WASHINGTON — Amid projections that tens of thousands of Americans could die needlessly this winter if they don’t get free coronavirus vaccine shots or treatments, White House Chief of Staff Ron Klain summoned health officials to a meeting last week with an urgent question: What can we do to prevent this?

What emerged from that session was a “fall playbook” to combat the virus that was timed to President Biden receiving an updated coronavirus vaccination shot (his fifth dose overall) on Tuesday, according to four people who spoke on the condition of anonymity because they were not authorized to comment. The steps include enlisting Walgreens, DoorDash and Uber to provide free delivery of antiviral prescriptions, and focusing on convincing vulnerable Americans, including seniors, to get vaccinations and booster shots.

“As a country … we have a choice to make,” Biden said, before rolling up his left shirt sleeve to get the new shot. If we repeat the mistakes of past winters, he warned, we will see “more infections, more hospitalizations, more loved ones getting sick, even dying, from the virus. Or can we have a much better winter, if we use all, all the tools we have available to us now,” including reformulated booster shots and antiviral pills, such as Paxlovid.

The administration also is encouraging businesses to set up vaccination clinics, offer paid time off for workers to get shots, and improve their indoor air quality – moves that officials and outside experts acknowledge recycle prior tactics rather than representing a new strategy and may not be enough to forestall many deaths.

Entering the nation’s third coronavirus winter, the United States appears to be in a far better position than it was during the past two: Treatments and booster shots are widely available, and most Americans have some protection against the virus’ worst consequences, as a result of vaccinations, prior infections or both. As schools and businesses have reopened, a CNN poll released this month found that 55 percent of respondents approve of Biden’s coronavirus response, versus just 36 percent who approve of his handling of the economy.

But health officials privately worry about limited funds, worn-out front-line health workers and the dwindling receptivity of many Americans to COVID precautions. Polls show that many people are apathetic or confused about the need to get further vaccinations, opposed to resuming mask mandates and eager to put the pandemic behind them.

Approval of agencies like the Centers for Disease Control and Prevention has fallen by about one-third since the start of the pandemic, according to a recent Pew Research poll, with the most significant criticism from Republicans who are disproportionately likely to be unvaccinated. Just 6 percent of eligible Americans have received an updated booster shot, according to federal data.

Nearly three years into a seemingly unending virus fight, local and national officials are weary, too, and said in interviews that they’ve effectively exhausted tactics to reach vaccine holdouts and are pivoting to protect the most vulnerable Americans, such as seniors and people with immune-system conditions. Meanwhile, resurgent flu and other respiratory viruses are crowding hospitals, heaping more pressure on employees coping with persistent workforce shortages.

One of the top officials in Klain’s meeting – CDC Director Rochelle Walensky, who joined remotely from Germany – would soon test positive, scarcely a month after receiving an updated booster shot, underscoring the limits of vaccines to prevent infections from the evolving virus, although studies show they protect against severe COVID infections and death.

“We’re in a very challenging phase, to be very honest. I know most folks don’t want to hear that,” said Syra Madad, an epidemiologist who helps oversee pandemic response for NYC Health and Hospitals, the nation’s largest municipal health-care system. “Barely anybody is masking. We have very low vaccination rates for the updated boosters, as well as generally waning immunity. And to top it all off, we have these highly immune-evasive subvariants that are circulating.”

Madad credited administration officials’ efforts to continue warning about the virus – but said nearly two years of pandemic response had taken its toll on them, as well as on the American public.

“They are working off of fumes,” she said.

The biggest unknown heading into the winter is a shape-shifting virus that is becoming more adept at evading immunity. At this point a year ago, the virus variant that became omicron had not been identified – but by Christmas 2021, it had caused tens of millions of infections, and by January 2022, it led to some of the highest death rates of the pandemic. Scientists say omicron variant descendants such B.Q.1.1 and XBB could soon render useless treatments such as Evusheld, a therapy used to prevent illness in immunocompromised people.

“If we hit a bad outcome (again), I think we’re going to be shocked again into action, while just realizing how much we let our guard down,” said J. Stephen Morrison, who oversees global health policy at the Center for Strategic and International Studies. He also pointed to struggles to deal with other recent outbreaks, such as monkeypox cases in the United States and Europe, and Ebola cases in Uganda, saying “sluggish” efforts to conduct contact tracing and implement protections show persistent cracks in the global health response. “It’s just depressing that three years into this pandemic, we’re in such a weak position – so much weaker than we should have been and so much weaker than we were when we started,” Morrison said.

The path could get tougher next year. Republicans are expected to win one or both chambers of Congress, further clouding the prospects of a long-stalled $20-billion-plus virus funding package sought by the White House. The Biden administration also plans to phase out government purchases of vaccines and other treatments in 2023, pushing the cost to patients and insurers and potentially hindering uptake.

About 360 deaths per day are still linked to COVID, and over the course of the winter, the administration is bracing for 30,000 to 70,000 additional casualties despite public health experts’ insistence that most of those deaths can be avoided with vaccinations and antiviral treatments.

“This year, nearly every death is preventable. Let me say it again: Nearly every death is preventable,” Biden said Tuesday.

Regional disparities have also emerged, with persistent gaps in vaccinations between Democrats and Republicans and higher death rates as a result.

“I worry about future responses because of how political we’ve made this thing,” said Alex Jahangir, a Vanderbilt Health trauma surgeon who led Nashville’s coronavirus task force for two years. “We’re at a place where most people know what to do to keep themselves from being super sick and dying. The problem – especially in the Southeast – is, we choose not to do it.”

Seeking to ramp up awareness of those tools, Health and Human Services Secretary Xavier Becerra is attending vaccination events in Texas and California this week, and his agency is launching ads targeting rural, Black and Latino populations.

AARP, an advocacy group for seniors, held a telephone town hall last week during which White House coronavirus coordinator Ashish Jha fielded questions, such as how to gather safely for Thanksgiving, from more than 35,000 attendees. AARP is also set to send its monthly magazine to its nearly 38 million members with a cover story on how seniors can “stay healthy this winter” by accessing coronavirus treatments, tests and vaccines.

“I’m both worried and optimistic” about the winter, said Debra Whitman, AARP’s chief public policy officer, saying her organization is focused on boosting vaccination rates among older adults. She pointed to high-risk settings such as nursing homes, where just 43 percent of employees and 55 percent of residents were “up-to-date” on their vaccinations, according to AARP’s latest scorecard. “These are preventable deaths, in places where far too many people have died already,” she said.

The Biden administration has also enlisted health-care providers, through groups such as the American Medical Association and the American Association of Nurse Practitioners, to encourage their patients to get vaccinated, part of a broader push toward shots in doctors’ offices and clinics, rather than in mass vaccination sites

“We don’t have a crystal ball … but there are some concerning signs about upticks (in cases) and some new variants,” said AMA President Jack Resneck Jr., who joined about a dozen clinical leaders at the White House last week. “And so the American Medical Association and physicians broadly are really encouraging Americans to get their updated boosters because we really want to reduce both hospitalizations and deaths this winter.”

Some outside experts have said the administration’s efforts are coming too late, pointing to moments when Biden or his deputies seemed to put the virus behind them – with the president declaring on television last month that “the pandemic is over,” for instance.

Cecília Tomori, director of global public health and community health at Johns Hopkins School of Nursing, said Biden officials had increasingly turned their pandemic strategy into individual choices, rather than taking responsibility for the nation’s collective response.

“When you make a rhetorical choice like ‘the pandemic of the unvaccinated,’ you’re really shifting blame,” Tomori said. She argued that the phrase, which was first uttered by Walensky and repeated by Biden and other officials, needlessly alienated Americans who had yet to get vaccinated. Republicans also mocked the statement after the virus evolved to the point that vaccines failed to prevent breakthrough infections.

Several of Biden’s former advisers said the president could do more to deliver on his campaign pledge to improve the nation’s public health infrastructure.

“We need to assess the opportunities squandered or missed in the COVID pandemic and seize them now,” four former Biden coronavirus advisers wrote in an op-ed in the New York Times last week. The column blamed Congress for not authorizing billions of dollars for such public health efforts and the administration for failing to adopt relatively low-cost interventions, such as standardizing how wastewater is sampled to detect COVID and other viruses, or issuing national air quality standards that could lead to safer restaurants, businesses and schools.

“We can’t let this moment pass with so few structural, substantive, institutional improvements. It would be a terrible tragedy,” said Ezekiel Emanuel, a University of Pennsylvania bioethicist and one of the co-authors. “Because a lot of people will die the next time around. We don’t know when exactly that’s going to be, but it’s going to be.”

Public health experts acknowledge that the messaging climate is difficult, partly because of public exhaustion with COVID, but also because Democrats have sought to amplify other messages, such as abortion access, heading into next month’s midterm elections.

In interviews, federal and state officials lamented, for instance, how they failed to proactively explain a planned vote by CDC advisers last week to add coronavirus vaccinations to the agency’s recommended immunization schedules for children, calling it a missed opportunity. Conservatives and Fox News personalities twisted the advisory panel’s vote into false claims that schools would immediately mandate that children receive the shots.

Resneck, the AMA’s president, said misinformation about COVID and vaccines is being driven by a “small number” of people whose messages are amplified by social media. “It has taken an enormous amount of effort for physicians to push back against that disinformation that’s out there,” he added.

The White House is also bracing for the departure of one of its top messengers, Anthony S. Fauci, the government’s lead infectious-disease expert and Biden’s chief medical adviser, who has said he will step down before the year’s end.

Fauci’s exit could align with other changes across the health team. Jeff Zients and Natalie Quillian, who led Biden’s coronavirus response before stepping down this spring, have returned to the White House to oversee potential personnel changes after the midterms, Axios first reported.

The White House’s persistent frustrations with Becerra, driven by concerns about his lack of experience in front-line public health and in running a sprawling federal agency, prompted internal discussions about replacing the health secretary early this year. Administration officials also faulted Becerra’s team this summer for stumbles on monkeypox, which included delays in ramping up testing and delivering vaccine doses that had been ordered and paid for, according to six people with knowledge of the conversations who were not authorized to comment.

Becerra’s spokesperson, Sarah Lovenheim, rebutted assertions by some officials that the longtime California congressman and former state attorney general is planning to leave after the midterms to pursue political opportunities in California.

“This is untrue. He would say he’s not doing that today, tomorrow or next year,” Lovenheim said in a statement. “He looks forward to negotiating prescription drug costs, protecting reproductive rights, doubling down to strengthen mental and behavioral health, public health preparedness and more.”

Administration officials have also discussed whether Walensky, who has faced criticism for the CDC’s sometimes-confusing messages on the pandemic, would leave after the midterms, according to three people with knowledge of those deliberations who spoke on the condition of anonymity to discuss sensitive conversations. Unlike other positions, such as HHS secretary, the role of CDC director does not require Senate confirmation, making it easier for the administration to execute a job change.

A spokesperson for Walensky referred The Washington Post to her interview this month with CNN’s Chris Wallace, in which the director touted her agency-reform plan, announced in August, and promised to stay on to oversee it. “My work is not done,” Walensky said.

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