Some families have borne the tragedy more than others, with multiple family members lost to COVID-19 in a matter of months.

This article was published on Monday, March 15, 2021 in Kaiser Health News.

By Will Stone

In the year since the World Health Organization declared a global pandemic, millions of families have endured the excruciating rise and fall of the U.S. outbreak — waves of sickness that leave untold wounds long after hospitalizations ebb and infections subside.

Some have borne the tragedy more than others, with multiple family members lost to COVID-19 in a matter of months.

For the Aldaco family of Phoenix, it has shattered a generation of brothers.

All three men — Jose, Heriberto Jr. and Gonzalo Aldaco — were lost to COVID, each at different moments in the pandemic: first in July, then December, and finally last month.

Their deaths are now among more than 530,000 in the United States, where, even as millions are vaccinated, the virus still leaves families grieving the new loss of a loved one each day.

"Those three men, they drove the family. They were like the strong pillars, the bones of the family. And now they're all gone," said Miguel Lerma, 31, whose grandfather Jose Aldaco raised him as his own son.

To Lerma, their deaths feel like an epic American story of resilience, courage and hard work cut short. All three came to the U.S. from Mexico and over the decades made it home for their families.

"They literally showed that you can come from nothing and struggle through all that and still build a life for yourself and your kids," said Lerma. "It just upsets me this is the way their story has to end."

Jose's daughter Brenda Aldaco said that, with so many Americans gone, the magnitude of each death and its reverberations are profound.

"When you really think about each single person, each person individually, what did that person mean to someone? It's just overwhelming. It's overwhelming," she said.

A Family 'Ready to Create Memories'

Jose Aldaco, 69 when he died, arrived in the Southwest in the early '80s when Brenda was still an infant, following his sister, Delia, and older brother, Gonzalo, who had both left Mexico not long before him.

"They came out here for a better opportunity — I don't even want to say a more comfortable life — but a more attainable, elevated life than what they had," said Priscilla Gomez, Jose's niece and Delia's daughter.

Gomez thinks of all three uncles as central figures — symbols of strength — for her and the entire extended family.

"They were so consistent, the most consistent male figures for me," said Gomez.

Big family gatherings were a staple of life in the Aldaco households.

"Those three men, when they were in the same room, it was just a good time," said Lerma, a dance teacher in Phoenix.

Reunions and holidays often evolved into joyous, music-filled events, where Gonzalo, the oldest, would pull out the guitar and the family would dance and sing together till the early hours of the morning.

"If it was someone's birthday, they would sing 'Las Mañanitas.' … They were just always ready to create memories for us," recalled Gomez.

Lerma said what Jose cultivated most of all was a family where love and affection was the main currency. "He's the one who taught us to be so amorous," said Lerma. "He was that warmth. He was that love for us."

Wave After Wave in Arizona

After a calm spring, the pandemic hit Arizona with terrifying force — the first of two waves that would rip through a state where pandemic precautions were slow to come and quick to disappear. Lerma said his family heeded the warnings.

"We were a family that accepted the pandemic was real," he said. "We did take it seriously."

Jose and his wife, Virginia, lived at their daughter Brenda's house, where they helped raise their teenage grandson.

Brenda's father worked a few days a week at his job in a hotel restaurant, but was mostly retired. "He was perfectly able — doing yardwork, cooking every day, jogging three times a week at the park," said Brenda.

Despite the family's effort to stay safe, the virus found a way into their household that summer. Jose was the first to get sick, but soon all four were ill and isolating in their bedrooms.

They waited on test results. Both elders were getting worse. When the bedroom door was open, Brenda's son would hear his grandfather.

"My son would say, 'Mom, Abuelo doesn't sound good. … He sounds like he's dying,'" recalled Brenda.

She felt paralyzed, though. Her mother was adamant that she didn't want him to go to the hospital.

Eventually, Lerma, who lives separately and did not have COVID, put on a mask and came to coax Virginia and Jose to go to the hospital. Lerma found Jose lying in bed, covered in a sheet, with a sky-high fever.

"He was forcing fast breaths to try to get any air that he could into his lungs," said Lerma. "That's when I started freaking out and losing it."

Virginia and Jose were admitted to the hospital. A few days later, Virginia was doing well enough to go home, but Jose's condition only got worse.

The last time Lerma saw him it was over FaceTime, while Jose was being wheeled through the hospital to be put on life support. "Losing my dad, this is what heartbreak is," said Lerma. "This is what the sad songs are about."

Three Brothers — 'Family Men' — Gone

By the time of Jose's death, the virus had already killed about 150,000 Americans. Like so many other families, the Aldacos were not able to have a proper funeral.

"It felt like his death was just brushed under the rug, like he's just another statistic," said Lerma.

Priscilla Gomez said she'll never forget hearing her mother take the phone call when she learned of her brother's death.

"To not be there in-person to comfort them or to hold them up when they feel like they just want to throw themselves on the ground and just sob … you feel completely helpless," she said.

As the pandemic stretched into the winter months, a new wave of infections and deaths gripped Arizona and much of the rest of the U.S. By late December, the total U.S death toll had surpassed 300,000, and Heriberto Aldaco Jr. — the youngest, in his late 50s — was now also hospitalized with COVID.

"You think you've gone to a particular point in your grieving, and then it's not done — here it comes again. … Now my dad's baby brother is sick," said Brenda Aldaco. "Then he passes away."

Less than two months later, yet more shattering news would come to the family.

The last remaining brother, Gonzalo Aldaco, the eldest in his early 70s, was hospitalized with COVID. He died in February.

Brenda Aldaco described her father and uncles as above all else "family men."

"They were totally and completely devoted to the people they loved — always present, always someone you could rely on," she said.

Sometimes, she still expects her father to come home from the hospital: "It was just hard for me to even grasp the concept of 'He's gone'… that the three of them are now gone and under the same circumstances and within a period of six months."

This story is from a reporting partnership between NPR and KHN.

After a brutal year in which the pandemic killed half a million Americans, despite unprecedented measures to curb its spread the vaccines are giving hope that an end is in sight.

This article was published on Monday, March 15, 2021 in Kaiser Health News.

By Melissa Bailey and Shoshana Dubnow

Joan Phillips, a certified nursing assistant in a Florida nursing home, loved her job but dreaded the danger of going to work in the pandemic. When vaccines became available in December, she jumped at the chance to get one.

Months later, it appears that danger has faded. After the rollout of COVID vaccines, the number of new COVID cases among nursing home staff members fell 83% — from 28,802 for the week ending Dec. 20 to 4,764 for the week ending Feb. 14, data from the Centers for Medicare & Medicaid Services shows.

New COVID-19 infections among nursing home residents fell even more steeply, by 89%, in that period, compared with 58% in the general public, CMS and Johns Hopkins University data shows.

These numbers suggest that "the vaccine appears to be having a dramatic effect on reducing cases, which is extremely encouraging," said Beth Martino, spokesperson for the American Healthcare Association and National Center for Assisted Living, an industry group.

"It’s a big relief for me," said Phillips, who works at the North Beach Rehabilitation Center outside Miami. Now, she said, she's urging hesitant co-workers and anyone else who can to "go out and take the vaccination."

After a brutal year in which the pandemic killed half a million Americans, despite unprecedented measures to curb its spread — including mask-wearing, physical distancing, school closures and economic shutdowns — the vaccines are giving hope that an end is in sight.

Noting that more than 3 million doses of vaccine have been doled out in nursing homes, CMS issued new guidelines Wednesday allowing indoor visits in the facilities, even among unvaccinated residents and visitors, under most circumstances.

National figures on healthcare worker infections in other settings are hard to come by, but some statewide trends look promising. In California and Arkansas, healthcare worker COVID cases have dropped faster than for the general public since December, and in Virginia the number of hospital staffers out of work for COVID-related reasons has fallen dramatically.

Research in other countries suggests that vaccines have led to big drops in infection. A study of publicly funded hospitals in England indicated that a first dose was 72% effective at preventing COVID among workers after 21 days and 86% effective seven days after the second shot. At Sheba Medical Center — Israel's largest hospital, with over 9,600 workers — 170 staff members tested positive from Dec. 19, the first day the vaccine was offered, through Jan. 24. Of those who tested positive, only three had already received both doses of the vaccine, according to The Lancet.

Along with other healthcare workers, nursing home staffers and residents were first in line to get vaccines in December because elderly people in congregate settings are among the most vulnerable to infection: More than 125,000 residents have died of COVID, CMS data shows, while over 550,000 nursing home staff members have tested positive and more than 1,600 have died.

Yet the vaccination rate among staffers is far lower than that of residents. When the first clinics ran from mid-December to mid-January, a median of 78% of nursing home residents took a dose, while the median for staff was only 38%, according to the Centers for Disease Control and Prevention. Now several nursing home associations say the rate of staff vaccination has been climbing, based on informal surveys.

While vaccines are "contributing to the observed declines in COVID-19 cases in nursing homes, other factors, like effective infection prevention and control programs/practices," are also at play, CDC spokesperson Jade Fulce said.

Vaccine uptake by nursing home residents has been "very promising," said Dr. Morgan Katz, a specialist in infectious diseases at Johns Hopkins University who is advising COVID responses in nursing homes. "I do think this is a huge contributing factor” to the drop in staff cases.

"When the immune system is activated more quickly" due to vaccination, "the virus is not able to multiply in your body and your respiratory tract," Katz said. So, having even one or two vaccinated people in a building can slow transmission.

Another factor, Katz said, is that "many nursing homes have already experienced large outbreaks — so there are probably a significant proportion of residents and staff who are already immune." Also, COVID rates have fallen nationally after a spike from holiday travel and gatherings in November and December, so staff members have less exposure in their communities.

But "even though we’re seeing a really wonderful turn in the number of cases," she said, "we need to remember that as long as the staff is 50 or 30% vaccinated, they remain vulnerable, and they’re also putting incredibly vulnerable long-term care residents at risk."

Vaccination efforts are racing against time as new COVID variants circulate and some states dramatically relax COVID restrictions, making it easier for the virus to spread.

During the second week in February, 2,850 nursing homes still reported at least one new COVID-positive test result for a staff member, CMS data shows.

When this happens, residents suffer, said Lori Smetanka, executive director of the National Consumer Voice for Quality Long-Term Care. She said she's hearing of cases in which one positive COVID test result sends a facility into lockdown, preventing families from visiting their loved ones.

‘They're Afraid’

The New Jersey Veterans Memorial Home at Menlo Park endured a major outbreak last year in which over 100 workers contracted COVID and over 60 residents and a certified nurse assistant, Monemise Romelus, died. Shirley Lewis, a union president representing CNAs and other workers, said it was traumatizing. Still, only about half of workers there have taken the vaccine, Lewis said, and one is out sick with COVID.

"A lot of my members are not too excited about taking this vaccine because they’re afraid," Lewis said.

Some workers want to wait a little longer to see how safe the vaccine is, she said. Others tell her they don't trust the vaccines because they were developed so quickly, she said.

Other staffers "feel like it’s an experimental drug," Lewis said, "because as you know, Blacks, Latinos, other groups have been used for experiments" like the Tuskegee syphilis study, she said. She said her members are mostly Black or Hispanic.

Certified nursing assistants, who make up the bulk of long-term care workers, have historically been less likely to get flu vaccines than other healthcare workers, noted Jasmine Travers, an assistant professor of nursing at New York University who studies vaccine hesitancy. Nursing homes typically don't have nurse educators, who address worker concerns about vaccines in hospitals, she said, and CNAs also face structural barriers such as limited internet access. Nursing homes tend to be hierarchies commonly led by white staffers, while about 50% of CNAs, at the bottom of the power structure, are Black or Hispanic, and carry mistrust and different attitudes toward vaccination, she added.

With the COVID vaccine, some are afraid they'll have to take sick time to miss work and don't want to burden their co-workers, who are already short-staffed, Travers said.

Vaccine hesitancy is higher among 30- to 49-year-olds, rural residents, and Black and Hispanic adults, according to KFF. Hispanic adults are less likely than white adults to say they will “definitely” get the COVID vaccine, as are Black adults who work in a healthcare setting. Black adults have been disproportionately burdened by the pandemic and left behind in the vaccination rollout because of barriers stemming from structural racism.

Deliberate Misinformation

Low vaccine uptake among long-term care workers has been a concern nationally — so much so that LeadingAge, a national group representing not-for-profit long-term care facilities, held a virtual town hall about vaccine safety this month with the Black Coalition Against COVID-19.

The event, which drew over 45,000 viewers, was geared toward Black long-term care workers.

Dr. Reed Tuckson, co-founder of the Black Coalition Against COVID-19, said viewers raised concerns about fertility, pregnancy and contraindications. He said the event also had "a lot of provocateurs" who insisted, "It’s all a myth. It’s all a lie."

His group plans to hold more public informational sessions aimed at Black audiences.

"There is no question that the three vaccines that we now have available to us are extraordinarily safe and tremendously effective," said Tuckson, a former public health commissioner in Washington, D.C.

The nursing home industry has set a goal of having 75% of staff members vaccinated nationwide by the end of June.

A Vaccine Mandate?

Most nursing homes have not mandated vaccinations, industry officials say, for fear of losing staff members. Because the vaccines were authorized on an emergency basis, liability is also a concern.

Juniper Communities, which runs 22 long-term care facilities in four states and employs almost 1,300 people, had 30 workers leave the job after it mandated vaccines, according to Dr. Lynne Katzmann, president and CEO.

"At the end of the day, if you can make a choice to promote well-being and prevent illness, that's the choice we want to make," she said.

Greenbrier Nursing and Rehabilitation Center in Arkansas made the vaccine mandatory, but because of medical exemptions it hasn't led to 100% vaccination.

However, Greenbrier has seen a significant drop in COVID infections since vaccinations began. In late November and early December, over 60% of staff members tested positive, according to Regina Jones, Greenbrier’s director of nursing. After the staff started receiving the vaccine in late December, four workers who had already received a dose tested positive but were asymptomatic.

Hesitancy Doesn't Mean Refusal

Tuckson said he's seeing a "dramatic decrease" in vaccine hesitancy based on surveys of Black audiences. He has heard "a hunger for scientifically valid information delivered to them by trusted sources," he said. "It's not as if their opinions are locked in stone."

Staff participation rates are rising with each round of vaccines, said Martino, the nursing home industry spokesperson.

At the Los Angeles Jewish Home, Chief Medical Officer Dr. Noah Marco said his staff has done "everything we could to counterbalance the nonsense out there on social media that has contributed to vaccine hesitancy," including producing videos and a weekly newsletter.

"The vaccine may have some unknown side effects," he recalled telling workers, "but we know the virus kills."

About 80% of his staff of 1,600 — which includes workers in nursing homes and other settings — are vaccinated, he said, along with 99% of residents. No nursing home residents have contracted COVID since Jan. 13, he said.

In southwestern Ohio, Kenn Daily runs two Ayden Healthcare nursing homes. About half his staff and 85% of residents got vaccinated by mid-February, he said, and they haven't had a case of COVID since. Still, he said, vaccine resistance persists among younger staffers who read misinformation online.

"Facebook is the bane of my existence," Daily said. Workers tell him they worry that "they’re going to microchip me," or that the vaccine will change their DNA.

Now that time has passed since the initial rollout, Daily said, "I’m hoping to put a little pressure on my staff to step up and get vaccinated." His message: "It’s working, guys. It’s working very well."

KHN data editor Elizabeth Lucas contributed to this report.

Melissa Bailey: @mmbaily

The 22 plaintiffs, a handful of whom were minors, filed suits from 2018 through 2020 over "BioJoint" surgeries pioneered by two university employees.

This article was published on Friday, March 12, 2021 in Kaiser Health News.

By Lauren Weber

COLUMBIA, Mo. — The University of Missouri has settled a collection of personal injury and false advertising claims over knee surgeries for $16.2 million, in what appears to be one of its largest public payouts in recent years.

The 22 plaintiffs, a handful of whom were minors, filed suits from 2018 through 2020 over "BioJoint" surgeries pioneered by two university employees, orthopedic surgeon Dr. James Stannard and veterinarian Dr. James Cook. The procedure involves a complex operation that the Mizzou BioJoint Center's website calls a "biological joint restoration," replacing parts of the knee with cadaver bones or cartilage to treat arthritis or joint damage. Some plaintiffs alleged in court documents that the procedure was sold to them as a way to avoid a traditional artificial knee replacement.

Plaintiffs alleged in court documents that Stannard did not advise plaintiffs that "the surgery he was proposing has a failure rate as high as 86%." Court documents argued the surgeries were "experimental" and "unproven" and sometimes left patients requiring follow-up surgeries and even total knee replacements, including for young patients.

The defendants denied those allegations in the court filings and the university settled the cases without admission of liability or negligence after the claims against Cook, Stannard and another employee were dismissed. The Mizzou BioJoint website says the program does not have 10-year data on effectiveness because the surgeries are "based on improvements to the traditional techniques." Unlike prescription medicines or medical devices, surgical procedures aren't directly regulated by federal or state agencies.

On Thursday, KHN obtained the settlement agreements, which were signed in February, through a public records request.

Michelle Mello, a Stanford University professor of law and medicine, said settlement amounts often reflect the public relations value to those sued as well as the value of what the plaintiffs could have gotten at trial.

"On a per capita basis, that seems like high damages, so there is something going on that's not great for the university," Mello said.

"We are pleased to resolve this litigation," Jonathan Curtright, CEO of University of Missouri Healthcare, said in a statement. "Providing safe, quality care is always our top priority, and we remain committed to excellence in restoring joint health and function for eligible patients. We are confident in the expertise and dedication of our staff and the innovative, science-based services offered by the Missouri Orthopaedic Institute and the Mizzou BioJoint program."

Stannard and Cook did not return requests for comment about the cases Thursday. Todd Hendrickson, an attorney for the plaintiffs, said the settlement agreements prohibited the lawyers and plaintiffs from speaking on the matter.

Central to the dispute in the consolidated lawsuits is how Cook was presented, given that veterinarians and veterinary surgeons are not generally allowed to perform medicine on humans. The lawsuits allege Stannard was negligent for allowing Cook to perform parts of the Mizzou BioJoint surgeries on plaintiffs "without appropriate medical direction and supervision."

Some patients allege in court documents they did not know when they underwent the procedures that Cook was not a "medical doctor or a licensed physician." In at least five of the plaintiffs' cases, court documents say Cook was sometimes listed on medical records as "surgeon — other."

And documents in one case said he was listed as a "surgeon." The defendants deny Cook was listed as a surgeon in response to that case but said he was listed as part of the surgical team. An additional filing by defendants said Cook was "orthopedic technologist — surgery certified" and that he joined the surgery team for the "majority of such surgeries performed by Dr. Stannard."

In one filing, the defending attorneys said Stannard and Cook had no obligation to tell patients that Cook was neither a medical doctor nor a licensed physician at any time prior to the operations because "surgery commonly includes persons in the operative suite who are not licensed physicians."

Many new medical techniques are tested on animals before they get to humans, so veterinarians may be involved in pioneering medical research, said Dr. Patrick McCulloch, vice chairman of Houston Methodist's orthopedic surgery department.

"It's not uncommon to have vets as part of your research team, but it would be uncommon to have them as part of your clinical patient care team," he said.

"You have to be licensed as a physician to perform surgery on a human being," added Jeff Howell, executive vice president of the Missouri State Medical Association.

Cook is known as an expert on surgery for other species. He recently performed two operations on a tiger at a Chicago-area zoo, the second after the more ambitious initial procedure did not succeed, the Chicago Tribune reported.

He holds the titles of William & Kathryn Allen distinguished chair in orthopedic surgery at the University of Missouri's medical school, chief of the school's orthopedic research division and director of operations and research for the Mizzou BioJoint Center. The state paid Cook $301,892.04 in 2020.

Stannard, one of the highest-paid University of Missouri employees other than top athletic coaches, received a state salary of $981,977.52 for 2020. Among his titles are chief medical officer for procedural services, medical director of the Missouri Orthopaedic Institute and chairman of the medical school's orthopedic surgery department. He's also a team doctor for Mizzou athletes.

Stannard's salary is nearly double that of Mun Y. Choi, president of the University of Missouri System. Missouri Gov. Mike Parson, meanwhile, earned $133,820.88 in 2020.

A university spokesperson told the St. Louis Post-Dispatch in August that Stannard had grown the Missouri Orthopaedic Institute from two surgeons to 30, and that only 2% of his salary comes from tuition dollars.

Part of the lawsuits' claims hinge on the university's advertising of the novel procedures, which had aired locally in Missouri during a Super Bowl and appeared at Chicago's O'Hare International Airport. Some of the plaintiffs alleged the extensive advertising led them to reach out to the Mizzou BioJoint Center to seek relief for their knee pain.

Such direct-to-consumer marketing of medical devices and surgery has been growing in recent years, following the success of ads for pharmaceuticals, according to McCulloch.

Still, Mello said, it is relatively uncommon for a university to advertise the availability of these techniques or products. She said the advertising claims likely allowed the plaintiffs' legal team to negotiate a higher settlement amount because of false advertising allegations in addition to the medical malpractice claims.

Lauren Weber: LaurenW@kff.org, @LaurenWeberHP

Recent studies have determined that a basic cough produces about 20 times more particles than intubation.

This article was published on Friday, March 12, 2021 in Kaiser Health News.

By Christina Jewett

Since the start of the pandemic, the most terrifying task in healthcare was thought to be when a doctor put a breathing tube down the trachea of a critically ill COVID patient.

Those performing such "aerosol-generating" procedures, often in an intensive care unit, got the best protective gear even if there wasn't enough to go around, per Centers for Disease Control and Prevention guidelines. And for anyone else working with COVID patients, until a month ago, a surgical mask was considered sufficient.

A new wave of research now shows that several of those procedures were not the most hazardous. Recent studies have determined that a basic cough produces about 20 times more particles than intubation, a procedure one doctor likened to the risk of being next to a nuclear reactor.

Other new studies show that patients with COVID simply talking or breathing, even in a well-ventilated room, could make workers sick in the CDC-sanctioned surgical masks. The studies suggest that the highest overall risk of infection was among the front-line workers — many of them workers of color — who spent the most time with patients earlier in their illness and in sub-par protective gear, not those working in the COVID ICU.

"The whole thing is upside down the way it is currently framed," said Dr. Michael Klompas, a Harvard Medical School associate professor who called aerosol-generating procedures a "misnomer" in a recent paper in the Journal of the American Medical Association.

"It's a huge mistake," he said.

The growing body of studies showing aerosol spread of COVID-19 during choir practice, on a bus, in a restaurant and at gyms have caught the eye of the public and led to widespread interest in better masks and ventilation.

Yet the topic has been highly controversial within the healthcare industry. For over a year, international and U.S. nurse union leaders have called for health workers caring for possible or confirmed COVID patients to have the highest level of protection, including N95 masks.

But a widespread group of experts have long insisted that N95s be reserved for those performing aerosol-generating procedures and that it's safe for front-line workers to care for COVID patients wearing less-protective surgical masks.

Such skepticism about general aerosol exposure within the healthcare setting have driven CDC guidelines, supported by national and California hospital associations.

The guidelines still say a worker would not be considered "exposed" to COVID-19 after caring for a sick COVID patient while wearing a surgical mask. Yet in recent months, Klompas and researchers in Israel have documented that workers using a surgical mask and face shield have caught COVID during routine patient care.

The CDC said in an email that N95 "respirators have remained preferred over facemasks when caring for patients or residents with suspected or confirmed" COVID, "but unfortunately, respirators have not always been available to healthcare personnel due to supply shortages."

New research by Harvard and Tulane scientists found that people who tend to be super-spreaders of COVID — the 20% of people who emit 80% of the tiny particles — tend to be obese or older, a population more likely to live in elder care or be hospitalized.

When highly infectious, such patients emit three times more tiny aerosol particles (about a billion a day) than younger people. A sick super-spreader who is simply breathing can pose as much or more risk to health workers as a coughing patient, said David Edwards, a Harvard faculty associate in bioengineering and an author of the study.

Chad Roy, a co-author who studied primates with COVID, said the emitted aerosols shrink in size when the monkeys are most contagious at about Day Six of infection. Those particles are more likely to hang in the air longer and are easier to inhale deep into the lungs, said Roy, a professor of microbiology and immunology at Tulane University School of Medicine.

The study clarifies the grave risks faced by nursing home workers, of whom more than 546,000 have gotten COVID and 1,590 have died, per reports nursing homes filed to the Centers for Medicare & Medicaid since mid-May.

Taken together, the research suggests that healthcare workplace exposure was "much bigger" than what the CDC defined when it prioritized protecting those doing "aerosol-generating" procedures, said Dr. Donald Milton, who reviewed the studies but was not involved in any of them.

"The upshot is that it's inhalation" of tiny airborne particles that leads to infection, said Milton, a professor at the University of Maryland School of Public Health who studies how respiratory viruses are spread, "which means loose-fitting surgical masks are not sufficient."

On Feb. 10, the CDC updated its guidance to healthcare workers, deleting a suggestion that wearing a surgical mask while caring for COVID patients was acceptable and urging workers to wear an N95 or a "well-fitting face mask," which could include a snug cloth mask over a looser surgical mask.

Yet the update came after most of at least 3,500 U.S. healthcare workers had already died of COVID, as documented by KHN and The Guardian in the Lost on the Frontline project.

The project is more comprehensive than any U.S. government tally of health worker fatalities. Current CDC data shows 1,391 healthcare worker deaths, which is 200 fewer than the total staff COVID deaths nursing homes report to Medicare.

More than half of the deceased workers whose occupation was known were nurses or in healthcare support roles. Such staffers often have the most extensive patient contact, tending to their IVs and turning them in hospital beds; brushing their hair and sponge-bathing them in nursing homes. Many of them — 2 in 3 — were workers of color.

Two anesthetists in the United Kingdom — doctors who perform intubations in the ICU — saw data showing that non-ICU workers were dying at outsize rates and began to question the notion that "aerosol-generating" procedures were the riskiest.

Dr. Tim Cook, an anesthetist with the Royal United Hospitals Bath, said the guidelines singling out those procedures were based on research from the first SARS outbreak in 2003. That framework includes a widely cited 2012 study that warned that those earlier studies were "very low" quality and said there was a "significant research gap" that needed to be filled.

But the research never took place before COVID-19 emerged, Cook said, and key differences emerged between SARS and COVID-19. In the first SARS outbreak, patients were most contagious at the moment they arrived at a hospital needing intubation. Yet for this pandemic, he said, studies in early summer began to show that peak contagion occurred days earlier.

Cook and his colleagues dove in and discovered in October that the dreaded practice of intubation emitted about 20 times fewer aerosols than a cough, said Dr. Jules Brown, a U.K. anesthetist and another author of the study. Extubation, also considered an "aerosol-generating" procedure, generated slightly more aerosols but only because patients sometimes cough when the tube is removed.

Since then, researchers in Scotland and Australia have validated those findings in a paper pre-published on Feb. 10, showing that two other aerosol-generating procedures were not as hazardous as talking, heavy breathing or coughing.

Brown said initial supply shortages of PPE led to rationing and steered the best respiratory protection to anesthetists and intensivists like himself. Now that it is known emergency room and nursing home workers are also at extreme risk, he said, he can't understand why the old guidelines largely stand.

"It was all a big house of cards," he said. "The foundation was shaky and in my mind it's all fallen down."

Asked about the research, a CDC spokesperson said via email: "We are encouraged by the publication of new studies aiming to address this issue and better identify which procedures in healthcare settings may be aerosol generating. As studies accumulate and findings are replicated, CDC will update its list of which procedures are considered [aerosol-generating procedures]."

Cook also found that doctors who perform intubations and work in the ICU were at lower risk than those who worked on general medical floors and encountered patients at earlier stages of the disease.

In Israel, doctors at a children's hospital documented viral spread from the mother of a 3-year-old patient to six staff members, although everyone was masked and distanced. The mother was pre-symptomatic and the authors said in the Jan. 27 study that the case is possible "evidence of airborne transmission."

Klompas, of Harvard, made a similar finding after he led an in-depth investigation into a September outbreak among patients and staff at Brigham and Women's Hospital in Boston.

There, a patient who was tested for COVID two days in a row — with negative results — wound up developing the virus and infecting numerous staff members and patients. Among them were two patient care technicians who treated the patient while wearing surgical masks and face shields. Klompas and his team used genome sequencing to connect the sick workers and patients to the same outbreak.

CDC guidelines don't consider caring for a COVID patient in a surgical mask to be a source of "exposure," so the technicians' cases and others might have been dismissed as not work-related.

The guidelines' heavy focus on the hazards of "aerosol-generating" procedures has meant that hospital administrators assumed that those in the ICU got sick at work and those working elsewhere were exposed in the community, said Tyler Kissinger, an organizer with the National Union of Healthcare Workers in Northern California.

"What plays out there is there is this disparity in whose exposures get taken seriously," he said. "A phlebotomist or environmental services worker or nursing assistant who had patient contact — just wearing a surgical mask and not an N95 — weren't being treated as having been exposed. They had to keep coming to work."

Dr. Claire Rezba, an anesthesiologist, has scoured the web and tweeted out the accounts of healthcare workers who've died of COVID for nearly a year. Many were workers of color. And fortunately, she said, she's finding far fewer cases now that many workers have gotten the vaccine.

"I think it's pretty obvious that we did a very poor job of recommending adequate PPE standards for all healthcare workers," she said. "I think we missed the boat."

California Healthline politics correspondent Samantha Young contributed to this report.

Christina Jewett: ChristinaJ@kff.org, @by_cjewett