Outlining the Case for Physicians to Approve Workplace Accommodations for Patients with Long Covid

The Berman Institute’s Zackary Berger and Seton Hall Law Professor Doron Dorfman have published “Approving Workplace Accommodations for Patients with Long Covid — Advice for Clinicians” in the new edition of The New England Journal of Medicine.

The article is geared toward medical professionals faced with issues regarding specific diagnosis for long Covid (also known as post-acute sequelae of Covid-19) often requisite for employer work accommodation forms and disability claims. The implications for employers, HR professionals, attorneys and employees are, however, significant – especially given the estimated prevalence of the condition.

The authors point out that, “As of January 2023, the estimated prevalence of long Covid among people in the United States who had had acute infection was 11%.”

To put this in perspective, as of February 28, 2023, more than a than a hundred million COVID-19 cases (103,268,408)had been reported in the U.S., meaning that the incidence of long Covid among the population of the United States could well be in excess of 11 million.

Of interest to employers and medical professionals, the authors further note:

“According to guidance released in August 2021 by the Department of Health and Human Services and the Department of Justice, long Covid can be considered a protected disability under the Americans with Disabilities Act (ADA) and under other disability-antidiscrimination mandates (such as Section 504 of the Rehabilitation Act and Section 1557 of the Affordable Care Act). Persons with long Covid whose symptoms “substantially limit” their ability to perform one or more ‘major life activities’ such as doing manual tasks or working, or even performing mundane actions such as breathing or standing, are considered to have a disability. That classification renders persons with long Covid eligible for reasonable workplace accommodations. Accommodations under the ADA include modifications to policies to allow disabled workers to complete their jobs, such as giving them additional breaks, the opportunity to sit down while working, or a more flexible work schedule.”

 “Although the pandemic itself has been officially declared ‘over,’ its impact – debilitating for millions – will be an issue in the workplace, the economy and the daily lives of many for years if not decades to come,” said Dorfman, who specializes in health care law, disability law and employment law. “The sheer volume of those estimated to be impacted by long Covid and the potential ramifications under the law for those effected essentially mandates that employers and attorneys as well as medical clinicians familiarize themselves with the administrative and legal protocols and strictures pertaining to long Covid.”

The authors contend that although debilitating, long Covid “has joined the ranks of such conditions as fibromyalgia, myalgic encephalomyelitis (or chronic fatigue syndrome), and post-traumatic stress disorder, which lack unique molecular ‘signatures’ — no biomarkers or other abnormal laboratory or imaging tests have been identified to support their diagnosis. These diagnoses are therefore contentious, and government agencies, employers, and many physicians do not accept these conditions as real.”

“The problem with that is that long Covid is real, and can be really debilitating,” said Berger, a medical doctor and associate professor at Johns Hopkins School of Medicine. “A legitimate diagnostic code for Long covid exists under the International Classification of Diseases and is available for clinicians to use in documenting this condition, but evidence shows it is being underutilized – especially in low-income and marginalized neighborhoods.”

The authors note that another potential reason for underutilization of the diagnostic code for Long covid is timing: “the code was first introduced in October 2021, well into the pandemic and after clinicians had grown accustomed to using various other codes for long Covid symptoms.”

The authors conclude: “We believe it’s time for clinicians to use the code regularly, when appropriate. Its common usage would increase the legitimacy of long Covid as an independent diagnosis within the medical community.”

The diagnostic code is not the only way to document long Covid, however:

“Alternatively, clinicians can document the experience of patients whose symptoms render them unable to work without accommodations, focusing on functional impairment rather than diagnostic testing. Such a clinical approach is in keeping with ADA regulations that broadly define a ‘major life activity’ in terms of ‘the operation of a major bodily function.’ According to the expansive construction of disability in regulations created since the passage of the ADA Amendments Act of 2008, impairments will ‘virtually always be found to impose a substantial limitation on a major life activity,’ meaning on bodily functions.”

“Covid has wreaked historic devastation upon the world and killed more than a million people so far in just the United States,” said Berger. “Long after a positive result, patients are presenting now with significant respiratory deficiencies, exhaustion, chest pain and a host of other maladies that were not a part of their lives prior to their infection with Covid-19. If the estimates hold true, there are approximately 11 million people suffering under these conditions. We don’t want to kill off another million of them just because we don’t want to offer them additional breaks, the opportunity to sit down while working, or a more flexible work schedule.”

Searching for Winning Public Health Strategies in Lessons from the Covid War

At the beginning of 2021, Ruth Faden, founder of the Johns Hopkins Berman institute of Bioethics, joined 33 other leading national experts to form the Covid Crisis Group. The goal of the group was to lay the groundwork for a National Covid Commission, thinking that the U.S. government would soon establish a formal commission to study the biggest global crisis of the twenty-first century. So far, it has not.

In the face of this faltering political momentum—a void where there should be an agenda for change—the group decided to speak out for the first time. On Tuesday, April 25, they will publish Lessons from the Covid War (PublicAffairs), the first book to distill the entire Covid story from ‘origins’ to ‘Warp Speed.’ With the U.S. ending its formal declaration of a public health emergency earlier this month, this investigative report reveals what just happened to us, and why. Plain-spoken and clear-sighted, Lessons from the Covid War cuts through the enormous jumble of information to make some sense of it all.

“Our public health system was neither set up nor able to respond in the way the country needed, in part because of an antiquated division of labor in our federalist system,” said Faden, who chaired President Clinton’s Advisory Committee on Human Radiation Experiments.

“There was not, and still is not, any kind of centralized national mechanism for responding to massive but non-military threats like a pandemic or climate change. As a consequence, too often, states were left without adequate guidance and had to create regulations and policies on their own.”

During the pandemic, Faden co-led a multi-disciplinary team that created the eSchool+ Initiative to  provide tools and resources regarding Covid policy for K-12 schools, as well as the  COMIT project to track global vaccine policies for pregnant and lactating people. Since June, 2020 she has also served on the WHO SAGE Working Group on COVID-19 Vaccines that provides policy guidance on vaccine prioritization and use. Faden also helped lead a partnership between the Berman Institute and the SNF Agora Institute that in May 2020 published an ethics framework for the Covid reopening process.

The Covid Crisis Group is holding a discussion of its findings at the National Academy of Medicine on Monday, April 24, one day in advance of their report’s publication. Faden will moderate the session, “19th Century System Meets 21st Century Pandemic,” at 2:15 p.m. The entire discussion will be broadcast online here, starting at 12:30 p.m. Faden says topics from the book that her panel will address include not only what went wrong with our public health and health care systems but also what strategies need to be adopted, what needs to be changed or updated, so that both public health and healthcare will be fit for 21st century pandemic purposes.

“The United States, despite its great wealth, advanced science, and state of the art medical care didn’t handle Covid better than other countries and, in fact, did worse than most,” said Faden.

“The pandemic showed Americans that our scientific knowledge had run far ahead of our nation’s ability to apply it in practice. I hope this book will show how Americans can come together, learn hard truths, build on what worked, and prepare for global emergencies to come.”

Q&A with Professor Seltzer: The Impact of COVID-19 on Children

In late 2021, as the COVID-19 pandemic wore on, the Berman Institute’s Annual Report asked a number of faculty members to look to the future and reflect not only on how Covid has impacted their areas of research expertise to date, but also share what they believe will be some of the lasting and perhaps permanent changes to the field.

In this excerpt pediatrician Rebecca Seltzer, MD, the Freeman Scholar for Clinical Ethics at the Berman Institute and an assistant professor at the Johns Hopkins School of Medicine, discuss the pandemic’s impact on children.

Because of my interest in child health policy even before the pandemic, I knew policies tend not to be driven by the needs of children. Kids don’t vote. But from an ethical perspective, children are an inherently vulnerable population. Their ability to survive and flourish is largely dependent on care from the adults and society that surround them. So, to say that during a pandemic, we don’t owe it to kids to protect them and put their needs at the forefront of policy decisions is a sad commentary on what we value. Why did we prioritize reopening bars before schools?

I still worry that this far into the pandemic, the narrative that Covid doesn’t impact children as much as adults doesn’t give enough attention to all the challenges they continue to face. While all children are vulnerable, there are pediatric populations that have been disproportionately impacted by the pandemic. Children of color have been more likely to be hospitalized or develop severe illness from Covid. Children in foster care missed visiting in-person with their biological parents or had adoptions put on hold due to court delays. And not only were children with medically complex conditions at greater risk of medical complications with Covid, but they faced challenges in all aspects of life. Access to and delivery of care was impacted by Covid policies, such as cancelling elective procedures. School based services, like speech and physical therapies, were abruptly stopped with school closures. Existing shortages in pediatric home nursing were exacerbated by illness and fears of exposure, leaving parents unable to sleep or work as they provided for their child’s 24/7 care needs without home nursing supports. It is morally problematic that the voices and experiences of these populations don’t seem to matter in discussions about Covid-related policies.

There were already problems with fragmented systems of care that didn’t properly promote optimal health and wellbeing for children with medical and/ or social complexities. Covid exacerbated these underlying challenges and disparities. It brought to light that some people are impacted differently, and more significantly. But through this pandemic we have seen one-size-fits-all policy decisions made by governments that don’t even talk about, let alone account for, these disparate impacts.

Ethics needs to be a part of policymaking. Ethics brings language and a framework for thinking through benefits and harms. Ethics professionals are good at recognizing that different people have different values, and at helping evaluate and prioritize competing interests and obligations, particularly when policies have different impacts on different populations.
I’m working with colleagues at the BI and Oxford on a project that looks at how policies impacted the families of children with chronic conditions. That’s grown into thinking about how the voices of these children and their families can be used in creating policies in the future. We’re trying to create a new methodology that will better include families’ lived experience in shaping the policies that will impact them directly

You mean other than exhaustion? It has made me feel even more of a need to advocate for vulnerable pediatric populations and remind decision-makers that kids matter. I feel strongly that in a lot of ways children have just been thrown to the side. Like I said before, I’ve seen just how inaccurate the belief is that children are spared or not impacted by Covid. While it is true that Covid causes severe illness and hospitalization in a small percentage of kids, there are now so many cases that even that small percentage is filling up our pediatric hospitals and ICUs—and it’s impossible to predict which kids are going to get very sick. As a primary care pediatrician, I see and feel the impact of COVID in every patient encounter—growth charts with weight trajectories skyrocketing since the start of the pandemic, teens with new onset depression and anxiety at alarming rates, kids falling behind in school, grief from the loss of loved ones to Covid, fears of contracting Covid, fears and uncertainty about the vaccine.

As a parent of two young children, I experience the frustrations and struggles that result from a lack of clear Covid policy guidance for early childcare centers. I recently called around several daycare centers to discuss Fall enrollment for my youngest and asked each of them about their Covid policies. No two were alike. It’s crazy that two years into this
pandemic there is still such confusion and no central guidance. Vaccination in small children is another similar area where young children have been left behind. For many, vaccination was the start of living a “normal” life again, but not for families with young children who are unprotected.

Considering the impact of this pandemic on kids, their exclusion from the discussion about policies has been quite eye-opening. As we begin thinking about the future, about establishing the policies that reflect our values and priorities, it’s important that a broader range of voices are heard, including those of the most vulnerable.

3rd Annual SNFBA Summer Course to focus on Ethics and Research: Lessons from the Pandemic

The Stavros Niarchos Foundation Bioethics Academy (SNFBA) is proud to announce that it will be hosting the 3rd Annual Bioethics Summer Course at the Stavros Niarchos Foundation Cultural Center in Athens, Greece June 19-22, 2022.

The Bioethics Summer Course is an annual training activity of the SNFBA whose goal is to support and enhance knowledge and awareness for bioethics among biomedical researchers, policy professionals, and healthcare administrators in Greece.  The course is co-directed by Prof. Jeffrey Kahn, the Andreas C. Dracopoulos Director of the Johns Hopkins Berman Institute of Bioethics (JHU), and Prof. Effy Vayena, Head of the Health Ethics and Policy Lab at the Swiss Federal Institute of Technology in Zurich (ETH).

The 3rd Annual Bioethics Summer Course  will be a three-day intensive course focusing on Ethics and Research: Lessons from the Pandemic and, as in past years, will include lectures from distinguished bioethics experts from Johns Hopkins and ETH Zurich, and in-depth small group discussion of case studies and lecture topics.


The SNFBA is free to accepted participants, and fully supported through the generosity of the Stavros Niarchos Foundation (SNF). Airfare and lodging is provided to accepted participants from outside of Greece and lodging (and travel where required) is provided to accepted participants who reside outside of Athens.  The total number of participants is limited to 50 to preserve a high-quality experience.


Applications are encouraged from professionals working in institutions in Greece and the Balkans, with the following experience and expertise:

  • Professionals working in, or overseeing, Clinical Research
  • Medical Students and Pharmaceutical Students interested in developing capacity in Clinical Research
  • Members of committees performing Biomedical Research Ethics Review
  • Professionals working in health and science policy


Applications are now being accepted online until April 11, 2022 but may close earlier if 50-person capacity is reached.

Required Application Documentation

  • Curriculum Vitae
  • Short Personal Statement no more than 250 words including why the Course is of interest to you, your motivation for applying, and how the Course will be of use in your professional work and professional development

Apply for the 3rd annual SNFBA Bioethics Summer Course now.

For questions please contact Katerina Ligomenides ([email protected])

Tracking COVID-19 Booster Doses in the US States

Tracking COVID-19 Booster Doses in the US States
Matthew A. Crane, John A. Romley, Ruth R. Faden

 This post reflects information on COVID-19 vaccination rates collected most recently on December 20, 2021.

On November 19, 2021, the Centers for Disease Control and Prevention (CDC) expanded recommendations for COVID-19 booster shots to include all adults over the age of 18. With the recent spread of the SARS-CoV-2 Omicron variant in the United States, public health authorities have increasingly emphasized the importance of being fully vaccinated and boosted for protection against COVID-19.

In order to track rates of booster doses in the United States, we conducted an analysis of CDC data on state-level variations in booster shot coverage. We examined a 9-week period during the booster rollout from October 24, 2021 to December 19, 2021. In this analysis, additional doses as termed by the CDC were considered booster doses. Our analysis only accounts for individuals over the age of 18.

The Video below depicts state-level variation over time, and Table 1 provides a summary of the state-level data. In Table 2 we provide results for individual states. This analysis finds substantial differences between state-level booster coverage, with states ranging in coverage from 10.6% (New Hampshire) to 49.5% (Vermont).

Video: Booster Doses over Time in the United States (as of 12/20/21)

Table 1. Summary of State-Level Booster Vaccination Rates (as of 12/20/21)

Percent of Adult Population with Booster Dose States
>10%-20% NH, HI, WV, NC
>20%-30% PA, DC, AL, GA, MS, TX, NV, LA, OK, AZ, UT, AR, FL, SC
>30%-40% NY, CA, NJ, KS, MO, TN, DE, SD, IN, KY, AK, WY, VA, ID, WA, ND, MD, MA, CT, IL, OR, OH, NE, NM, MT
>40%-50% RI, CO, MI, ME, IA, WI, MN, VT


Table 2. State-Level Booster Vaccination Rates (as of 12/20/21)

State Percent of Adult Population with Booster Dose
Vermont 49.5
Minnesota 47.1
Wisconsin 43.7
Iowa 43.2
Maine 42.2
Michigan 40.9
Colorado 40.5
Rhode Island 40
Montana 39.7
Nebraska 39.6
New Mexico 39.6
Ohio 39.4
Illinois 37.5
Oregon 37.5
Connecticut 37.2
Massachusetts 36.9
Maryland 36.7
North Dakota 36.5
Washington 36.1
Idaho 35.9
Virginia 35.6
Wyoming 35.4
Alaska 35
Kentucky 34.7
Indiana 33.8
Delaware 33.7
South Dakota 33.7
Missouri 33.3
Tennessee 33.3
Kansas 33
New Jersey 32.4
California 32.2
New York 30.5
Arkansas 29.9
Florida 29.9
South Carolina 29.9
Utah 29.4
Arizona 29.3
Oklahoma 29.1
Louisiana 28.9
Nevada 27.7
Texas 27.3
Mississippi 26.3
Georgia 25.9
Alabama 25.8
District of Columbia 25
Pennsylvania 23
North Carolina 19.7
West Virginia 18.9
Hawaii 18.3
New Hampshire 10.6


eSchool+ Initiative Finds Widespread Discrepancies in School Covid Policies Between and Even Within Individual States

In an analysis of all 50 states’ policies about masking in schools, requiring COVID-19 vaccines for eligible students and teachers, and providing COVID-19 services in the school setting, Johns Hopkins University researchers have found widespread discordance and variation not only between states but also within states themselves as individual districts adopt policies at odds with their own governors’ guidelines.

“The COVID-19 virus doesn’t care about school district or state lines. The current uncoordinated approach has us in a third year of schooling impacted by coronavirus and we’re rapidly closing in on a fourth,” said Megan Collins, a bioethicist and associate professor of medicine at the Wilmer Eye Institute who co-directs the Johns Hopkins Consortium for School-Based Health Solutions. “Our goal is to provide useful, reliable information for education and public health policy stakeholders and researchers, teachers, school staff, and parents from across the country – anyone working on or thinking about kids going back to school and staying there.”

The analysis utilizes information from a new online tracker that examines state policies about masking in schools, COVID-19 vaccines for eligible students and teachers, and COVID-19 services offered in the school setting in all 50 states, the District of Columbia, the Bureau of Indian Education, and major U.S. territories. The tracker also includes details from 56 index school districts selected from 20 states, representing the lowest and highest poverty, as well as the largest school district in each state.

Currently, the tracker lists North Dakota as the only state that prohibits individual districts from requiring masks in school. Similar mask mandate bans in Florida, Oklahoma are on hold, awaiting the outcome of lawsuits seeking to overturn them. South Dakota and Oklahoma prohibit a vaccine mandate.   But the JHU researchers found marked variations at the district level, identifying 46 instances where district policies for masking or vaccination did not align with their state’s policy.

“The disconnect between state and district policy can create issues of trust for parents and teachers, as they being told one thing by the state, and often something entirely different by their school district,” said Collins. The tracker also includes information about school-based testing and vaccination availability, and if virtual/hybrid learning options are offered for students based on the state or district mask or vaccination policies.

“While all children have suffered from in this pandemic, disadvantaged children have suffered the most. However, on mask and vaccine policies, the biggest differences seem to by size of school district, rather than poverty or affluence,” said Ruth Faden, founder of the Johns Hopkins Berman Institute of Bioethics. “We found that the largest districts are requiring masks and teacher vaccination at much higher levels than smaller districts, regardless of poverty level.”

The study also found that, as with other pandemic policies, who is in the governor’s mansion matters. While 65 percent of states with Democratic governors require teacher and student masking, only 10 percent of states with Republican governors do. Similarly, 31% of states with Democratic governors require teacher COVID-19 vaccination; three percent of states with Republican governors do.

“The team’s work is designed to bring attention to the accumulating body of data about school COVID-19 policies, and to examine which policies risk to worsen existing inequities in access to educational resources,” said Annette Campbell Anderson, Deputy Director of the Johns Hopkins Center for Safe & Healthy Schools and a professor in the School of Education.

“We want to share the pulse of what’s happening across the country as policymakers analyze the landscape for 2022 and think about appropriate actions.”

The tracker will be updated on a weekly basis. The Johns Hopkins eSchool+ Initiative was established in the early months of the COVID-19 pandemic as an interdisciplinary effort to develop guidance for schools and policy stakeholders to think responsibly and equitably about students during school closures and reopening. The Initiative includes broad representation from the Johns Hopkins Schools of Education, Public Health and Medicine, the Berman Institute of Bioethics, and the Center for Civic Impact, bringing together expertise in ethics, equity and structural injustice, education, school-based health care, food security, and public health policy.

Global Policies on COVID-19 Vaccination in Pregnancy Vary Widely by Country

Although pregnant people are at elevated risk of severe COVID-19 disease and death, countries around the world vary widely in their policies on COVID vaccination in pregnancy, with 41 countries recommending against it. Ninety-one countries have policies that allow for at least some pregnant people to receive COVID vaccines – 45 of which broadly permit or recommend vaccines in pregnancy – according to Johns Hopkins University’s COVID-19 Maternal Immunization Tracker (COMIT), a newly launched online resource providing a global snapshot of public health policies that shape access to COVID-19 vaccines for pregnant and lactating people.

“Data about COVID vaccines’ safety for pregnant people and their offspring have generally been reassuring. But countries around the world have taken a variety of positions on COVID vaccination and pregnancy — ranging from highly restrictive policies that bar access to vaccines, to permissive positions in which all pregnant or lactating people can receive vaccine and, in some cases, are recommended and encouraged to do so,” said Ruth Karron, Director of the Center for Immunization Research at the Johns Hopkins Bloomberg School of Public Health and a professor in the School’s Department of International Health.

COMIT is the first resource that provides a global snapshot of public health policies that influence access to COVID-19 vaccines for pregnant and lactating people, enabling users to explore policy positions by country and by vaccine product. Through maps, tables, and country profiles, COMIT provides regularly updated information on country policies as they respond to the dynamic state of the pandemic and emerging evidence.

“This is an extremely valuable resource for anyone concerned with the health of pregnant women and their offspring anywhere in the world. By compiling and updating countries’ policy positions regarding COVID-19 vaccination for pregnant and lactating people, COMIT makes it possible to track at a glance the ongoing global changes in this rapidly changing sphere,” said Alejandro Cravioto, Chair of SAGE, the international panel of experts making COVID-19 vaccine recommendations to the World Health Organization.

In the past month alone, seven countries have joined the ranks of those with policies recommending COVID-19 vaccination for pregnant and lactating people.

“The variability in policy positions is in part a consequence of the absence of evidence on vaccines in pregnancy, because pregnant and lactating people are excluded from the vast majority of clinical trials. As a result, public health authorities and recommending bodies are developing guidance on COVID vaccines and pregnancy with far less evidence than they have for most other populations,” said Ruth Faden, founder of the Johns Hopkins Berman Institute of Bioethics.

“Our hope is that COMIT might convince policy makers worldwide to expand access to vaccination for pregnant people. We are seeing some momentum in that direction, but we need to see more.”

The COMIT team notes that varying policies regarding vaccination of pregnant people could have serious implications for gender equity in the global rollout of COVID-19 vaccines, including among the high-priority group of health workers who would otherwise be first in line to receive vaccine.

“In many countries, the health system is hugely dependent upon female health workers in their reproductive years, many of whom are pregnant or breastfeeding. If they cannot be adequately protected from serious COVID-19 disease or death, it would not only be a threat to a gender-inclusive response, but potentially set back the health system during a crucial time in the response and for years to come,” said Carleigh Krubiner, a Berman Institute faculty member and a policy fellow at the Center for Global Development.

COMIT’s interactive global map conveys at a glance whether pregnant or lactating individuals are allowed or encouraged to receive any vaccine currently authorized for use in individual countries. Other features include:

  • Tables that enable visitors to compare vaccine policies across countries, including any special requirements (e.g. a doctor’s note), with various sort and filter features to understand how individual country policy positions compare across geography and vaccine products.
  • Maps that filter by product and policy position, with an easy toggle between pregnancy and lactation to see how recommendations differ for pregnant and breastfeeding individuals
  • Individual country pages that give a detailed account of policy positions, and changes over time, and provide links to source documents.

“The COMIT website will be an invaluable source of information for policymakers around the world as the COVID-19 vaccine rollout continues,” said Chizoba Barbara Wonodi, a faculty member in the International Health department at the Bloomberg School and Nigeria Country Director at the School’s International Vaccine Access Center. “Even as the COVID vaccination rate in the United States approaches 50 percent, only about six percent of the world’s population has been fully vaccinated to date. This inequity in access needs urgent global attention.”

The COMIT policy tracker was developed by members of the Johns Hopkins Berman Institute of Bioethics and the Johns Hopkins Center for Immunization Research, with support from the Bill & Melinda Gates Foundation and Wellcome.

New Global Tracker to Measure Pandemic’s Impact on Education Worldwide

The COVID-19 pandemic has disrupted education for 1.6 billion children worldwide over the past year. To help measure the ongoing global response, Johns Hopkins University, the World Bank, and UNICEF have partnered to create a COVID-19 – Global Education Recovery Tracker.

Launched today, the tool assists countries’ decision-making by tracking reopening and recovery planning efforts in more than 200 countries and territories.

The effort captures and showcases information across four key areas:

  • Status of schooling
  • Modalities of learning (remote, in-person or hybrid)
  • Availability of remedial educational support
  • Status of vaccine availability for teachers

The Global Education Recovery Tracker seeks to build upon Johns Hopkins University’s pivotal work in gathering quality data on COVID-19 cases, testing, and vaccinations, along with the strategic roles that the World Bank and UNICEF play in operational and policy support to countries during the pandemic.

“Throughout the pandemic Johns Hopkins has demonstrated the vital role for universities in providing accurate, evidence-based data and information for the world,” said Johns Hopkins Provost and Senior Vice President for Academic Affairs Sunil Kumar. “We hope the work of this partnership will build understanding of how COVID-19 continues to affect students everywhere.”

Data through early March 2021 show that 51 countries have fully returned to in-person education. In more than 90 countries, students are being instructed through multiple modalities, with some schools open, others closed, and many offering hybrid learning options.

Regionally, there are emerging indications of shifts in learning modalities. Remote learning continues to dominate in the Middle East and North Africa where schools were largely closed in recent weeks. However, in Sub-Saharan Africa, most students are physically attending school. In the East Asia and Pacific region, in-person education has mostly resumed, with stringent social distancing measures. The regions of South Asia, Central Asia, and Europe are mainly relying on hybrid education where the infrastructure allows. Across Latin America, countries are using mixed approaches that include remote, hybrid, and in-person education. However, the majority of schools remain partially or fully closed to in-person classes with remote education as the most used modality.

“The world was facing a learning crisis before COVID-19,” said Jaime Saavedra, World Bank Global Director for Education. “The learning poverty rate – the proportion of 10-year-olds unable to read a short, age-appropriate text – was 53% in low- and middle-income countries prior to COVID-19, compared to only 9% for high-income countries. A year into the pandemic, continued disruptions to schooling, shifts in learning modalities, and concerns for students’ well-being are ever greater, and this learning crisis is getting worse. COVID-19 related school closures are likely to increase learning poverty to as much as 63%.”

Saavedra emphasized the importance of this Tracker, “In many countries, students and teachers need urgent supplemental support. The return to school requires accelerated, remedial, and hybrid learning, as well as other interventions. Collecting and monitoring this data on what countries are doing is critically important to help us understand the magnitude of what support is needed as we go forward, learning from the major trends observed among countries.”

In addition to tracking the operational status of schools, the Tracker will also monitor how students are being supported. This includes changes to the school year schedule, tutoring, and remediation, especially for the primary school grades. These interventions will be a critical component of the education recovery process after a year that has affected the learning and well-being of 95% of school children across the globe.

In countries where the COVID-19 vaccine is available, the tool is tracking whether teachers are eligible as a priority group. As of early March, teachers are largely not being immunized as a priority group in low- and low-middle-income countries. Of the 130 countries where vaccine information was available, more than two-thirds are not currently vaccinating teachers as a priority group.

“Even as vaccines are beginning to rollout worldwide, for hundreds of millions of the world’s schoolchildren, the consequences of this pandemic are far from over,” said UNICEF Chief of Education Robert Jenkins. “We must prioritize the reopening of schools, including prioritizing teachers to receive COVID-19 vaccines once frontline health personnel and high-risk populations are vaccinated. While such decisions ultimately rest with governments making difficult tradeoffs, we must do everything in our power to safeguard the future of the next generation. And this begins by safeguarding those responsible for opening that future up for them.”

The Tracker is intended to offer evidence that informs policy makers and researchers working on COVID-19 responses.  The tool is built to have the flexibility to incorporate emerging issues while offering a time trend of actions in the past months.


The Johns Hopkins University eSchool+ Initiative is a collaboration between the Consortium for School-Based Health Solutions, the Berman Institute of Bioethics, and the Johns Hopkins Schools of Education, Medicine, and Public Health. The eSchool+ Initiative focuses on child well-being from an equity lens, developing tools and resources for K-12 schools to help policy makers and educators support students during the COVID-19 pandemic.
For more information about the eSchool+ Initiative, please visit: https://equityschoolplus.jhu.edu.

States Must Implement Teacher Vaccination Plans and Tracking to Ensure Safe School Reopenings

Even as President Biden this week urged states to prioritize teachers for vaccinations, an analysis conducted with Johns Hopkins University’s teacher vaccination tracker, launched today, shows no correlation between states’ school reopening status and the ability for teachers to get vaccinated against COVID-19. And no states are reporting the percentage of teachers and school staff that have been vaccinated.

“There is an accumulating body of scientific evidence that should be reassuring the public that kids can be brought back to school safely when appropriate mitigation measures are in place and community transmission is low. Right now, there is a massive disconnect between where schools are open and whether or not teachers have been prioritized for vaccination,” says Megan Collins, co-director of the Johns Hopkins Consortium for School-Based Health Solutions, who helped create the new eSchool+ Teacher & School Staff COVID-19 Vaccination Dashboard, which provides state-by-state information on school reopening status, teacher vaccination policies, and other vital data.

The new dashboard compiles data that will be essential to education and public health policy makers, teacher and school staff, and parents in making informed decisions about safe school reopening. In addition to monitoring state-by-state school reopening status, and vaccination prioritization for teachers and school staff, the dashboard includes a wide range of epidemiological data, including trends in cases, infection rate, and hospitalizations. It is updated at least twice weekly with publicly available information from state and territory departments of education, health, state COVID-19 dedicated websites, and news sources.

“More and more teachers will be eligible for vaccine over the coming weeks. There are many reasons why it is important that all or at least most teachers seize that opportunity and get vaccinated, including helping to build trust in vaccination in the wider school community,” said Ruth Faden, Founder of the Johns Hopkins Berman Institute of Bioethics.

The dashboard also monitors whether a state is making COVID-19 vaccination compulsory for teachers to return to in-person instruction, and if a state is monitoring uptake of vaccines by teachers/school staff, including acceptance and refusal rates, data that is not currently being tracked anywhere else. Monitoring vaccine acceptance rate will be a critical next step as vaccines become more readily available for teachers. To date, no states are reporting this information, says Faden.

“While many well-resourced parents are trusting the reopening process, other families are saying we’re not sure our children will be safe in schools. The question is not, who is sending their kids back, the question is who is not?” said Annette Campbell Anderson, deputy director of the Johns Hopkins Center for Safe and Healthy Schools and an assistant professor and faculty lead in the university’s School of Education.

“The information from this dashboard will provide data that will help rebuild trust among all families and will play an important role in achieving the ambitious, but realistic, goal of having all children back in schools by next fall.”

Collins said student learning loss must be top of mind for everyone.

“Recognizing the deleterious effect of lost learning over the past 12 months, especially for students from disadvantaged backgrounds, our efforts must be directed towards getting children back in the classroom this spring and next fall,” said Collins, who is also an assistant professor at the Wilmer Eye Institute and Berman Institute of Bioethics. “Many people assume that things will be back to normal in time to start the next school year, but it’s going to take an immense amount of work to make that happen.”

The eSchool+ Initiative is a collaboration between the Consortium for School-Based Health Solutions, the Berman Institute of Bioethics, the Rales Center for the Integration of Health and Education, and the Johns Hopkins schools of Education, Medicine, and Public Health. The Initiative develops tools and resources for K-12 schools to consider when and how to ethically reopen and close during the COVID-19 pandemic.

Government Leaders Should Not Skip to the Front of the COVID-19 Vaccine Line

Government leaders should not be allowed to move to the front of the line for COVID-19 vaccinations unless the criteria for such prioritization is well reasoned, clearly articulated in advance, and transparently applied, according to a new commentary published January 21 in The New England Journal of Medicine by a trio of Johns Hopkins University faculty.

There must be clear justification and explanation for why elected officials should be vaccinated before such high-priority groups as health care personnel, first responders, long-term care facility residents, critical infrastructure workforce, and those at increased risk for severe COVID-19, according to the authors of the article “Who Goes First? Government Leaders and Prioritization of SARS-CoV-2 Vaccines.”

“In all the planning, discussion and establishment of priority tiers, there was no early prioritization for government officials, so their being among the very first people vaccinated makes it look like they jumped the queue,” said Jeffrey Kahn, Andreas C. Dracopoulos Director of the Berman Institute of Bioethics, who co-authored the article with Profs. Mark T. Hughes and Allen Kachalia.

“We’re then faced with the perception of government leaders saying ‘Do as we say, not as we do,’” added Dr. Kachalia, Senior Vice President of Patient Safety and Quality for Johns Hopkins Medicine.

The article notes that few nationally recognized prioritization frameworks grant government leaders priority status: “Whether they must work in settings posing higher transmission risk is debatable at best, and they can protect themselves from exposure in ways health care workers cannot.”

Government officials undoubtedly fulfill roles important to societal functioning, but vaccination recommendations developed by the CDC and other national groups place them in Phase 2, after higher risk groups. Non–risk-based factors that merit consideration for their prioritization include ensuring government stability, maintaining national security, and instilling public confidence in vaccination. Whether publicly receiving vaccination “will generate support for vaccination is uncertain and may not justify diverting vaccines from high-risk populations,” write the authors.

“Providing vaccine first to government officials without clear guidelines can undermine public trust in the rules that were put forward for all members of our society,” said Dr. Hughes, a faculty member at the Berman Institute and JHU School of Medicine, as well as co-chair of the Johns Hopkins Hospital Ethics Committee.

Any prioritization of government leaders requires clear articulation of why their incapacitation from COVID would be a serious threat to society. Additionally, it would need to be shown why a leader’s role renders protective measures other than vaccination to be impractical or ineffective.

“Public health officials making vaccine-distribution decisions should be impartial and apply allocation criteria uniformly, while aiming to mitigate health inequities,” say the authors. “Letting government officials jump the queue suggests that they’re more important than other members of society and that the rules don’t apply to them.”

How Are Teachers Prioritized for COVID-19 Vaccination by the US States?

How are Teachers Prioritized for COVID-19 Vaccination by the US States?

Matthew A. Crane, Ruth R. Faden, Megan E. Collins

This post reflects information on vaccination planning collected on January 12, 2021.

As states contend with limited initial supply of COVID-19 vaccines, prioritization decisions are being made about local distribution. Many current prioritization decisions reflect guidance from the National Academies of Sciences, Engineering, and Medicine (NASEM), as well as the Advisory Committee on Immunization Practices (ACIP). However, the states have the authority to allocate vaccine as they see fit. Currently available state planning is highly dynamic, and subject to change.

One priority group for vaccination, teachers, has been the subject of scrutiny in recent weeks, with some education groups advocating that teachers and school staff be moved up in prioritization plans, relative to other groups. Because of this advocacy, and especially ACIP’s recent decision to recommend teachers and school staff for Phase 1b of vaccination, states that do not currently include the K-12 workforce in Phase 1 may reconsider their current prioritization.

In order to understand where teachers and school staff stand in current vaccination plans, we conducted an analysis of available COVID-19 vaccination planning from all fifty States and Washington D.C. For this search, we used the most-recent available information from state websites or health agencies about Phase 1 prioritization. Keywords for inclusion included “teachers,” “school staff,” and “education.” For each jurisdiction with available data in planning documents, we collected information about the subphase in which teachers or school staff are listed, as well as the exact language used. Sources included for this analysis are available in the Appendix.

As of January 12, 2021, 37 of 51 jurisdictions include teachers and/or school staff in vaccination planning for Phase 1 vaccination (Table 1). Language varies widely between jurisdictions, with exact language presented in Table 2. Teachers are most commonly prioritized in Phase 1b. Utah was the only state to have an undivided Phase 1 among these 37, and in that state teachers were included along with multiple other groups of high risk and essential workers. These results show an increase from an earlier collection of plans on December 19, 2020, where we found that only 23 of 51 jurisdictions prioritized teachers and/or school staff for Phase 1 vaccination.

Table 1: Phase 1 Prioritization of Teachers and School Staff in the United States (as of 1/12/21)

Subphase # of Jurisdictions Jurisdictions Prioritizing Teachers for Phase 1
Phase 1 1 UT a
Phase 1a No States
Phase 1b 34 AL, AK, AZ, AR, CA, CO, DE, HI, ID, IL, IA, KS, KY, ME, MD, MI, MS, MO, NE, NV, NM, NY, NC, ND, OH, PA, SC, TN, TX, VT, VA, DC, WA, WY
Phase 1c No States
Phase 1d 2 SD, WV

a Utah has no Phase 1 subphase listed for teachers

These findings have limitations. They are limited to published prioritization information on government websites (recently updated full state plans, webpages, and phase 1-specific documents). We did not analyze all sources available, such as meeting minutes or recordings of ongoing discussions, or secondary sources such as news coverage. Additionally, state vaccination plans are being updated frequently, and may change in response to additional CDC guidance based on recent ACIP recommendations. Due to these limitations, caution should be exercised in interpreting the prioritization decisions from states which have not updated guidance documents recently. Furthermore, some states have not yet made their guidance on teacher sub-phase explicit. In these instances, our categorizations are based on best estimates of Phase 1 sub-phases from currently available information

Map showing states prioritizing teachers

Table 2: Jurisdictions Prioritizing Teachers for Phase 1 Vaccination (as of 1/12/21)

Jurisdiction Subphase Language about Teachers Sources

(version, date last updated if available)

Alabama 1b “Education sector (teachers, support staff members)” Vaccination Allocation Plan


Alaska 1b “Education (Pre K-12 educations and school staff)” Vaccine Allocation Guidelines


Arizona 1b “Education (K-12) and childcare workers” County Health Department Website
Arkansas 1b “Teachers and school staff” State Health Department Website
California 1b “Education” State Website
Colorado 1b “Frontline essential workers in Education” State Website
Delaware 1b “Education (teachers, support staff, daycare)” State Vaccination Playbook


Hawaii 1b “Teachers and childcare and educational support staff (childcare, early education, K-12, post-secondary)” State Plan Executive Summary
Idaho 1b “Pre-K-12 school staff and teachers and daycare [childcare] workers” Advisory Committee Slides


Illinois 1b “Education (Congregate Child Care, Pre-K through 12th grade): Teachers, Principals, Student Support, Student Aids, Day Care Workers.” State Website
Iowa 1b “Teachers/school staff” State Vaccination Strategy

(V2, 12/4)

Kansas 1b “K-12 and Childcare Workers, including teachers, custodians, drivers and other staff” Vaccine Prioritization Plan
Kentucky 1b “K-12 School Personnel” Vaccine Phases Update


Maine 1b “Education sector (teachers, and support staff) State Website


Maryland 1b “Education, including K-12 teachers, support staff, and daycare providers” Vaccine Distribution Announcement


Michigan 1b “School and child care staff” Prioritization Guidance


Mississippi 1b “K-12 Teachers/Staff; College/University Teachers/Staff” State Website
Missouri 1b “Teachers & Education Staff” State Website
Nebraska 1b “Education (teachers, support staff, daycare)” State Website
Nevada 1b “Educators in pre-school and K-12 settings, including teachers, aides, special education and special needs teachers, ESOL teachers, and para-educators; workers who provide services necessary to support educators/students, including but not limited to administrators, administrative staff, IT staff, media specialists, librarians, guidance counselors, essential workers in the Nevada Dept. of Education, etc.; workers who support the transportation and operational needs of school settings, including bus drivers, crossing guards, cafeteria staff, cleaning and maintenance staff, and bus depot and maintenance staff.” State Playbook

(V3, 1/11)

New Mexico 1b “Early education and K-12 educators/staff” State Website
New York 1b “P-12 school or school district faculty or staff (includes all teachers, substitute teachers, student teachers, school administrators, paraprofessional staff and support staff including bus drivers)


Contractors working in a P-12 school or school district (including contracted bus drivers)”

State Website
North Carolina 1b “Education Sector (teachers and support staff members)” State Website
North Dakota 1b “Workers employed by preschools or Kindergarten through 12th grade: Teachers, nutritional services, aides, bus drivers, principals, administrative staff, custodians, etc.” State Website
Ohio 1b “Adults/employees in all schools that want to go back, or to remain, educating in person.” State Website
Pennsylvania 1b “Education workers” State Website
South Carolina 1b “Those who work in the educational sector—teachers, support staff, and daycare workers” State Website
South Dakota 1d “Teachers and other school/college staff” State Website
Tennessee 1b “Childcare, pre-school, and kindergarten through twelfth grade teacher, school staff, and school bus drivers” Vaccination Plan
(V3, 12/30)
Texas 1b “Teachers and school staff who ensure that Texas children can learn in a safe


Phase 1B Guidance
Utah 1 “K-12 teachers and school staff” State Website
Vermont 1b “Education Sector” Vaccination Plan

(V2, 12/28)

Virginia 1b “Childcare/PreK-12 Teachers/Staff” State Website
Washington D.C. 1b “School teachers and staff” Phase 1 Guidance


Washington 1b “K-12 educators and staff during in-person schooling” Guidance Summary
West Virginia 1d “Higher education and K-12 Faculty and Staff” State Website
Wyoming 1b “K-12 Education (teachers and support staff)” Vaccination Priorities



The structure of this analysis was inspired by the work of the Prison Policy Initiative on tracking incarcerated people and corrections staff in vaccination plans.

Appendix: Sources for Information on Prioritization of Teachers and School Staff for Phase 1 of COVID-19 Vaccination

Jurisdiction Link
Alabama https://www.alabamapublichealth.gov/covid19/assets/adph-covid19-vaccination-allocation-plan.pdf
Alaska http://dhss.alaska.gov/dph/Epi/id/SiteAssets/Pages/HumanCoV/COVIDvaccine_AlaskaAllocationGuidelines.pdf
Arizona https://www.maricopa.gov/5641/COVID-19-Vaccine
Arkansas https://www.healthy.arkansas.gov/programs-services/topics/covid-19-vaccination-plan
California https://covid19.ca.gov/vaccines/
Colorado https://covid19.colorado.gov/vaccine
Delaware https://coronavirus.delaware.gov/wp-content/uploads/sites/177/2021/01/COVID-19-Vaccination-Playbook-DE-V11_010721_FINAL.pdf
Hawaii https://hawaiicovid19.com/wp-content/uploads/2021/01/Executive-Summary_Final1_010721.pdf
Idaho https://coronavirus.idaho.gov/wp-content/uploads/2020/12/CVAC-Prioritization-for-HCP-and-Essential-Workers.pdf
Illinois https://www.dph.illinois.gov/covid19/vaccination-plan
Iowa https://idph.iowa.gov/Portals/1/userfiles/61/covid19/vaccine/V%202%20IOWA%20COVID-19%20VACCINATION%20STRATEGY%2012_4_20_FINAL.pdf
Kansas https://www.kansasvaccine.gov/DocumentCenter/View/121/Vaccine-Prioritization-Slides-PDF
Kentucky https://chfs.ky.gov/agencies/dph/covid19/20210104_Phasesbupdate.pdf
Maine https://www.maine.gov/covid19/vaccines/public-faq
Maryland https://covidlink.maryland.gov/content/wp-content/uploads/2021/01/Marylands-Phased-COVID-19-Vaccine-Distribution_1.8.pdf
Michigan https://www.michigan.gov/documents/coronavirus/MI_COVID-19_Vaccination_Prioritization_Guidance_710349_7.pdf
Mississippi https://msdh.ms.gov/msdhsite/_static/14,0,420,976.html#phases
Missouri https://covidvaccine.mo.gov/
Nebraska http://dhhs.ne.gov/Pages/COVID-19-Vaccine-Information.aspx
Nevada https://nvhealthresponse.nv.gov/wp-content/uploads/2021/01/NEVADA-COVID-19-VACCINE-PLAYBOOK-V3-BRIEF_011121.pdf
New Mexico https://cv.nmhealth.org/covid-vaccine/
New York https://covid19vaccine.health.ny.gov/phased-distribution-vaccine#phase-1a—phase-1b
North Carolina https://covid19.ncdhhs.gov/vaccines
North Dakota https://www.health.nd.gov/covid-19-vaccine-priority-groups
Ohio https://coronavirus.ohio.gov/wps/portal/gov/covid-19/covid-19-vaccination-program
Pennsylvania https://www.health.pa.gov/topics/disease/coronavirus/Pages/Vaccine.aspx
South Carolina https://scdhec.gov/covid19/covid-19-vaccine#phase1a
South Dakota https://doh.sd.gov/Covid/Vaccine/Public.aspx
Tennessee https://www.tn.gov/content/dam/tn/health/documents/cedep/novel-coronavirus/COVID-19_Vaccination_Plan.pdf
Texas https://www.dshs.state.tx.us/coronavirus/immunize/vaccine/EVAP-Phase1B.pdf
Utah https://coronavirus.utah.gov/vaccine-distribution/
Vermont https://www.healthvermont.gov/sites/default/files/documents/pdf/COVID19-VT-Jurisdictional-Vaccination-Interim-Plan.pdf
Virginia https://www.vdh.virginia.gov/covid-19-vaccine/
Washington D.C. https://coronavirus.dc.gov/sites/default/files/dc/sites/coronavirus/page_content/attachments/Phase%201%20COVID-19%20Vaccine%20Prioritization%20Guidance_r4.pdf
Washington https://www.doh.wa.gov/Portals/1/Documents/1600/coronavirus/SummaryInterimVaccineAllocationPriortization.pdf
West Virginia https://dhhr.wv.gov/COVID-19/Pages/Vaccine.aspx
Wyoming https://health.wyo.gov/wp-content/uploads/2020/12/WDH_Phase-1a-and-1b-COVID-19-Vaccination-Priorities_12.30.20.pdf

Prof. Collins Helps Create Educational Modules for School and District Leaders About In-Person Learning in COVID Era

As COVID-19 cases surge across the country, school and district leaders are looking for clear and consistent guidance on the safest ways to reopen school facilities. They want to know how to minimize COVID-19 infection risk for students, teachers, and staff in K-12 schools. In response to that demand, faculty from the Johns Hopkins Berman Institute of Bioethics, Bloomberg School of Public Health, School of Medicine, and the Consortium for School-Based Health Solutions, with support from Bloomberg Philanthropies, today launched online educational modules. These modules aim to help school and district leaders plan for and implement in-person instruction when they deem it safe and appropriate to do so, and to help schools and districts that are already open assess their current COVID-19 prevention strategies.

The series of self-paced, web-based, educational modules and videos is part of the COVID-19 Resources for Practitioners and the Johns Hopkins University COVID-19 Training Initiative, which offer expertise and practical guidance to anticipate and meet emerging needs in response to COVID-19 where people live, learn, and work.

These educational modules focus on a range of best practices and guidance on topics that school leaders need to be aware of, including considerations for implementing public health mitigation strategies, such as masking, distancing, ventilation, and creating cohorts of students, as well as screening and testing approaches.

“The goal of these modules is to provide schools and districts with accessible, practical strategies to help them tackle the responsibility of school reopening that minimizes risk of transmission. The modules can also help them identify gaps in their current plans,” said Sara Johnson, PhD, MPH, associate professor at Johns Hopkins School of Medicine and the Bloomberg School of Public Health, director of the Rales Center for the Integration of Health and Education at Johns Hopkins, and co-director of the Johns Hopkins Consortium for School-Based Health Solutions.

In the past nine months, Johns Hopkins faculty have offered technical assistance to school systems around the country to support reopening planning processes. “In speaking with school leaders, we’ve found they often have many of the same questions,” said Megan Collins, MD, MPH, assistant professor of Ophthalmology, Wilmer Eye Institute, the Berman Institute of Bioethics, and co-director of the Consortium for School-Based Health Solutions. “These modules are designed to walk school leaders through the process of developing, implementing, and continuously updating a COVID-19 strategy when they are ready to bring students and staff back for in-person school.”

Johns Hopkins created these educational modules to ensure that school officials have access to the same general information and approaches to decrease the risk of COVID-19 in schools.

“Although we designed these learning modules primarily for educational leaders, they may also help public health agencies, school health staff, and others who collaborate closely with school systems to synergistically plan, implement, and manage in-person school,” commented Megan Tschudy, MD, MPH, assistant professor of Pediatrics and medical director of the Johns Hopkins Harriet Lane Clinic.

“Schools are facing an enormous responsibility to reduce transmission of COVID-19 in their buildings to keep kids, teachers and staff, and communities safe,” said Kate Connor, MD, MSPH, assistant professor of Pediatrics at the Johns Hopkins University School of Medicine and medical director of the Ruth and Norman Rales Center for the Integration of Health and Education. “We hope the modules will help streamline the health and safety planning process and provide the kind of tailored support that many schools are asking for,” said Connor.

As the COVID-19 pandemic continues to affect the United States and the world, public health practitioners and other frontline leaders need clear, consistent guidance and tools. From early on in this global health emergency, the Johns Hopkins Bloomberg School of Public Health, with the support of Bloomberg Philanthropies, has provided practitioners at the national and local levels with free, online educational modules and tools to plan and execute evidence-based prevention strategies.

The free education modules can be accessed on Consortium website here.