The company reported that in eight patients who had been followed for a month and a half, the vaccine at low and medium doses triggered blood levels of virus-fighting antibodies that were similar or greater than those found in patients who had recovered. The antibody-rich blood plasma donated by patients who have recovered is separately being tested to determine whether it is an effective therapy for covid-19.

The vaccine showed no worrisome safety signals, aside from redness at the injection site for one patient and some “systemic” symptoms in three patients given the highest dose, the company said.

The interim data Moderna announced come from a clinical trial aimed at showing the safety of its experimental vaccine and helping the company select the correct dose. The company has not yet picked the dose or announced the size or length of the large trial that it will start in July, which will be the key one that regulators consider to decide whether the vaccine is safe and effective.

“We are very, very happy because first the vaccine was generally safe,” Stephane Bancel, chief executive of Moderna said in an interview. “The piece that was really exciting and was the big question, of course, was can you find antibodies in people in enough quantities” to prevent disease.

Moderna also reported that the vaccine protected mice who were vaccinated and then exposed to the virus, preventing it from multiplying in their lungs. The animal and human data being released by the company have not yet been published.

Moderna’s vaccine uses a genetic material called messenger RNA that codes for the distinctive spike protein that studs the outside of the novel coronavirus. The vaccine delivers the messenger RNA to cells, which then follows the genetic instructions to create the virus protein – allowing the body to learn to recognize and neutralize the pathogen.

Moderna’s announcement comes days after one of its board members, Moncef Slaoui, stepped down from the board to become chief scientist for Operation Warp Speed, a White House initiative to speed up vaccine development. Slaoui still owns stock options in Moderna, and made an apparent reference to the early data in a Rose Garden news conference on Friday afternoon.

The 12-year-old from Covington, Louisiana, padded out of her room in her PJs shortly after 7 a.m., ate a half-bowl of Rice Krispies, and got on a Zoom call with her sixth-grade social studies class. She had been feeling unwell all weekend with twisting abdominal pains, vomiting and a fever of 101.5, but she seemed to be on the mend.

The weird thing, she recalled, was that her lips looked bluish in the mirror and she was super tired. In fact, she kept falling asleep unexpectedly. On the couch. In front of her computer. In the bath.

“I thought I was feeling a bit better,” she said, “but I couldn’t keep my eyes open.”

With all the news swirling around them about the pandemic, her parents, Sean and Jennifer Daly, had been monitoring their daughter’s illness closely. She had been healthy and did not have a cough, shortness of breath or other typical symptoms of covid-19, so Jennifer, a radiologist, initially suspected appendicitis, some kind of stomach bug, or perhaps the flu.

That afternoon, they took Juliet to the emergency department, where doctors noticed an unusual constellation of symptoms pointing to a different problem. Her heart rate was extraordinarily low, jumping around in the 40s when it should have been between 70 to 120 beats per minute. And when they squeezed her nails, they turned white and stayed white when they should have gone back to pink.

Juliet was in a kind of toxic shock, and her heart had become so inflamed it was barely beating.

It was still relatively early in the outbreak, April 6, and the hospital hadn’t seen other children in this condition. But the doctors knew enough about the pathogen’s effects on adults that they immediately suspected the coronavirus.

– – –

Cases like Juliet’s, a puzzling inflammatory syndrome in children believed linked to covid-19, had been popping up in different parts of the world for months, but it wasn’t until recently that health authorities began tracking the phenomenon.

The number of infected children, while still small, is estimated to be a few hundred – larger than anyone anticipated for a disease thought to inflict little, if any, harm on children. Doctors in Britain and Italy had issued alerts in April, and the American Heart Association warned last week that some pediatric patients “are becoming very ill extremely quickly,” urging providers to evaluate them right away.

On Thursday night, the Centers for Disease Control and Prevention issued an advisory and gave the unusual condition a name – multisystem inflammatory syndrome in children, or MIS-C.

More than 100 children are believed to have it in New York state, with about half in New York City, where three have died. In recent days, medical centers in 14 other states have reported similar cases. Scientists still believe most children and young people experience only mild illness or none at all if they become infected with the coronavirus. But they’re concerned about the critical nature of the inflammatory syndrome cases, which seem to be appearing in children weeks after a wave of infections in their communities.

“We’ve been seeing kids steadily for two months,” said Roberta DeBiasi, infectious disease specialist at Children’s National Hospital in the District. “But this presentation is clearly different. It’s not that we just didn’t notice this before. It’s a new presentation. And the fact that it’s happening two months after the initial circulation of the virus gives weight to the idea that it’s an immune-mediated phenomena.”

Jennifer Owensby, a pediatric intensivist at Rutgers’s Robert Wood Johnson University Hospital in New Brunswick, New Jersey, said the first group of children she saw with covid-19 appeared to have classic respiratory symptoms, such as shortness of breath. Now, she said, “The vast majority are coming in with symptoms of cardiac failure, which is extremely rare in pediatrics, especially in normal, healthy kids – which is why this is so alarming.”

Writing in the Lancet medical journal this week, Italian doctors reported on a cluster of 10 children struck with the inflammatory condition in the coronavirus epicenter of Bergamo. The cases appear to have characteristics of an illness first identified in Japan known as Kawasaki disease, which causes inflammation in blood vessels and includes a persistent fever. But these children were older than is typical with Kawasaki, which usually strikes those younger than 5, and they had more serious heart issues.

Just like Juliet, who is among the first known children in the United States to develop multisystem inflammatory syndrome.

– – –

Sean Daly was at the hospital with “Jules,” as he sometimes called her, while Jennifer was on the phone from work.

A transportation planning consultant with no medical background, Sean remembers feeling confused as doctors told him they were giving his daughter an epinephrine drip to help her heart, and were sending her to a larger hospital with more expertise and equipment. They said they would put her on a ventilator to stabilize her for the helicopter trip to Ochsner Medical Center, about 50 miles away in New Orleans.

Sean, unaware of the gravity of his daughter’s condition, thought ridiculous thoughts about the absurdity of his shorts and flip-flops amid the alien-looking hospital workers in head-to-toe protective equipment. And he thought about how, just a few minutes earlier, his daughter had been well enough to walk across the parking lot and into the ER. He heard an announcement about something called a “code blue” and wondered why more and more people kept rushing into her room.

When the attending doctor finally popped out, Sean recalled, she was shaking. She said Juliet had gone into cardiac arrest, and it took them nearly two minutes of CPR, or cardiopulmonary resuscitation, to revive her.

“It didn’t process all that well with me,” he said. “She was telling me Juliet was ‘back,’ and I was like, ‘That’s good. I didn’t know she had gone anywhere.’ Thankfully I was not in the room. I don’t think I would have handled that.”

Jennifer was hysterical.

“It was horrific. It was beyond anything. It was shocking how quickly it happened,” she recalled.

– – –

When Jennifer arrived at Ochsner, she didn’t understand how she could have possibly beaten her daughter there. She had driven for about an hour in a semicircle around Lake Pontchartrain while Juliet had been airlifted.

“I was crying and freaking out,” she recalled. By the time she was able to grab a nurse, she feared the worst. “I just need to know one thing now,” she demanded. “Is she alive?”

Juliet’s helicopter had been delayed because she had coded a second time and, again, doctors restarted her heart. But by the time they wheeled her into the pediatric intensive care unit in the new hospital, some of her other organs had begun failing, too, probably because the heart was unable to pump the oxygen-filled blood they needed.

Juliet’s liver and kidneys were in shock. There was blood in her lungs. Her pancreas was inflamed.

Heartbeats are controlled by electrical impulses that travel down the right and left branches of the heart at the same speed. Somewhere in Juliet’s heart, a block was causing the system to go haywire.

A team of pediatric cardiology specialists gave Jennifer a name for her daughter’s condition: acute fulminant myocarditis – a sudden onset of heart failure, shock or life-threatening arrhythmias.

The doctors began medications, requisitioned a heart bypass machine in case it was needed, and prepared Jennifer for the possibility that Juliet might need a transplant.

“They were not sure she was going to make it the first night,” Jennifer said. “It was a total nightmare.”

Meanwhile, Juliet’s nasal swabs came back positive for the coronavirus and adenovirus, one cause of the common cold. The results were bewildering because none of the other family members – Sean, Jennifer or Juliet’s brothers, ages 5 and 16 – had been the least bit sick. But if her condition was post-viral, occurring weeks after infection – as scientists increasingly suspect in such cases – there were any number of ways she could have been exposed, since school had still been in session and stay-at-home orders had not yet been issued.

Since none of Juliet’s family had symptoms and test kits were in short supply in the area, doctors opted not to test them.

After confirming the coronavirus diagnosis, doctors gave Juliet an immunoglobulin product used successfully on Kawasaki patients. They ruled out using hydroxychloroquine, the anti-malarial touted by President Donald Trump, because they were worried about cardiac side effects given her already fragile heart condition.

As Jennifer sat in the room with full protective equipment, including a face shield, mask and gown, she held her daughter’s hand. Only one parent was allowed, so Sean stayed at home with the boys.

Unable to sleep, Jennifer started a group text chat so she could keep family and friends updated. She played Juliet’s favorite song – Maroon 5′s “Moves Like Jagger” – vowed to be as optimistic as possible and prayed.

– – –

That first night was torture. Juliet’s heart was starting and stopping, beating too fast and then too slow, as doctors adjusted the medications. But within 24 hours, almost miraculously, she seemed to be stabilizing. The numbers on her labs for her kidneys and liver were moving in the right direction, and the echocardiogram of her heart had improved.

While Jennifer joked with her husband about Juliet being a heavy sleeper, there were instances when her daughter woke up and seemed to understand her completely.

“We love you,” Jennifer would say. “You’re going to get better.”

She talked about an Easter egg hunt she would have in the yard with her brother, Dominic.

Juliet was able to give a thumbs up and squeeze her hand.

“I’m optimistic she is neurologically intact,” Jennifer texted to Sean. Her tone was clinical, but it had been one of her worst fears as a mother.

By Thursday, doctors were confident enough in Juliet’s progress that they took her off the ventilator, letting Juliet breathe on her own. She was still on a lot of medications and confused and upset about all the tubes coming out of her body.

Jennifer remembers reassuring her she was safe in the hospital, but that she was still very sick and weak.

Juliet’s reaction wasn’t what she expected: “No Mommy, I’m not weak. I’m strong!”

“The first day of regaining consciousness, I was freaking out. I wanted to go home badly,” Juliet recalled. She said she was terrified of how everyone kept stepping on all her cords, which were tangled and plugged in outside because the nurses wanted to limit how many times they came into her room. The Band-Aid on her neck was “way too sticky for humankind.” And she could taste the saline they were giving her via IV, and it was bad.

Then on April 15, almost as suddenly as she had been admitted nine days before, doctors told Juliet she was well enough to go home.

– – –

Juliet has no memories of when her heart stopped twice, and her parents are grateful for that.

She was discharged on four medications – two for the heart, a blood thinner and one for her pancreas – but bounced back physically in no time. She was able to return to her school’s online classes, in which she’s continuing her streak of As, and has no trouble riding her bike around the neighborhood.

Doctors monitoring her closely say the drugs are temporary and that they are hopeful she’ll make a full recovery. On Friday, she returned to Ochsner for the first time since her hospitalization for a one-month follow-up appointment. Jake Kleinmahon, the pediatric cardiologist who is treating her, said he was thrilled when the echocardiogram of her heart looked “completely normal.” Like other children with myocarditis, she is restricted from competitive sports for six months (Juliet’s parents say that’s not a problem as she doesn’t really like to sweat) but is otherwise free to engage in activities.

“I do not expect her to have any long-term complications or limitations, even though she came in so severely ill,” Kleinmahon said. “She is quite a fighter and such a brave young girl.”

The only odd change, Juliet said, is that she came out of the hospital with a monster craving for bacon, which she didn’t love before. And she no longer wanted doughnuts, which had been among her favorite foods. Such changes in taste are not uncommon after ICU stays, doctors say.

The emotional part of her recovery has been more challenging. Juliet thinks about other kids who might become sick with the same syndrome. She says she would advise them “not to freak out too much because freaking out makes things worse. Because that’s what I did, and that didn’t help at all.”

She worries more about her family and friends, their future and hers, and the strange world of viruses she knew nothing about before.

“I feel like I’m a bit self-conscious about my body because I don’t know what’s going to happen next,” she said. “I’m worried about how there’s a lot of other stuff you can get.”

The pushback came after comments by Sanofi Chief Executive Paul Hudson.

“The U.S. government has the right to the largest preorder because it’s invested in taking the risk,” Hudson told Bloomberg News in a story published Wednesday. The United States, Hudson said, expanded its investment in the company’s vaccine research in February and thus expects that “if we’ve helped you manufacture the doses at risk, we expect to get the doses first.”

Those comments did not sit well in Paris.

“For us, it would be unacceptable if there were privileged access from this or that country under a pretext that would be a monetary pretext,” France’s state secretary for economy and finance, Agnès Pannier-Runacher, told France’s Sud Radio on Thursday.

Olivier Véran, France’s health minister, said he was shocked when he saw Hudson’s interview.

“When I read that, I took my phone – it was late, it would have been something like 11 at night – and I called the CEO of Sanofi France for an explanation,” Véran said, speaking Thursday to France’s BFM TV.

A covid-19 vaccine “should be a global public good,” Prime Minister Edouard Philippe tweeted. “Equal access for everyone to the vaccine is not negotiable.”

A spokesman for the Elysee Palace, the seat of the French presidency, said that President Emmanuel Macron was struck by Hudson’s comments in the same way as his ministers were, and that Hudson would meet Macron at the Elysee next week, although a date for that meeting had not yet been set.

The Elysee said it was “concentrating its efforts on a coordinated multilateral response so that a vaccine is available to all and at the same time, because it knows no borders.”

Early in the coronavirus outbreak, France came under heavy criticism for its reluctance to share protective medical equipment with its European neighbors. It subsequently has taken a more communal approach. And Macron, along with German Chancellor Angela Merkel, has been an especially vocal proponent of a global initiative to develop a successful covid-19 vaccine that would not favor any particular country.

“We need to make sure it is rendered accessible to all of those around the world,” he said in April.

Macron and Merkel, along with the World Health Organization, spearheaded a roughly $8.2 billion vaccine fundraising drive that culminated in a virtual summit this month, during which world leaders and prominent philanthropists pledged to fund vaccine research, testing kits and mass-produced drugs that could effectively fight the coronavirus.

The United States did not participate in the conference. It has instead partnered directly with pharmaceutical companies, contributing half a billion dollars to Johnson & Johnson’s vaccine effort and hundreds of millions of dollars to Sanofi and to Moderna, a biotech company in Massachusetts teaming with a Swiss company for vaccine manufacturing.

More than 100 covid-19 vaccine research efforts are in progress around the world, in laboratories in the United States, Britain, Germany, France and elsewhere. The question of national preference in these trials has been present from the beginning.

Heralding an Oxford University trial last month, for instance, British Health Secretary Matt Hancock said citizens of Britain should have preference if the trials proved successful. But Prime Minister Boris Johnson has talked about the importance of a globally available vaccine.

“The race to discover the vaccine to defeat this virus is not a competition between countries but the most urgent shared endeavor of our lifetimes,” Johnson said at the virtual vaccine summit.

The agency that approves medicine for the European Union said Thursday that in an optimistic scenario, a vaccine could be approved by early 2021.

Sanofi has two coronavirus candidate vaccines in pre-clinical evaluation.

The research behind the first, investigating a preclinical SARS (severa acute respiratory syndrome) candidate vaccine, was conducted in conjunction with British pharmaceutical conglomerate GlaxoSmithKline and supported by the Biomedical Advanced Research and Development Authority, part of the U.S. Department of Health and Human Services.

Sanofi said it expects to launch human trials for that vaccine in the second half of 2020.

The firm’s second candidate vaccine is being developed with Translate Bio, a Lexington, Massachusetts-based therapeutics company.

Hudson’s comments and additional messaging from Sanofi may be part of an effort to prod European governments to invest more in vaccine research. As Hudson told Bloomberg, his aim was partially to “to try to create a debate in Europe to say, ‘Don’t let Europe be left behind.’ ”

But by Thursday morning, the company appeared to be backpedaling somewhat.

Olivier Bogillot, head of Sanofi’s French division, told France’s BFMTV network that the vaccine would be available to Europeans at the same time as Americans if the European Union were as “efficient” a partner.

“If we discover a vaccine, it will be accessible to everyone – the Americans and the Europeans will have it at the same time,” Bogillot said. “The words of Paul Hudson were misunderstood; he was just calling on the European Union to be more efficient.

“For me, the debate is closed,” he said. “The vaccine, if discovered, will be made available to French patients.”

“GSK and Sanofi both believe that global access to COVID-19 vaccines is a priority,” the company said in a statement. “And we are committed to making any vaccine developed through the collaboration available and affordable through mechanisms that offer fair access to people around the globe, including the U.S.

“It is critical that governments support this goal and collaborate to help industry to make fair allocation decisions,” the company said.

The Baltimore plant is the second of four planned locations around the world where Johnson & Johnson plans to pump out vaccine on a massive scale, months before testing the first dose in a human being. The manufacturing head start is one part of a worldwide scramble to protect the human population from the virus that is not expected to vanish on its own.

If SARS-CoV-2 establishes itself as a stubborn, endemic virus akin to influenza, medical experts say there almost certainly will not be enough vaccine for at least several years, even with the unprecedented effort to manufacture billions of doses. About 70 percent of the world’s population – or 5.6 billion people – will likely need to be inoculated to begin to establish herd immunity and slow its spread, scientists say.

Yet the nationalistic priorities of individual nations could thwart the strategic imperative to tamp down hotspots wherever they are on the planet – including poor countries that can’t afford the vaccine. The United States in particular could be left in the cold if vaccines developed here as part of a go-it-alone approach turn out to be less effective than those produced in China or Europe.

The scenario public health experts fear most is a worldwide fight in which manufacturers sell only to the highest bidders, rich countries try to buy up the supplies, and nations where manufacturers are located hoard vaccines for their own citizens.

“The model of countries thinking only of themselves is not going to work. Even if you’re living somewhere that’s somehow perfectly without any infections. Your best efforts to fight the virus are going to fail unless you shut off all your borders and trade,” said Seth Berkley, CEO of Gavi, a public-private partnership that helps provide vaccines to developing countries. “This is a global problem that requires a global solution.”

International health advocates want to avoid a repeat of 2009, when wealthy countries – including the United States, which was led by the internationalist-leaning Barack Obama – were at the head of the line for H1N1 swine flu vaccine, leaving underdeveloped countries with little supply until after the pandemic subsided.

Such an approach will be sorely tested by President Donald Trump and other world leaders with nationalistic impulses and their own anxious populations who want to reduce the deadly threat and bring their economies back to life.

In the United States, the federal government agency in charge of emergency vaccine development indicated it is prioritizing domestic concerns – an “America First” mentality that has shaped much of the Trump administration’s pandemic response.

“Right now, we’re focused on the whole-of-America approach required to expedite the availability of vaccines,” said Gary Disbrow, acting director of the Biomedical Advanced Research and Development Authority (BARDA), in an emailed response to written questions from The Washington Post.

BARDA – which is tasked with protecting Americans from biological threats – is channeling nearly half a billion dollars in emergency funds to Johnson & Johnson to develop a vaccine. It also is providing hundreds of millions of dollars in financial support for vaccine efforts by Sanofi, the large French drug company, and Moderna, a biotech company in Massachusetts teaming with a Swiss company for vaccine manufacturing.

“By working with multiple companies, we have more ‘shots on goal’ to increase the chances that the U.S. will have one or more vaccines available as quickly as possible,” Disbrow said.

The global grab for protective equipment and ventilators that left poorer countries empty-handed suggests the competition over vaccines could be at least as fierce. Dozens of companies large and small are rushing to develop vaccines using different technologies and approaches. Avalere Health, a pharmaceutical consulting company, is tracking at least 120 separate vaccine projects sponsored by governments, universities, nonprofit institutes and private companies.

Large-scale manufacturing capacity will be required to produce viable products out of those experiments and clinical trials. Some vaccines may require two doses, putting greater pressure on manufacturing capacity. Some top officials in the Trump administration are raising attention to the issue. Francis Collins, the director of the National Institutes of Health, and Anthony Fauci, director of the National Institute for Allergy and Infectious Diseases, both physicians, were co-authors of an article published in the journal Science on Monday that urged international coordination.

“Cost, distribution system, cold-chain requirements, and delivery of widespread coverage are all potential constriction points in the eventual delivery of vaccines to individuals and communities,” they wrote. “All of these issues require global cooperation among organizations involved in health care delivery and economics.”

Recognizing the financial and logistical bottlenecks for smaller biotech firms, Bill Gates, the philanthropist and Microsoft founder, announced in April on The Daily Show with Trevor Noah that the Bill and Melinda Gates Foundation would make billions of dollars available to help seven undisclosed companies build out manufacturing capacity.

The race for a vaccine is full of risks because no one knows which projects will succeed. That forces companies to scale up to produce millions of doses of vaccine that might end up being worthless. There is another risk.

The United States might not be well-positioned if the best vaccines end up coming from other countries or international collaborations – such as a development and manufacturing cooperative that world leaders pledged billions toward this month at an online event the Trump administration skipped. A Trump administration official, not speaking for attribution this month under White House rules for speaking to reporters, said the United States supports such efforts despite skipping the pledge event.

“We need to lay the groundwork for global vaccine sharing now, before we know who is the winner. It’s basically negotiated – there’s not a global framework or protocol, there’s not a preexisting framework about how to do this,” said Jeremy Konyndyk, a senior policy fellow at the Center for Global Development, who worked on the U.S. government’s response to international disasters in the Obama administration. “What we don’t want is a situation of haves and have-nots, based on either who gets vaccine to work or who has the production capacity or who has the wealth.”

Much of the international outrage during the H1N1 swine flu pandemic 11 years ago centered on supply contracts western governments secured with vaccine manufacturers. The United States, under former President Barack Obama, had contracts in 2009 that entitled it to 600 million doses, The Washington Post reported at the time, a huge share of potential global supply.

Stronger frameworks for international planning have since been established for influenza vaccines. But those frameworks do not automatically apply to the coronavirus. David Fidler, adjunct senior fellow for cybersecurity and global health at the Council on Foreign Relations and a visiting professor at the Washington University School of Law in St. Louis, said the much larger threat of the coronavirus could make it more difficult for countries to act together – especially in the United States, which has experienced the highest covid-19 caseload and death toll in the world.

“Access to vaccine, as a safety valve to release that political and economic pressure, is going to be astronomical for anyone who is in the White House. That pressure is not going to dissipate if (presumptive Democratic nominee) Joe Biden wins in November,” he said.

Large drug companies may enter into vaccine contracts again as they face pressure to recoup their investments, Fidler added.

“For pharmaceutical companies that make vaccines, your best customer for return on investment are high-income countries,” Fidler said. “If you’re going to get a return on investment, somebody has to buy it.”

According to data from the Centers for Disease Control and Prevention, more than 80 million Americans were inoculated in the 2009 swine flu pandemic – an amount that roughly equals the total number of doses that were received in 77 different countries under a distribution plan organized by the World Health Organization.

“Rich countries monopolized the vaccine, poor countries were left behind. They got the vaccine later, and they got less of it,” Gavin Yamey, director of the Center for Policy Impact in Global Health at Duke University said in a university podcast. Allowing a repeat scenario in the battle against the coronavirus would be a devastating mistake, he said.

“Unless we make this vaccine globally available,” he said, “we are not going to be able to end the pandemic because . . . an outbreak anywhere is an outbreak everywhere.”

BARDA has not yet signed contracts with Johnson & Johnson or other companies for delivery of specific numbers of doses, a step Disbrow said would be “premature at this point.”

Johnson & Johnson “has indicated that approximately 300 million doses of vaccine would be available in the U.S. each year,” he said, which is enough to vaccinate 90 percent of the U.S. population of 330 million people. That number of doses matches up with the projected annual capacity at the Baltimore plant, which is operated by a publicly traded corporation called Emergent BioSolutions and receives funding as one of four federal Centers for Innovation in Advanced Development and Manufacturing.

Asked about Disbrow’s assertion, a top executive at Johnson & Johnson did not commit to specific volumes or timing of delivery of vaccine in the United States, citing the need to evaluate global priorities to stop the pandemic.

The company wants to produce 1 billion doses by the end of 2021, making the first doses available as early as this winter. Where vaccine will be most needed is not known, although health care workers will be a high priority, Paul Stoffels, Johnson & Johnson’s executive vice president and chief scientific officer, said in an interview.

Stoffels said Johnson & Johnson is committed to satisfying demand wherever it is most needed. The company also is not interested in making a profit on the coronavirus vaccine, he said.

“It’s very difficult to determine at the moment where the epidemic is then going to be,” Stoffels said in an interview. “We think honestly . . . that the priority should go to the people who need it most – first, that are probably the health care workers and people at high risk, and maybe wherever they are in the world.

“On the one hand, we work very much with the U.S.,” he added, “but on the other hand we also do our best to make sure we can serve the world.”

Johnson & Johnson says its vaccine technology is particularly well suited to underdeveloped regions because vials of doses can be shipped at relatively warm temperatures in the last stage of delivery. In addition to Baltimore, it will be producing a vaccine at its own plant in the Netherlands and is looking for at least two other locations in Asia and Europe, according to the company. It also is contracting with glass-vial manufacturers to buy 5-dose vials to ease shortages of packaging, Stoffels said.

Pfizer, which is testing multiple vaccine candidates, has identified factories in the United States and Belgium and is securing its supply chain, with the goal of having 10 to 20 million doses available by fall and hundreds of millions of doses next year, the company said.

“We’re thinking completely outside of what is, quote-unquote, normal. We come up with unique approaches, we’re getting into contract negotiations with suppliers, and we haven’t seen a single clinical data point,” said Kathrin Jansen, head of Vaccine Research and Development for Pfizer. “It’s unheard of.”

Pfizer’s vaccine contains genetic material encapsulated in a fat droplet made of four different lipids. Before it even knew which vaccine would move forward, Pfizer had to secure enough of each of those lipids. Pfizer managers need enzymes to make the genetic material, called RNA, so they had to find suppliers and secure enough supply for their anticipated demand.

Layered on top of the logistical supply chain is scientific uncertainty. Pfizer’s planning scenario is built on a “worst-case prediction” that the vaccine it ends up making will be the one that requires the highest dose. If the company succeeds with a different version – one that makes copies of itself once inside cells and thus is effective at about a tenth of the dose – Pfizer could be thinking about billions of doses as opposed to hundreds of millions.

“All those are wild cards, and the whole planning right now needs a certain amount of flexibility,” Jansen said. “We don’t want to have too little capacity, we don’t want to have too much capacity, we don’t know how much we need. It’s a very interesting dance going on right now to get it right, and none of us has ever done this.”

Jansen said that the global community will have to figure out how to distribute vaccine equitably through the world, through organizations like the WHO She did not say where Pfizer’s vaccines would go.

“I think by the time we will face the issue, I’m very confident there will be plans in place, to make sure that there’s an equitable roll out,” Jansen said.

Moderna has a factory in a suburb south of Boston capable of producing 100 million doses in a year. This month, the company announced a 10-year partnership with Lonza, a Swiss contract development and manufacturing firm that will help it scale up production, with the goal of beginning manufacturing in July. The partnership could expand manufacturing capabilities to 1 billion doses a year.

Stephane Bancel, chief executive of Moderna, said he hopes governments will place large orders with companies like his before the products are formally approved – so that they can spend the next 12 to 18 months making as much vaccine as they can, to be ready for the surge in demand if and when they get the regulatory okay.

“If we start stockpiling now,” he said, “all the products we make between now and launch are available the day of launch.”

Harvard researchers found that women who consumed the most fiber overall were 8% less likely to develop breast cancer than those who consumed the least, according to a report in the journal Cancer, based on analysis of data involving more than 8.5 million women. They found that the risk reduction applied to women of all ages, both pre- and postmenopausal, although studies that focused solely on premenopausal women revealed a greater effect, with risk 18% lower for women who consumed the most fiber, compared with those who consumed the least.

The researchers noted that the risk-reduction benefit was similar for all fiber-containing foods that had been tracked, including cereals, fruits, vegetables and legumes such as beans and peas. Health experts tend to believe that the beneficial effects of dietary fiber on breast cancer risk relate to the ability of fiber to help control blood sugar and decrease estrogen levels.

Current dietary guidelines call for the average adult woman to consume about 25 grams of fiber a day to achieve the most benefit (38 grams a day for men), although people often fall short of that goal – a situation described as America’s “fiber gap.” People adding dietary fiber to their daily menu are advised to do so gradually and to drink plenty of water, to avoid the gas, bloating and cramping that can develop as the digestive system adjusts to the change.

“I ran backwards to hit the Wiffle ball and I slipped, fell and broke my fall with my left wrist,” she told me. She was in enough pain to know an X-ray was in order, but did she dare go to the emergency room, where she could be exposed to the novel coronavirus?

Barr’s husband called the hospital to ask what precautions they were taking in the ER to protect patients.

Upon arrival, she would be directed to a separate entrance, and the hospital staff assured the Barrs that heightened sanitizing protocols were in place. Before entering, she encountered a security booth in the parking lot staffed with a nurse, who, Amy Barr says, “asked questions about where I’ve been, how I felt, if I had a fever – and then she instructed my husband that he could not go inside.”

The hospital’s no-visitors policy protects everyone from needless exposure and follows the Centers for Disease Control and Prevention guidelines for health-care facilities, which specifically call for: screening for fever, cough and difficulty breathing before entering a facility; ensuring proper use of personal protective equipment by personnel who come in close contact with “confirmed or possible patients with covid-19”; and considering strategies to prevent patients who can be cared for at home from coming into a facility.

Barr didn’t have much choice about whether to go to the hospital – she ended up with a broken wrist that needed a metal plate, multiple pins and a cast. But for many others, the answer is less clear. And it’s apparent from friends, acquaintances and others around the country that there’s real fear in many places about interacting in person with the health-care system.

Poet Kathryn Levy says she’s “trying to avoid doctors at all costs.” Many others, such as George Bishopric, who lives in South Florida, are putting off routine appointments because “a doctor’s office seems like high-risk environment,” he said. Brooke Shelby Biggs, who works as a media literacy educator and at Trader Joe’s in San Francisco, postponed a hysterectomy “until the worst is past, not out of fear but so as not to tax the health-care system.” She’s lucky she had any choice – many hospitals canceled all elective surgeries in March (although some are starting to slowly restart those procedures).

Caity McArthur, a North Carolinian who had a baby boy last month, said it has been “a very scary time to be giving birth.” She had a Caesarean-section delivery at her hospital, fearful all the while for her asthmatic husband facing greater risk from covid-19.

Hospitals across the country have seen a sharp decline in patients coming in with heart attack, stroke, cardiac arrest – even appendicitis – out of fears about covid-19. Recently, the American Heart Association, the American College of Emergency Physicians and several other medical groups issued a joint statement urging those experiencing symptoms of such threatening conditions to call 911 and go straightaway to the hospital.

So how do we balance the risk of contracting covid-19 at a health facility against the risk of not seeking care? Several moms told me they hover over stir-crazy kids’ risky behaviors to reduce the chance of needing an ER, but children (and even adults) break bones and can get sick. How do we stay safe when it’s necessary to get care?

“Hospitals and clinics are reducing the on-site transmission risk by limiting or restricting visitors, postponing elective procedures, screening staff for illness before they start their shifts and accelerating the use of telehealth,” Amy Williams, a physician and executive dean for practice at Mayo Clinic, said in an email.

The CDC issued covid-19 care guidelines, which specify ideal infection control procedures, but Williams acknowledges “resource constraints are making it nearly impossible to meet guidelines.” It doesn’t mean hospitals aren’t providing good care, she says. It means, “they are providing the best care they can in extremely difficult circumstances.”

That puts some of the burden back on us, the patients, to stay safe and be proactive. Arthur Caplan, director of the division of medical ethics at the NYU Grossman School of Medicine, suggests following the new normal precautions.

“Make sure you’re not all sitting in a waiting room together,” he says. “If the waiting room looks crowded, I might yell, ‘Are we going to do social distancing, or what’s happening here? Can’t we spread the seats in the hall?’ ”

I’m not sure I would shout, but I would definitely speak to the receptionist or office manager – pronto. We all need to take responsibility for safeguarding one another from exposure.

Caplan also recommends a mask, even if it is not required, just to be safer. (When I went to check out my hospital for this column, all but one person in the largely empty lobby was masked.) Before meeting your health-care provider, Caplan recommends washing your hands or using hand sanitizer (bring it with you, just in case). When you get home, wash your hands, your clothes and that mask (or throw it away), and take a shower, he cautions.

I wondered whether it was safer to seek treatment at a small local facility, where covid-19 might be less prevalent than at a large urban hospital. Mayo Clinic’s Williams says “the risk of exposure in a hospital or clinic is related to the level of infection in the community where it is located. … (F)amilies must make the best decisions for themselves (in consultation with their doctors).”

After Amy Barr learned that her broken wrist required surgery, and had returned home, one of her sons wanted her to get a second opinion at a university medical center. Barr told him she felt comfortable with the orthopedic surgeon at the local hospital, who had done hundreds of similar surgeries.

“I also didn’t want to expose myself to the virus in another hospital, or go to New York (City),” she added.

Deciding whether to go to an ER or doctor can be tough decisions, especially since we can’t turn to Yelp or Healthgrades to see which hospitals, clinics and doctors are tightly following CDC guidelines for covid-19. If I needed surgery right now, I’d have to balance the number of coronavirus patients in a particular hospital with the expertise of the surgeon there. And what if I did get sick with covid-19? It’s a tough question.

“Hospitals that have the resources and highly trained and experienced clinical care teams will be able to care for these very sick patients more successfully than hospitals that do not,” Williams says. So a small local clinic for a broken arm and a large urban hospital for the virus? It’s a conundrum and often not that black and white.

Regardless, Williams said, their campuses expect “to operate in a covid environment for the next year or longer … where infections will be within our hospitals and the communities we serve.”

For visits that don’t require face-to-face contact, there’s a great alternative: telemedicine, aka video visits. The Mayo Clinic, for instance, has gone from 40 scheduled video appointments a day in early March to more than 2,000 daily by late April, Williams says.

NYU’s Caplan says, “If you can do it by telemedicine, then do it by telemedicine.” It’s not only safer, but “it’s not taking anybody’s resources away,” he says.

As for Amy Barr, who didn’t have a choice, she said she felt safe at the hospital and is home sporting a cast.

“They were wearing masks and I was wearing a mask, but they had to touch me,” she says. “And I thought, ‘How scary for them that they have to touch a stranger.’ It really struck me as such an act of selflessness and bravery that every single day they’re touching people.”