the cyst, which she said was eight inches in length, seven pounds in weight and was filled with two liters of fluid.

The cyst was diagnosed as a paratubal, or paraovarian cyst, a type of cyst that forms near an ovary or fallopian tube but does not adhere to an internal organ, like an ovary.

“It was the best possible case scenario because they were able to save both my ovaries,” she said. “When I went into surgery they said they were likely going to have to take out an ovary and my fallopian tube.”

While she was recovering, Reese said she saw a video on TikTok that prompted her to share her own story publicly.

“I saw someone else’s TikTok about having something similar and all the comments on her video were like, ‘That’s normal. Everyone has it,'” said Reese. “I thought this was exactly why I didn’t think much of my own [stomach bump].”

Reese posted a now-viral video sharing her own story, explaining, “I feel like if I had seen my own TikTok, I would have gone to the doctor a lot earlier.”

She said she was overwhelmed by the response, both from women thanking her for the information and women who also had paratubal cysts.

“When it started to get picked up I was very nervous because I’m like I’m not a doctor, but I saw that it brought awareness to a lot of women,” said Reese. “I got messages from women who had the same situation and they said was the first time they heard anyone even talk about it, so it was super emotional.”

The type of paratubal cyst Reese had differs from the more well-known ovarian cyst because a paratubal cyst does not attach to the ovary or fallopian tube.

While most paratubal cysts do not cause symptoms, some develop and become extremely large before causing symptoms including abdominal pain, frequent urination and feelings of fullness in the abdomen.

Problematic cysts can be removed through surgery.

Women with frequent or painful cysts, including paratubal cysts or ovarian cysts, may be advised by their doctor to take over-the-counter pain medication or hormonal birth control, according to the U.S. Office on Women’s Health.

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(NEW YORK) — The American Medical Association and the American Nurses Association have joined up with over 50 other health care organizations to call for mandatory vaccinations in their industry, citing rising COVID cases and their trust in the vaccine.

“Due to the recent COVID-19 surge and the availability of safe and effective vaccines, our health care organizations and societies advocate that all health care and long-term care employers require their workers to receive the COVID-19 vaccine,” the organizations wrote in a joint statement on Monday morning.

Between them, these health care organizations represent millions of physicians, nurses and other health care workers across the country, including pediatricians, oncologists and pharmacists.

And they don’t think the health care industry should be the only one to require vaccines. They also called on other industries to follow suit.

“As the health care community leads the way in requiring vaccines for our employees, we hope all other employers across the country will follow our lead and implement effective policies to encourage vaccination,” the joint statement said. “The health and safety of U.S. workers, families, communities, and the nation depends on it.”

According to the Centers for Medicare and Medicaid, just 58% of nursing home staff are vaccinated. According to one estimate in late May, 1 in 4 health care workers were unvaccinated in the U.S. In some places, like Florida, the rates were as low as 40%.

Nationwide, the U.S. is struggling to increase its vaccination rates past 50% of the total population, including children, and missed President Joe Biden’s goal to get 70% of adults vaccinated with one shot by July Fourth. As of Monday, about three weeks later, still just 69% of adults had met that goal, while 60% of adults were fully vaccinated, according to Centers for Disease Control and Prevention data.

The influential statement has the potential to move the needle on an issue that, so far, has held up in court and proven to be effective at increasing vaccinations, at least in the health care field. Over the winter, Houston Methodist became the first hospital to require vaccines for its staff, and many hospital systems around the country have followed suit. In Houston, the hospital was sued, but won a lawsuit over the requirement and saw the vast majority of its 26,000-person staff get vaccinated, while around 150 quit or were fired for not adhering to the policy.

That decision spurred a recent statement from another massive health care organization, the American Hospital Association, to call for mandatory vaccinations in hospitals and paved the way for even more to get on board as they did on Monday.

“I think it’s incredible to see these organizations come together and make the bold statement to mandate vaccinations, which we know are safe and effective,” said Dr. Jay Bhatt, the former chief medical officer for the AHA and an ABC News contributor.

“We know, as Americans, it’s hard for folks to agree on a lot of things. So if we’re seeing big organizations agree on vaccinations, we should be paying attention to it,” Bhatt said.

In defending their reasons, the groups that came out in support of vaccine mandates on Monday said it was necessary for caregivers to protect patients who might be immunocompromised or not yet eligible for a vaccine, and for their own health.

The organizations emphasized their confidence in the vaccines, which are safe and effective, and hinted at the fact that the vaccines would be fully approved by the FDA soon, which will also bring more employer mandates. Currently, the vaccine is authorized under an Emergency Use Authorization, which is a temporary approval.

“As we move towards full FDA approval of the currently available vaccines, all health care workers should get vaccinated for their own health, and to protect their colleagues, families, residents of long-term care facilities and patients. This is especially necessary to protect those who are vulnerable, including unvaccinated children and the immunocompromised,” the joint statement said. “Indeed, this is why many health care and long-term care organizations already require vaccinations for influenza, hepatitis B, and pertussis.”

Also on Monday, the Department of Veteran Affairs announced that it would mandate the vaccine for its doctors and nurses. The decision came after four unvaccinated employees of the department died in recent weeks. The mandate will go into place in two months.

Department of Veterans Affairs Secretary Dennis McDonough said the mandate is “the best way to keep veterans safe, especially as the Delta variant spreads across the country.”

While there is a risk of pushback that could lead to people leaving their jobs, particularly in parts of the country where there is more refusal to get the vaccine, the rising levels of the delta variant, which currently makes up 83% of all cases in the U.S., could also hit hospital workforces hard, particularly for doctors and nurses on the frontlines of the pandemic.

“Either way, there’s a risk of them not being in the workforce. And I would say the cost of getting COVID is great enough that it warrants vaccination,” said Bhatt.

But for those who can’t be vaccinated because of medical reasons, which the groups estimated to be “a small minority of all workers,” they should be evaluated individually.

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(WASHINGTON) — As pressure grows for the Food and Drug Administration to give full approval for the vaccine, a move that could drive up vaccinations by allowing vaccine mandates in places such as the military and schools, the agency told ABC News on Monday that reviewing the vaccines is among its “highest priorities.”

“The FDA recognizes that vaccines are key to ending the COVID-19 pandemic and is working as quickly as possible to review applications for full approval,” FDA spokesperson Alison Hunt said in a statement.

But critics maintain that full approval of the Pfizer and Moderna vaccines, beyond the temporary approval that they currently have, needs to happen quicker. The argument is that the vaccine has proven to be safe and effective, and full FDA approval could increase Americans’ confidence in the vaccines at a time when the country is teetering dangerously at just 50% full vaccination while up against the fast-spreading delta variant.

“I think a lot of us are baffled why the FDA is taking so long,” Dr. Ashish Jha, dean of the Brown University School of Public Health, said on ABC’s Good Morning America on Monday.

The FDA will surely approve of the vaccines, Jha said, but needed to “move a bit faster now.”

So what do we know about the timeline?

Full approval of a vaccine under priority review, as both Pfizer and Moderna are, usually takes six months. The FDA has said it intends to complete it much quicker than that, and Dr. Anthony Fauci, chief medical adviser to the White House, recently said he expected full approval for Pfizer in a month or so, by August, and Moderna to follow thereafter.

Pfizer submitted for full approval on May 7, almost three months ago, and Moderna on June 1, almost two months ago. So, the decision should not be too far off.

And what does FDA say about the criticism that it’s moving too slowly?

Asked by ABC News on Monday if the review is moving slower than anticipated, the FDA stood by the process.

FDA spokesperson Alison Hunt said that reviewing the vaccines is “among the highest priorities of the agency, and the agency intends to complete the review far in advance of the PDUFA Goal Date.” The goal date is January 2022, though that’s a regulatory deadline and not when it’s expected.

“The FDA recognizes that vaccines are key to ending the COVID-19 pandemic and is working as quickly as possible to review applications for full approval,” Hunt said.

The FDA also emphasized that the current authorization — an Emergency Use Authorization — was conducted thoroughly, signaling that it stands on solid ground and should be fully approved.

“Although an authorization is not an FDA approval, the FDA conducted a thorough scientific evaluation of each of the authorized vaccines and can assure the public and medical community that the vaccines meet FDA’s rigorous standards for safety, effectiveness and manufacturing quality,” Hunt said.

Some have also argued that the FDA has to take its time so that any vaccine mandates that follow the full approval go as smoothly as possible. Any cracks in the approval process or accusations of rushing, could lead to even more pushback. That’s already played out over the last few months, as hesitant Americans have refused to take the vaccine because they fear it was given emergency authorization too hastily.

That was White House press secretary Jen Psaki’s defense on Monday.

“The FDA is the gold standard in our view, and they move at the speed of science,” Psaki said to ABC News Chief White House Correspondent Cecilia Vega, who asked why the FDA hadn’t yet given full approval of the vaccines.

“It wouldn’t be responsible to expedite that process at a faster speed than the science and data allows.”

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(WASHINGTON) —  New Hampshire residents cannot be required to get a COVID-19 vaccine in order to “access any public facility, any public benefit, or any public service” according to a new bill signed into law by Republican Gov. Chris Sununu.

The so-called “medical freedom” bill does not override state vaccine law, which “requires that all children enrolled in any school, pre-school, or child care have certain immunizations to protect them and those around them from vaccine preventable diseases,” according to the New Hampshire Department of Health and Human Services.

The COVID-19 vaccine is not currently listed as a requirement for attending school, nor is it approved for children younger than 12.

Other exceptions to the new law include correctional facilities, such as jails and prisons, where immunizations can be mandated “when a direct threat exists,” as well as county nursing homes and medical facilities operated by the state.

The governor’s office did not immediately respond to ABC News’ request for comment.

New Hampshire’s law stands in contrast to some other parts of the Northeast, which have edged toward mandatory vaccinations in recent days.

In New York City, Mayor Bill de Blasio announced Monday that COVID-19 vaccination would be compulsory for all city workers, including police officers, firefighters and teachers, starting Sept. 13. City workers will have the option of getting tested weekly for COVID-19 if they choose not to get vaccinated.

“We’re doing this out of a sense of urgency,” de Blasio said. “It is about protecting the workforce, their health and safety, and the people they serve.”

New Hampshire’s vaccination rate is slightly higher than the national average. As of Sunday, 64% of residents had received at least one dose, and 58% were fully vaccinated, according to the Centers for Disease Control and Prevention. By comparison, 57% of Americans have gotten at least one shot, and 49% are fully vaccinated.

ABC News’ Aaron Katersky contributed to this report.

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(LOS ANGELES) — Pfizer and Moderna are expanding the size of their COVID-19 vaccine studies in children ages 5 to 11, according to a new report.

The decision, which came after a push from the Food and Drug Administration, according to The New York Times, is intended to detect rare side effects in young people under the age of 30, such as myocarditis (inflammation of the heart muscle) and pericarditis (inflammation of the outer lining of the heart). The original size of the studies was too small to detect those rare side effects.

Pfizer declined to comment on The Times’ report to ABC News and pointed to a vaccine timeline the pharmaceutical company had previously released. Testing on 5- to 11-year-olds began in early June, Pfizer said, and on kids younger than 5 on June 21. The company anticipates having initial Phase 2 and 3 results for 5- to 11-year-olds in September.

Moderna told ABC News in a statement: “It is our intent to expand the trial and we are actively discussing a proposal with the FDA.”

It’s unclear what effect these changes might have on the timeline for emergency use authorization for COVID-19 vaccines in children. “The objective is to enroll a larger safety database which increases the likelihood of detecting rarer events,” according to Moderna. “Timelines are regularly reevaluated based on agency discussions and requests.”

Moderna said it expects to seek emergency use authorization by the end of 2021 or in early 2022.

“Some of the advisory committee members have said they’d like to see a longer median follow up time after vaccination – more than the 2 months used to support FDA’s emergency use authorizations for older age groups – in the trials in the younger ages, which is something that the agency intends to take into consideration, though it is not bound by the recommendations of advisory committees or statements from advisory committee members during the course of scientific discussions,” the FDA said to ABC News in a statement last week.

As of July 22, more than 4 million children have tested positive for COVID-19 and 346 have died, according to the American Academy of Pediatrics.

ABC News’ Eric Strauss contributed to this report.

This is a developing story. Please check back for updates.

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(NEW YORK) — Although reports of breakthrough COVID-19 cases occurring among fully vaccinated Americans are garnering much attention, as the country experiences a viral resurgence, new data illustrates just how rare these breakthrough infections are likely to be, and further shows that the vast majority of those becoming severely ill are the unvaccinated.

“While anecdotal cases and clusters can conjure concern around the vaccine, when put in the larger context of how many people have been vaccinated and the sheer volume of cases in the unvaccinated population, we recognize that the vaccines are working and how rare breakthroughs actually are,” said Dr. John Brownstein, the chief innovation officer at Boston Children’s Hospital and an ABC News contributor.

With more than 156 million Americans fully vaccinated, nationwide, approximately 153,000 symptomatic breakthrough cases are estimated to have occurred as of last week, representing approximately 0.098% of those fully vaccinated, according to an unpublished internal Centers for Disease Control and Prevention document obtained by ABC News. These estimates reflect only the adult population and do not include asymptomatic breakthrough infections.

Substantial vaccination coverage amid increasing COVID-19 case rates are driving an increase in “expected” symptomatic breakthrough infections in recent weeks, the CDC wrote in the document.

Experts stress that no vaccine can provide 100% protection, but they are still very effective at preventing severe illness and death.

“The risk to fully vaccinated people is dramatically less than that to unvaccinated individuals. The occurrence of breakthrough cases is expected and, at this point, is not at a level that should raise any concerns about the performance of the currently available vaccines,” Matthew Ferrari, director of the Center for Infectious Disease Dynamics at Pennsylvania State University, told ABC News.

“Some vaccinated folks may still get infected, some may still transmit. And the more vaccinated people there are, the more breakthrough cases we’ll see,” he added.

Coronavirus cases are now at their highest point since early May, according to CDC data, with the U.S. average nearly quadrupling since June to 47,000 new cases a day, largely driven by the highly infectious delta variant, which now accounts for more than 83% of new cases nationwide.

Virus-related hospitalizations have also increased, with more than 27,000 patients hospitalized around the country, though that number is still significantly lower than in January, when over 125,000 patients were receiving care at one time.

According to the White House COVID-19 Task Force, severe breakthrough infections remain rare, and nearly all of these hospitalized patients — 97% — are unvaccinated.

Earlier this week, the popular summer destination of Provincetown, Massachusetts, was thrust into the spotlight after at least 430 COVID-19 infections were confirmed, many of them breakthroughs, following a busy July Fourth weekend.

Confirmed cases among Massachusetts residents, stemming from the Provincetown cluster, have been found to be predominantly symptomatic, with 69% of affected individuals reported to be fully vaccinated, according to local officials. Apart from three hospitalizations — two in state and one out of state — symptoms from cases associated with this cluster are known to be mild and without complication, Alex Morse, the town manager for Provincetown, said.

“The transmissibility of the delta variant raises the likelihood of sporadic ‘super spreader’ events among vaccinated people, especially when indoors and in close proximity without masks. These events raise the risk to those unvaccinated while the vast majority of the breakthrough cases will be mild or asymptomatic,” Brownstein added.

Statewide in Massachusetts, state health officials report there have been at least 5,166 breakthrough infections as of July 17. More than 4,800 of these infections resulted in no hospitalization or death. A total of 80 of these breakthrough cases resulted in death, representing 0.0015% of individuals fully vaccinated — and 272 cases resulted in hospitalization, representing 0.006% of those fully vaccinated.

The hospitalizations and deaths that do occur among fully vaccinated individuals tend to occur among people who are older or those with serious underlying medical conditions for whom the vaccines may have reduced efficacy, experts said.

Ankoor Shah, principal senior deputy director at the Washington D.C. Department of Health, said during a Thursday press conference that the district had 200 fully vaccinated breakthrough cases of COVID-19, out of a total record nearly 376,000 fully vaccinated people, representing “only point .05 percent, which just strengthens our confidence on how great these vaccines are.”

And in New Jersey, the total number of breakthrough cases, so far, is 5,678 out of a total of 4.8 million people vaccinated by July 12, according to state data. Forty-nine fully vaccinated individuals have died as a result of COVID-19.

“It is important to point out that 49 deaths due to COVID-19 among 4.8 million fully vaccinated state residents is slightly greater than one in 100,000 fully vaccinated individuals. That means vaccines are about 99.999% effective in preventing deaths due to COVID-19,” Dr. Ed Lifshitz of the New Jersey Department of Health said in a statement to ABC News.

Additionally, 27 of these individuals had pre-existing conditions, Lifshitz said, and many had more than one condition.

Of concern to some experts is the decline in daily COVID-19 tests, which makes it more difficult to track the spread of the virus. The nation is now recording just under 600,000 COVID-19 tests a day, which has ticked up slightly in recent weeks but is still much lower than at the country’s peak in January, when U.S. was recording over 2 million tests a day. In addition, the CDC has, since May, ceased reporting asymptomatic or mild breakthrough cases.

According to Brownstein, the combination of the overall testing decline, the mild nondescript nature of breakthrough infections, and the general perception that vaccines are protective, means that any count of breakthrough infections is likely an underestimate.

Hence, he said, “given the efficacy of the vaccines, we recognize that even more cases will be asymptomatic, so these data only show part of the story. While asymptomatic cases are not of clinical relevance, they do help understand important patterns of transmission in the community.”

Experts concur that even with lower case levels than this past winter, the pandemic is not yet over, and it is critical to track the disease in order to attempt to slow its spread.

In a recent editorial in the Journal of the American Medical Association, experts urged the CDC to “re-energize” its testing services in light of the highly transmissible delta variant, “because without vigorous testing, the nation cannot be sure whether declining cases are a function of decreased numbers of infections or reduced numbers of tests.”

“As long as the virus is circulating, with or without causing illness, it can change and mutate, including into new strains that may be even harder to control,” Samuel V. Scarpino, managing director of pathogen surveillance at the Rockefeller Foundation, told ABC News.

“To get ahead of the pandemic we need to track the virus more closely and collect high-quality information on how and where COVID-19 is changing,” he said. “This high-quality, detailed information is crucial for COVID-19 and future pandemics.”

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