The Food and Drug Administration is expected this week to allow the overdose-reversal medication to be sold without a prescription, a step toward making it a common emergency tool.If Narcan, the nasal spray that saves lives by reversing opioid overdoses, receives approval to be sold over the counter, public health officials hope the palm-size plunger could one day become as commonplace as a kitchen fire extinguisher.The Food and Drug Administration is expected to authorize the switch from prescription status this week, a step long sought by state health officials and welcomed by parents worried about teens taking counterfeit, fentanyl-tainted pills and by owners of businesses from clubs to mall shops where people have succumbed to overdoses. By late summer, the rescue medication could be available in corner convenience stores, vending machines and through online retailers, and it could help to reduce national overdose deaths, which have exceeded 100,000 annually in the last two years.But clinics and harm reduction groups, who have long pressed for the switch, worry that several factors may still impede widespread access to the medication — namely its price and the stigma that surrounds it.Currently, a two-dose pack of prescription Narcan is often free to people covered by Medicaid or private insurance, or costs, at most, less than $10. But public and private insurance programs do not cover most over-the-counter medicines. Whether an exception will be made for Narcan could take months to resolve.This month, a big-box pharmacy in Manhattan was charging $98 for the two-dose box of Narcan to customers without insurance. Another pharmacy chain in New Jersey charged $73.Narcan’s manufacturer, Emergent BioSolutions, declined to disclose the price plans for an over-the-counter version, pending F.D.A. approval. The company said it would “work with public interest” groups, who are now charging about $47.50 a box. Health economists predict the new price could land somewhere between $35 and $65 — plus a retailer’s markup.So the cost of the new out-of-pocket Narcan could make the spray prohibitive for many individuals, especially for those who inject opioids, and, indirectly, for the organizations that buy the medication in bulk.“People who really need it won’t be able to afford it, so it is much more likely that it becomes an item that is shoplifted,” said Jim Thacker, who directs the Target4 Project, a statewide program based at the University of Kentucky that focuses on H.I.V. prevention and gives out free Narcan.And that, he said, may create another obstacle: “Then Narcan will probably be put behind the pharmacist’s counter or behind glass, which creates a barrier to the people who can afford it but don’t want to ask for it,” he said.An outreach worker with Prevention Point Philadelphia, a health services center, distributing Narcan sprays throughout the city’s Kensington neighborhood.Hilary Swift for The New York TimesMany community groups distribute a liquid, injectable version of naloxone, which works swiftly and is far cheaper than Narcan.Kendrick Brinson for The New York TimesWalgreens, CVS and Walmart would not comment on product placement for Narcan. A spokeswoman for the Consumer Healthcare Products Association, a trade group, would say only that “individual retailers work with manufacturers on in-store placements and make their own decisions regarding approaches to theft prevention.”Narcan is the nasal spray version of the drug naloxone, which blocks an opioid’s effect on the brain. It has become naloxone’s dominant brand, because even a panicky, untrained bystander can easily administer it. A major impetus behind making Narcan more accessible is to encourage onlookers to step up during emergencies. The Centers for Disease Control and Prevention said that in 2021, bystanders had been present at about 46 percent of fatal overdoses.Often bystanders are themselves people who have become dependent on opioids. Clinics and many harm reduction groups, who distribute millions of naloxone doses a year for free, fear that their ability to keep doing so could be compromised by the growing focus on the Narcan brand.That is because many groups distribute a different form of naloxone: a liquid, that comes in a vial with a small syringe. Some studies say the injectable version of the medication works more swiftly than the spray.Most critically, it is far less expensive. Maya Doe-Simkins, a co-director of Remedy Alliance, which distributes hundreds of thousands of injectable naloxone doses to community groups in 44 states, Washington, D.C., and Puerto Rico, said that as Narcan blankets the market, “States are spending their entire naloxone budget on expensive product, and there’s not enough money left for cheap injectable products.” Typically, these groups rely on state health department allotments, state and federal grants, plus newly released settlement funds from the national opioid litigation to pay for naloxone.Some health economists predict that Narcan prices will gradually decrease, as volume increases and competitors enter the over-the-counter market. Ironically, two of the likely competitors have ties to pharmaceutical companies that were targets of litigation for their role in the opioid epidemic.James Moore of Hattiesburg, Miss., lowers a purple flag to half-mast when someone in the area dies from an overdose. He gives out Narcan for free at his bicycle shop.Edmund D. Fountain for The New York TimesWhenever people ask for Narcan, Mr. Moore always trains them in how to use it.Edmund D. Fountain for The New York TimesOne, a naloxone nasal spray called RiVive, is awaiting F.D.A. approval. It is made by Harm Reduction Therapeutics, a nonprofit company whose goal is to develop a low-cost, over-the-counter naloxone spray to sell mostly to community groups and clinics, bypassing retailers’ markups. Since 2018, the company has received nearly $24 million from Purdue Pharma, the makers of the prescription painkiller OxyContin, a highly addictive opioid medication that is widely thought to have been a primary cause of the ongoing opioid epidemic.Purdue is going through bankruptcy proceedings to settle thousands of opioid lawsuits against it, and will be restructured into a public benefit corporation. Last week, a bankruptcy judge authorized Purdue to donate another $9 million to Harm Reduction Therapeutics. Both companies said that Purdue had no commercial stake in RiVive.Another naloxone nasal spray, currently available by prescription, is made by Teva Pharmaceuticals, a manufacturer of generic and branded drugs, including opioids. Teva will donate large quantities of its overdose reversal product as part of its opioid settlement agreements.Under naloxone access laws, every state already permits pharmacists to dispense the nasal sprays to anyone who asks for it, regardless of whether the person has a prescription. But according to a recent report by the Reagan-Udall Foundation, an independent group that analyzes issues facing the F.D.A., of the 16.95 million naloxone doses distributed in 2021 — an acknowledged underestimate — just 2.64 million went through pharmacies. Most doses are given to emergency responders, clinics and community outreach workers.That’s because in addition to price, there are other access barriers to naloxone. Studies show that independent pharmacists in particular, especially those in rural and impoverished urban areas, do not regularly stock the nasal sprays, often saying they do not want to engage with people who use drugs.“Because of stigma, a large percentage of pharmacists will not offer naloxone to patients,” said Evan Peet, a health economist at the Rand Corporation who favors over-the-counter naloxone but is concerned about out-of-pocket costs.Mr. Moore and his son, Jeffrey, who died in 2015 from an overdose. Mr. Moore hadn’t known about naloxone when Jeffrey was alive.Edmund D. Fountain for The New York TimesJeffrey’s childhood bicycle on the wall of Mr. Moore’s shop. Mr. Moore donates refurbished bikes to people who need transportation to and from drug court.Edmund D. Fountain for The New York TimesThat deeply embedded stigma, plus price, are why direct naloxone distribution by clinics and harm reduction groups nationwide is vital to the people who most often need the medication.James Moore, who owns a family-friendly bicycle shop in Hattiesburg, Miss., is trying to combat bias as well as the price of Narcan, which, he said, in his area can run well over $100 for a double-dose box without insurance. At his shop, he gives out free Narcan and training to anyone who asks for it.Mr. Moore said he was excited about the spray becoming available over the counter because he thought it could eventually help to ease the stigma toward people who struggle with addiction — people like his son Jeffrey, who died in 2015 from an overdose.Mr. Moore hadn’t known about naloxone when Jeffrey was alive. Ever since, he has worked tirelessly to educate families, students and law enforcement about its lifesaving properties. Television stations run his Narcan public service announcements.Addiction and overdose fatalities are often still hushed up in Hattiesburg, Mr. Moore said. So when he learns about someone local who has just died from an overdose, he lowers the American flag over his shop and flies a purple flag at half-mast for five days. He hosts annual candlelight services for friends and families of loved ones who struggle with addiction. He takes people enrolled in inpatient rehabilitation programs out for group bike rides, and donates refurbished bicycles to those needing transportation to and from drug court.But Mr. Moore, who receives Narcan from state mental health services, also worries about the out-of-pocket price for Narcan if it is approved for open shelf sales.“As much as I love Narcan’s existence,” he said, “it pains me to know what it costs an individual without insurance every time they go to buy it. So I’m anxious to see it go up on Walmart’s shelves, and for the competitors to come along. I want somebody to be able to buy Narcan for the price of a hamburger.”

The overdose reversal drug has been administered mostly by emergency responders and outreach workers. If the agency approves a nonprescription version, it could become as easily available as aspirin.Two federal panels of addiction experts on Wednesday unanimously recommended that Narcan, the overdose-reversing nasal spray, be made widely available without a prescription, a significant step in the effort to stem skyrocketing drug fatalities.Making Narcan an over-the-counter drug has been urged by doctors, patient advocacy groups and the Biden administration.The unanimous vote by the committees, which advise the Food and Drug Administration, makes it highly likely that the F.D.A. will approve an over-the-counter version, also known generically as naloxone, next month. It could potentially become available in vending machines, schools, convenience shops, big box stores and supermarkets by summer.As the overdose crisis worsened in recent years, the use of Narcan has become commonplace, but the millions of doses have been administered largely by outreach workers, health care providers and emergency responders. For people who use drugs as well as their friends and relatives, ready access to the prescription medication has been elusive.Many public health experts believe that if more people were to have the spray readily available at home, or in their pockets or knapsacks, many fatalities could be averted.Fentanyl Overdoses: What to KnowCard 1 of 5Devastating losses.

PHILADELPHIA — Over a matter of weeks, Tracey McCann watched in horror as the bruises she was accustomed to getting from injecting fentanyl began hardening into an armor of crusty, blackened tissue. Something must have gotten into the supply.Switching corner dealers didn’t help. People were saying that everyone’s dope was being cut with something that was causing gruesome, painful wounds.“I’d wake up in the morning crying because my arms were dying,” Ms. McCann, 39, said.In her shattered Philadelphia neighborhood, and increasingly in drug hot zones around the country, an animal tranquilizer called xylazine — known by street names like “tranq,” “tranq dope” and “zombie drug” — is being used to bulk up illicit fentanyl, making its impact even more devastating.Xylazine causes wounds that erupt with a scaly dead tissue called eschar; untreated, they can lead to amputation. It induces a blackout stupor for hours, rendering users vulnerable to rape and robbery. When people come to, the high from the fentanyl has long since faded and they immediately crave more. Because xylazine is a sedative and not an opioid, it resists standard opioid overdose reversal treatments.More than 90 percent of Philadelphia’s lab-tested dope samples were positive for xylazine, according to the most recent data.“It’s too late for Philly,” said Shawn Westfahl, an outreach worker with Prevention Point Philadelphia, a 30-year-old health services center in Kensington, the neighborhood at the epicenter of the city’s drug trade. “Philly’s supply is saturated. If other places around the country have a choice to avoid it, they need to hear our story.”A study published in June detected xylazine in the drug supply in 36 states and the District of Columbia. In New York City, xylazine has been found in 25 percent of drug samples, though health officials say the actual saturation is certainly greater. In November, the Food and Drug Administration issued a nationwide four-page xylazine alert to clinicians.Shawn Westfahl, center left, attended to a man who Mr. Westfahl believed had just injected tranq dope, in the Kensington section of Philadelphia.Hilary Swift for The New York TimesTracey McCann is in recovery from tranq dope at a treatment center near St. Louis. “I’d wake up in the morning crying because my arms were dying,” she said.Neeta Satam for The New York TimesIn December, the Office of National Drug Control Policy said it was tracking the spread closely, and the journal Pediatrics published an analysis of three cases of xylazine ingestion by toddlers.But xylazine’s true prevalence is unknown. Hospitals don’t test for it. Some state medical examiners don’t routinely do so, either.The drug exists in a legal gray zone. Approved 50 years ago by the F.D.A. as a veterinarian-prescribed analgesic, it is not listed as a controlled substance for animals or humans and so is not subject to strict monitoring. Thus, it has not been on the radar of federal law enforcement for diversion or abuse.As with many trapped by tranq, Ms. McCann’s hellish descent began with prescription opioids. In 2009, when she was 27, she developed a dependence on painkillers prescribed after a severe car crash. A boyfriend she met at one of her six stays in rehab introduced her to heroin. Cheaper and more potent fentanyl elbowed heroin off the streets. Then, as the Covid-19 pandemic descended in 2020, tranq stormed Philadelphia.Fentanyl Overdoses: What to KnowCard 1 of 5Devastating losses.

PHILADELPHIA — Over a matter of weeks, Tracey McCann watched in horror as the bruises she was accustomed to getting from injecting fentanyl began hardening into an armor of crusty, blackened tissue. Something must have gotten into the supply.Switching corner dealers didn’t help. People were saying that everyone’s dope was being cut with something that was causing gruesome, painful wounds.“I’d wake up in the morning crying because my arms were dying,” Ms. McCann, 39, said.In her shattered Philadelphia neighborhood, and increasingly in drug hot zones around the country, an animal tranquilizer called xylazine — known by street names like “tranq,” “tranq dope” and “zombie drug” — is being used to bulk up illicit fentanyl, making its impact even more devastating.Xylazine causes wounds that erupt with a scaly dead tissue called eschar; untreated, they can lead to amputation. It induces a blackout stupor for hours, rendering users vulnerable to rape and robbery. When people come to, the high from the fentanyl has long since faded and they immediately crave more. Because xylazine is a sedative and not an opioid, it resists standard opioid overdose reversal treatments.More than 90 percent of Philadelphia’s lab-tested dope samples were positive for xylazine, according to the most recent data.“It’s too late for Philly,” said Shawn Westfahl, an outreach worker with Prevention Point Philadelphia, a 30-year-old health services center in Kensington, the neighborhood at the epicenter of the city’s drug trade. “Philly’s supply is saturated. If other places around the country have a choice to avoid it, they need to hear our story.”A study published in June detected xylazine in the drug supply in 36 states and the District of Columbia. In New York City, xylazine has been found in 25 percent of drug samples, though health officials say the actual saturation is certainly greater. In November, the Food and Drug Administration issued a nationwide four-page xylazine alert to clinicians.Shawn Westfahl, center left, attended to a man who Mr. Westfahl believed had overdosed on tranq dope, in the Kensington section of Philadelphia.Hilary Swift for The New York TimesTracey McCann is in recovery from tranq dope at a treatment center near St. Louis. “I’d wake up in the morning crying because my arms were dying,” she said.Neeta Satam for The New York TimesIn December, the Office of National Drug Control Policy said it was tracking the spread closely, and the journal Pediatrics published an analysis of three cases of xylazine ingestion by toddlers.But xylazine’s true prevalence is unknown. Hospitals don’t test for it. Some state medical examiners don’t routinely do so, either.The drug exists in a legal gray zone. Approved 50 years ago by the F.D.A. as a veterinarian-prescribed analgesic, it is not listed as a controlled substance for animals or humans and so is not subject to strict monitoring. Thus, it has not been on the radar of federal law enforcement for diversion or abuse.As with many trapped by tranq, Ms. McCann’s hellish descent began with prescription opioids. In 2009, when she was 27, she developed a dependence on painkillers prescribed after a severe car crash. A boyfriend she met at one of her six stays in rehab introduced her to heroin. Cheaper and more potent fentanyl elbowed heroin off the streets. Then, as the Covid-19 pandemic descended in 2020, tranq stormed Philadelphia.Fentanyl Overdoses: What to KnowCard 1 of 5Devastating losses.

A third of parents now feel they should be the ones to decide whether to get their children immunized against measles, mumps and other childhood diseases.For generations of most American families, getting children vaccinated was just something to check off on the list of back-to-school chores. But after the ferocious battles over Covid shots of the past two years, simmering resistance to general school vaccine mandates has grown significantly. Now, 35 percent of parents oppose requirements that children receive routine immunizations in order to attend school, according to a new survey released Friday by the Kaiser Family Foundation.All of the states and the District of Columbia mandate that children receive vaccinations against measles, mumps, rubella and other highly contagious, deadly childhood diseases. (Most permit a few limited exemptions.)Throughout the pandemic, the Kaiser foundation, a nonpartisan health care research organization, has been issuing monthly reports on changing attitudes toward Covid vaccines. The surveys have showed a growing political divide over the issue, and the latest study indicates that division now extends to routine childhood vaccinations.Forty-four percent of adults who either identify as Republicans or lean that way said in the latest survey that parents should have the right to opt out of school vaccine mandates, up from 20 percent in a prepandemic poll conducted in 2019 by the Pew Research Center. In contrast, 88 percent of adults who identify as or lean Democratic endorsed childhood vaccine requirements, a slight increase from 86 percent in 2019.The survey found that 28 percent of adults overall believed parents should have the authority to make school vaccine decisions for their children, a stance that in the 2019 Pew poll was held by just 16 percent of adults.Read More on the Coronavirus PandemicUpdated Shots: The Food and Drug Administration expanded eligibility for the updated coronavirus boosters to children as young as 6 months old.Plummeting Demand: A key partner of Covax, the organization leading efforts to bring Covid vaccines to poor and middle-income countries, will stop supplying the shots to a huge part of the global population in 2023.Pregnant Women: Even though studies have shown that the Covid vaccine is safe for expectant women, many have avoided getting the shots, unaware of the risks that the virus poses.Pandemic Response: Some experts fear that the chance to create an independent panel to investigate the pandemic response is slipping away.The shift in positions appears to be less about rejecting the shots than a growing endorsement of the so-called parents’ rights movement. Indeed, 80 percent of parents said that the benefits of vaccines for measles, mumps and rubella outweighed the risks, down only slightly from 83 percent in 2019. “The talking point that has been circulated is the concept of taking away parents’ rights,” said Dr. Sean O’Leary, chairman of the American Academy of Pediatrics’ committee on infectious diseases. “And when you frame it that simply, it’s very appealing to a certain segment of the population. But what about the right to have your children be safe in school from vaccine-preventable diseases?”An anti-vaccine demonstration outside the California Capitol in Sacramento in 2020. Rich Pedroncelli/Associated Press Still, Dr. O’Leary said that he wasn’t overly worried that school vaccine mandates would be lifted but that the growing embrace of parents’ rights might further slow compliance with state-required immunization schedules, a timeline that has long been endorsed by pediatricians.“We know a lot of kids missed their vaccines during the pandemic, not because they were refusing, but because, for many reasons, people weren’t going to the doctor,” he said. “And we do have a global dip in vaccine coverage. So this is not a time to be considering a rollback of these laws.”The latest survey was based on interviews with a nationally representative sample of 1,259 adults and was conducted from Nov. 29 through Dec. 8.It showed disappointing rates of uptake of the latest Covid booster, a “bivalent” shot that targets both the original coronavirus and the Omicron variant and has been available since September. Just four in 10 adults said they had either gotten the booster or intended to do so. Among those 65 and older — the age group at the highest risk — about one in four said they had been too busy to get it or hadn’t found the time to do so.Even among adults who had received previous Covid vaccines, the survey found that more than four in 10 said they felt they did not need this latest shot.Only about a third of respondents said they personally feared getting very ill from Covid, though half expressed concerns in general about rising rates of Covid this winter. About two-thirds of Black and Latino adults were apprehensive about Covid rates, compared with about four in 10 white adults.The survey also found that about half of parents worried that their children could fall sick this winter from Covid-19, the flu or R.S.V. (respiratory syncytial virus), a sign that Covid-19 was increasingly becoming normalized in the public’s perception and joining the landscape of seasonal illnesses.

The issue is whether a federal law that seeks to place Native American foster children in Native American homes is constitutional. The case could turn on whether the justices see tribes as racial groups or sovereign nations.The little girl who will soon be known by the nine justices of the United States Supreme Court as Y.R.J. is now 4 years old. For much of her short life she has been living with Dr. Jennifer Brackeen and Chad Brackeen, a suburban Texas couple fighting with the Navajo Nation to adopt her. Y.R.J.’s birth mother is Navajo. The Brackeens are white.On Wednesday, the Supreme Court will hear arguments in their case, which could affect not only the little girl’s adoption but those of thousands of Native American children in foster care. Depending on how broadly the justices rule, the outcome of the case, Brackeen v. Haaland, could also start the unraveling of other federal protections that have long been extended to tribes.That is because the case, which primarily pits the Brackeens and Texas against the U.S. Department of the Interior and five tribes, could turn on whether the Supreme Court finds that tribes are racial classifications rather than political ones — a prospect that the tribes find deeply threatening.“It would put at risk every treaty, every property and political right and every power that Indian nations possess today,” said Robert Miller, a professor of federal Indian law at Arizona State University, tribal court judge and enrolled citizen of the Eastern Shawnee Tribe.“All of a sudden, lands would be owned by ‘a race of Indian people,’ not a tribal government,” he said. “Your borders, your police laws, everything on the reservation would be in question. I’m not being hyperbolic. I am afraid of this case.”Specifically, the Brackeens want the Supreme Court to overturn a federal law, the Indian Child Welfare Act of 1978. The law says that when a child who is eligible for tribal membership winds up in state foster care, the child should, whenever possible, be adopted by a tribal family.Lawyers for the Brackeens argue that the law discriminates against Native American children as well as non-Native families who want to adopt them because it determines placements based on race. But tribes say they are political entities, not racial groups.Legal scholars said that, beyond resolving the Solomonic fight over the fate of a child, a decision against the tribes could, in the long term, shake their centuries-old legal status as sovereign nations with a unique relationship to the U.S. government. For 250 years, that relationship has been the foundation of treaties and regulations for tribal health and education benefits; criminal jurisdiction; and hunting, fishing, oil, mineral and gaming rights.In the short term, if the Supreme Court determines that tribal citizenship is based on race, the child welfare law, often known as the I.C.W.A., will be struck down for violating the equal protection rights of Native children and non-Native adoptive families.Matthew McGill, a lawyer for the Brackeens, said that catastrophic predictions about the ramifications of overturning the law were overblown. The law is unique in the federal Indian canon, he said, because it deals with Indian child welfare cases occurring off tribal lands. (On reservations, those cases are overseen by tribal social workers and tribal courts.)Understand the Supreme Court’s New TermCard 1 of 6A race to the right.

The dual agreements would resolve thousands of lawsuits over the retailers’ role in the addiction crisis. But a large majority of state, local and tribal governments must sign on.CVS and Walgreens, two of the nation’s largest retail pharmacy chains, said on Wednesday that they had reached tentative agreements to pay about $5 billion each to settle thousands of lawsuits over their role in the opioid crisis, a development that could signal the beginning of the end of years of opioid litigation.Since 2013, a snowballing number of state, local and tribal governments have been seeking to make companies across the pharmaceutical industry pay to reduce the ongoing costs of addiction, death and crime in an epidemic that began with prescription painkillers. While most of the big opioid manufacturers and drug distributors agreed to pay billions of dollars in national settlements in recent years, the retail chains had so far resisted negotiating a broad settlement deal.Wednesday’s announcements change the narrative.“My sense is that we’re nearing the end of the saga,” said Alexandra Lahav, who teaches complex litigation at Cornell University Law School.Citing recent court decisions, she added: “Things weren’t looking super for them, so it makes sense that they were finally coming to the table. And I’m guessing the rest of the defendants are going to follow.”In a sign that others may indeed follow, a person familiar with the negotiations said that Walmart had agreed to pay $3.1 billion in its settlement negotiations. The company declined to comment.“We’re a lot closer to the end today than we were yesterday,” said Jayne Conroy, a lawyer on the negotiating committee who represents cities and counties.CVS and Walgreens disclosed the tentative agreement in government filings. Finalization is conditional on an overwhelming majority of plaintiffs signing on, they said.Fentanyl Overdoses: What to KnowCard 1 of 5Devastating losses.

The latest shots, which target Omicron and its subvariants, could offer protection against a winter surge in cases. But many people are unsure if they’re eligible.The new, redesigned Covid booster, which now protects against Omicron and its extremely contagious subvariants, appears to have a visibility problem.Federal authorities authorized the shot at the end of August, but by mid- to late September, nearly half of adults had heard little or nothing about it, according to a report by the Kaiser Family Foundation, based on the latest of its monthly surveys about attitudes toward the Covid vaccines. That could have troubling implications. The Biden administration has been touting the booster as a means of warding off a fresh fall or winter surge of the virus.“America is not rushing out to get the new booster,” said Drew Altman, the president of the Kaiser Family Foundation. “Most are only dimly aware of it, which is not surprising in a country that seems to have mostly moved on.” He added, “The exception may be older folks, who are at greater risk and early on are more interested in the new booster.” The survey was conducted from Sept. 15 to 26, online and by telephone, among a nationally representative sample of 1,534 adults.Read More on the Coronavirus PandemicAn ‘Anti-Vax’ Capital No More: Vaccine skeptics once found a home in Marin County Calif. Now, the pandemic has made them unwelcome, as Covid vaccine rates soar there.New Boosters: The updated shots were authorized at the end of August, but nearly half of U.S. adults had heard little or nothing about it by mid- to late September, according to a new report.A Persistent Variant: Ten months have passed since Omicron’s debut. Since then it has displayed a remarkable capacity to evolve new tricks.A Blunted Response: Major data gaps, the result of decades of underinvestment in public health, have undercut the U.S. government’s response to Covid — and now to monkeypox.Ever since the first shots were rolled out, people 65 and older, who are the most vulnerable to Covid complications, have been the most compliant with getting the vaccine. They also displayed the broadest awareness of the new booster, the survey found, with almost half reporting either having already received the new dose or aiming to get it “as soon as possible.” Nearly a third of adults overall said they had planned to get it soon as well.But otherwise, confusion over eligibility seemed widespread, according to the survey.The Food and Drug Administration authorized the new booster made by Pfizer and BioNTech for fully vaccinated people as young as 12 and the new Moderna booster for those 18 and older. But among fully vaccinated adults 30 and under, 43 percent said they were unsure of whether the dose had been approved for them, and an additional 19 percent said they did not believe it had been.Dr. Mary Politi, a professor in the Division of Public Health Sciences at the Washington University School of Medicine, said that Americans had been experiencing Covid information overload and, as a consequence, decision-making fatigue. One way to overcome both, she said, “is to keep information simple, clear and consistent.” She added, “Unfortunately, the information coming from various sources has often been conflicting, with uncertain, unclear or changing guidelines.”Older adults were also better informed about their booster eligibility status. Among those 65 and older, more than half knew the booster was recommended, as did nearly half of those between the ages of 50 and 64.While the Centers for Disease Control and Prevention recommends that fully vaccinated people 12 and older get the updated booster, it urges those 50 and older in particular to get it.The report, which also looked at parents’ views of the vaccine, found that there had been a modest uptick in vaccination among the youngest children since July, when Covid vaccines for those between six months and 4 years old received emergency authorization. At the time, scarcely 7 percent of parents said they intended to get their children vaccinated; that percentage has risen to 19 percent, or nearly one in five parents.But more parents are refusing the vaccine for their children, too. Now 53 percent of parents of children between six months and 4 years say they will “definitely not” let their children get the shots. Last January, 26 percent held that view.While some 60 percent of parents said that their children between the ages of 12 and 17 had been vaccinated, about 30 percent of parents with children in that age group said their children would definitely not get the Covid vaccine.Overall, 77 percent of respondents said they had gotten at least one dose of the Covid vaccine, with nearly half of those saying they had received at least one booster. But 23 percent said they were not vaccinated, and nearly all of that group said they would “definitely not” get it.

The risk of canine cognitive dysfunction, a.k.a. “doggy dementia,” is far greater in dogs who don’t get enough exercise, researchers found. Their risk factors echo some in humans, whose homes they share.Around the time Dante turned 8, he started to seem a little off. The 70-pound Bernese mountain dog would pace his family’s home in Interlaken, N.Y., like a caged bear. Then he might stand stock still, staring trance-like at the pedals of the family’s organ. Or at a corner of a room. In the middle of the night, he would wake up and begin barking incessantly, for no obvious reason.Then the indoor incontinence began.A brain scan confirmed that Dante had canine cognitive dysfunction, colloquially known as doggy dementia. It is often described as the dog’s analog to Alzheimer’s disease. Some studies have found it can occur in at least 14 to 35 percent of older dogs. But because the symptoms resemble those in other diseases, its true prevalence is difficult to confirm.A large new study of 15,019 dogs enrolled in the Dog Aging Project, an ongoing investigation into canine illness and aging, published Thursday in the journal Scientific Reports, identifies the top factors associated with a dog’s risk of getting the disease.A key finding: Exercise may play a significant preventive role. The odds of a cognitive dysfunction diagnosis were 6.47 times higher in dogs reported as not active compared with those reported to be very active, researchers at the University of Washington found. But they also said that the disease itself could lead to lack of exercise, emphasizing that the study results, which are based on observations by owners, suggest correlation, not causation.Odds of getting the disease also appear to increase in dogs that have neurological disorders, or impaired hearing or sight. Annette Fitzpatrick, a co-author of the study and a University of Washington research professor with expertise in dementia in people as well as canines, commented, “When you don’t get stimulation from the outside world, it seems to increase the risk of our not even being able to use our brains as well.”The study, she said, “shows that there may be other things we can be aware of, to try to reduce the onset of cognitive dysfunction.”And certainly age matters. A dog’s life expectancy often depends on breed, size and body mass: think mastiff (six to 12 years) versus Chihuahua (12 to 20 years). During the later years of a dog’s projected life span, each successive year contributed to the potential for disease onset, the study found.In fact, the researchers noted, risk factors that correlate with canine cognitive dysfunction mirror some of the factors for humans with dementia, including Alzheimer’s disease.Earlier studies of canine cognitive dysfunction often drew from veterinary assessments in smaller populations of older dogs; this one is culled from dogs who range in age from puppyhood to mid-20s. In the coming years, as these dogs grow older, the project, which has enrolled more than 40,000 dogs and hopes to reach 100,000, will issue more complex findings on cognitive dysfunction and other diseases.In this study, the prevalence of canine cognitive dysfunction among all the dogs, young and old, was 1.4 percent. But the average age of the dogs was just 6.9 years, and only 19.5 percent of the dogs analyzed were in the last quarter of their life span.“This study compares dogs with cognitive dysfunction to those that don’t have it,” Dr. Fitzpatrick said. “But as the years progress, we can look at the same dog who maybe had great cognitive function but then declined.”Matt Kaeberlein, a co-director of the Dog Aging Project, with Dobby, his 12-year-old German shepherd, in their Seattle backyard.Grant Hindsley for The New York TimesDobby and Dr. Kaeberlein’s late dog Chloe keep inspiring him to research causes of canine aging.Grant Hindsley for The New York TimesThe results were derived from just one baseline accounting by owners of their dog’s health and lifestyle experience between 2019 and 2020, and a particularly high-threshold cognitive function questionnaire.Among the questions:How often does your dog pace up and down, walk in circles and/or wander with no direction or purpose?How often does your dog get stuck behind objects and is unable to get around?How often does your dog walk into walls or doors?How often does your dog have difficulty finding food dropped on the floor?If the study findings have a familiar, even intuitive ring, that may be because the Dog Aging Project, which receives funding from the National Institute on Aging, a branch of the federal National Institutes of Health, may shed insight into factors that affect the life span of humans well as the dogs who share their homes.Unlike laboratory animal subjects such as fruit flies and mice, companion dogs are affected by their owners’ environmental and social factors, such as secondhand cigarette smoke, lawn pesticides and access to health care.“Estimates of human longevity say that about 75 percent is due to environment and 25 percent is genetic,” said Matt Kaeberlein, a biogerontologist at the University of Washington who is a co-director of the Dog Aging Project. “So companion dogs give us the opportunity to really understand the role of that environmental variability in the biological aging process.”Moreover, because dogs age much more rapidly than humans, the studies underway within the project provide opportunities along an expedited timeline for insights into human and canine aging.Dr. Kaeberlein’s motivation derives not only from his professional background but also from his many years as a dog owner. He shared stories of Chloe, his lively, loving, now-deceased keeshond, who began to stare blankly and get tangled in furniture, stricken with canine cognitive dysfunction. Or Dobby, his current inspiration, the family’s longhaired German shepherd who “is just a special dog,” but who, at 12 years old, has already beat back cancer once and can no longer cavort in the backyard to chase wand soap bubbles.“I would really like it if my dogs could live longer,” Dr. Kaeberlein said. “And I would really like it if I could help other people’s dogs live longer.”The trials now underway within the project, which began in 2014 and has researchers from the University of Washington and Texas A&M, as well as from the Cornell University College of Veterinary Medicine and other universities, includes those for potentially life-expanding drugs and a biobank of tissue donated by owners of deceased dogs. It released a study that is shaking the dog world, because of its finding that better health in dogs is correlated with a single daily feeding.(As Dr. Kaeberlein discussed that association during a phone interview, two small, highly food-motivated canines who had been snoozing at this reporter’s side sat up abruptly, whining and howling in protest. Dr. Kaeberlein hastened to add that the study’s observation is more likely a comment on obesity and morbidity than it is a prescription for feeding frequency, which is in keeping with the latest study’s positive correlation with exercise.)Dante with his owner Lisa Mitchell, who worked with one of her other dogs, Rook, on obedience at Cass Park in Ithaca.Heather Ainsworth for The New York TimesCanine cognitive dysfunction is difficult to pinpoint. A dog’s seeming ignorance of a commonplace command could indicate deafness or old-age stubbornness rather than an atrophying brain. Symptoms that look like cognitive dysfunction could actually be from stroke, brain inflammation, diabetes or Cushing’s disease, said Dr. Nicole Ehrhart, a veterinarian and director of the Columbine Health Systems Center for Healthy Aging at Colorado State University. Veterinarians rely initially on keen owner observation, she said, and then perform diagnostic tests.“Look at your dog looking into your eyes and see how long they hold your gaze, especially if you have a treat by your face,” she said. “Because as dogs get dementia, they can’t focus on things they would normally focus on.”Dr. Ehrhart, who was not involved in the Dog Aging Project study, called the new research “wonderful confirmation of something that we know across all species: that exercise is good for healthy aging and that lifelong habits of exercise can be preventive for Alzheimer’s disease and other cognitive issues.”In fact the average life expectancy for Bernese mountain dogs is six to eight years; Dante is now 11. But he had been particularly active in his younger years: He had the physical and mental acuity to gleefully navigate complex obstacle course competitions and leap imperviously off top stairs at a single bound.But now, the typically love-seeking Berner shies away from his household pack — three Golden retrievers and two doting, worried humans. Instead, he prefers to plop down under his favorite lilac bush, even in the pouring rain.“I used to try to make him come inside to be with us,” said Lisa Mitchell, his owner. “But after a year I thought, ‘Tomorrow might be his last day and maybe he’s more comfortable there.’ So we’ve just given over to letting him stay outside alone, if that’s where he wants to be.Although there are medicines and diets that can ameliorate the dog’s cognitive dysfunction for a time, Dr. Ehrhart said, owners needed to be sensitive to their dog’s increasing disorientation. Don’t disrupt their routines. Don’t move around furniture. Secure your yard, so the dog can’t wander away and get lost. If you want to host a loud dinner party with unfamiliar humans, put the dog in a comforting environment that is not so stimulating.And know that dogs, like older humans, can get “sundowner syndrome”: increased anxiety and disorientation as the day comes to a close.“It turns out that probably the best model for human aging has been aging alongside of us for hundreds and hundreds of years,” Dr. Ehrhart said. “This is a two-way street: Anything we’re going to be doing to improve our dogs’ health and life span is likely to improve ours, and anything we’re doing for humans is very likely to improve our dogs’. And who doesn’t want that?”

If finalized, the agreement, along with a companion deal reached by Teva earlier this week, would send as much as $6.6 billion to communities harmed by the opioid epidemic.A bipartisan group of state attorneys general announced Friday morning that it had struck an agreement in principle with the pharmaceutical company Allergan for $2.37 billion to resolve more than 2,500 opioid-related lawsuits brought by states, local governments and tribes nationwide who have suffered during the ongoing opioid epidemic.The company did not immediately respond to requests for comment, but a quarterly earnings report on Friday by Allergan’s parent company, AbbVie, characterized the amount as “a charge related to a potential settlement of litigation involving Allergan’s past sales of opioid products.”The proposed settlement is a companion agreement to a $4.25 billion deal in principle announced earlier in the week from Teva Pharmaceuticals. If a significant majority of states and communities sign on, the combined deal, when finalized, could be worth $6.6 billion, said lawyers familiar with the negotiations. That is higher than a nationwide settlement struck with Johnson & Johnson or an offer from Purdue Pharma, opioid manufacturers with much higher public profiles.The deals are linked largely because, in 2016, Teva bought Allergan’s generic drug portfolio, including its substantial opioid business. Teva made this week’s settlement contingent in part on Allergan reaching its own deal for opioid liability.“We’ve worked hard to get the best result for Americans harmed by the opioid crisis, and it’s rewarding to take another step in the right direction,” said Tom Miller, the attorney general for Iowa, whose office led the bipartisan group in the negotiations with Allergan and Teva. “We continue to make it a priority to hold manufacturers responsible, while ensuring victims of this epidemic receive the help they need.”Unlike Teva’s deal, under which plaintiffs can elect to receive a portion of the payout in overdose drug reversal and addiction treatment medication rather than cash, Allergan’s offer is all cash with no product, lawyers familiar with the negotiations said. Teva’s payments to states and communities would be disbursed over 13 years, while Allergan’s would be over six years. The amounts of both pharmaceutical companies presumably include the settlement figures that were already struck over the past year with a handful of states and counties.Both Allergan and Teva sold branded as well as generic opioid painkillers. Lawyers for thousands of entities asserted that these manufacturers, like so many others, exaggerated the benefits of opioids to doctors and the public and downplayed the drugs’ addictive properties. In addition, although the companies are required to report suspicious orders to authorities, both failed to do so, lawyers said.Teva had said that the potential agreement was not an admission of wrongdoing.The deals still have a ways to go before money actually starts flowing to communities. Issues such as allocation of funds, tighter monitoring of suspicious orders and the creation of a public repository of internal documents have yet to be resolved.Josh Stein, the North Carolina attorney general, commented on the arc of the opioid epidemic and the litigation to emerge from it. “In 2020, nine North Carolinians died each day from opioid overdose,” he said. “There is no amount of money that could ever repair that kind of loss. But there is hope in recovery, and, thanks to our ongoing work to hold these companies accountable, people across this state are getting the treatment and support they need to get healthy. And we’re still not done.”