Two-thirds of deceased healthcare workers for whom the Lost on the Frontline project has data identified as people of color.

This article was published on Thursday, April 8, 2021 in Kaiser Health News.

By Jane Spencer, The Guardian and Christina Jewett

More than 3,600 U.S. healthcare workers perished in the first year of the pandemic, according to "Lost on the Frontline," a 12-month investigation by The Guardian and KHN to track such deaths.

Lost on the Frontline is the most complete accounting of U.S. healthcare worker deaths. The federal government has not comprehensively tracked this data. But calls are mounting for the Biden administration to undertake a count as the KHN/Guardian project comes to a close today.

The project, which tracked who died and why, provides a window into the workings — and failings — of the U.S. health system during the COVID-19 pandemic. One key finding: Two-thirds of deceased healthcare workers for whom the project has data identified as people of color, revealing the deep inequities tied to race, ethnicity and economic status in America's healthcare workforce. Lower-paid workers who handled everyday patient care, including nurses, support staff and nursing home employees, were far more likely to die in the pandemic than physicians were.

The yearlong series of investigative reports found that many of these deaths could have been prevented. Widespread shortages of masks and other personal protective gear, a lack of COVID testing, weak contact tracing, inconsistent mask guidance by politicians, missteps by employers and lax enforcement of workplace safety rules by government regulators all contributed to the increased risk faced by healthcare workers. Studies show that healthcare workers were more than three times as likely to contract COVID as the general public.

"We rightfully refer to these people without hyperbole — that they are true heroes and heroines," said Dr. Anthony Fauci in an exclusive interview with The Guardian and KHN. The COVID deaths of so many are "a reflection of what healthcare workers have done historically, by putting themselves in harm's way, by living up to the oath they take when they become physicians and nurses," he said.

Lost on the Frontline launched last April with the story of Frank Gabrin, the first known American emergency room doctor to die of COVID-19. In the early days of the pandemic, Gabrin, 60, was on the front lines of the surge, treating COVID patients in New York and New Jersey. Yet, like so many others, he was working without proper personal protective equipment, known as PPE. "Don't have any PPE that has not been used," he texted a friend. "No N95 masks — my own goggles — my own face shield."

Gabrin's untimely death was the first fatality entered into the Lost on the Frontline database. His story of working through a crisis to save lives shared similarities with the thousands that followed.

Maritza Beniquez, an emergency room nurse at Newark's University Hospital in New Jersey, watched 11 colleagues die in the early months of the pandemic. Like the patients they had been treating, most were Black and Latino. "It literally decimated our staff," she said.

Her hospital has placed 11 trees in the lobby, one for each employee who has died of COVID; they have been adorned with remembrances and gifts from their colleagues.

More than 100 journalists contributed to the project in an effort to record every death and memorialize those who died. The project's journalists filed public records requests, cross-connected governmental and private data sources, scoured obituaries and social media posts, and confirmed deaths through family members, workplaces and colleagues.

Among its key findings:

• More than half of those who died were younger than 60. In the general population, the median age of death from COVID is 78. Yet among healthcare workers in the database, it is only 59.
   
• More than a third of the healthcare workers who died were born outside the United States. Those from the Philippines accounted for a disproportionate number of deaths.
   
• Nurses and support staff members died in far higher numbers than physicians.
   
• Twice as many workers died in nursing homes as in hospitals. Only 30% of deaths were among hospital workers, and relatively few were employed by well-funded academic medical centers. The rest worked in less prestigious residential facilities, outpatient clinics, hospices and prisons, among other places.

The death rate among healthcare workers has slowed dramatically since COVID vaccines were made available to them in December. A study published in late March found that only four of 8,121 fully vaccinated employees at the University of Texas Southwestern Medical Center in Dallas became infected. But deaths lag behind infections, and KHN and The Guardian have tracked more than 400 healthcare worker deaths since the vaccine rollout began.

Many factors contributed to the high toll — but investigative reporting uncovered some consistent problems that heightened the risks faced by health workers.

The project found that Centers for Disease Control and Prevention guidance on masks — which encouraged hospitals to reserve high-performance N95 masks for intubation procedures and initially suggested surgical masks were adequate for everyday patient care — may have put thousands of health workers at risk.

The investigation exposed how the Labor Department, run by Donald Trump appointee Eugene Scalia in the early part of the pandemic, took a hands-off approach to workplace safety. It identified 4,100 safety complaints filed by healthcare workers to the Occupational Safety and Health Administration, the Labor Department's workplace safety agency. Most were about PPE shortages, yet even after some complaints were investigated and closed by regulators, workers continued to die at the facilities in question.

The reporting also found that healthcare employers were failing to report worker deaths to OSHA. The data analysis found that more than a third of workplace COVID deaths were not reported to regulators.

Among the most visceral findings of Lost on the Frontline was the devastating impact of PPE shortages.

Adeline Fagan, a 28-year-old OB-GYN resident in Texas, suffered from asthma and had a long history of respiratory ailments. Months into the pandemic, her family said, she was using the same N95 mask over and over, even during a high-risk rotation in the emergency room.

Her parents blame both the hospital administration and government missteps for the PPE shortages that may have contributed to Adeline's death in September. Her mother, Mary Jane Abt-Fagan, said Adeline's N95 had been reused so many times the fibers were beginning to disintegrate.

Not long before she fell ill — and after she'd been assigned to a high-risk ER rotation — Adeline talked to her parents about whether she should spend her own money on an expensive N95 with a filter that could be changed daily. The $79 mask was a significant expense on her $52,000 resident's salary.

"We said, you buy this mask, you buy the filters, your father and I will pay for it. We didn't care what it cost," said Abt-Fagan.

She never had the opportunity to use it. By the time the mask arrived, Adeline was already on a ventilator in the hospital.

Adeline's family feels let down by the U.S. government's response to the pandemic.

"Nobody chooses to go to work and die," said Abt-Fagan. "We need to be more prepared, and the government needs to be more responsible in terms of keeping healthcare workers safe."

Adeline's father, Brant Fagan, wants the government to begin tracking healthcare worker deaths and examining the data to understand what went wrong. "That's how we're going to prevent this in the future," he said. "Know the data, follow where the science leads."

Adeline's parents said her death has been particularly painful because of her youth — and all the life milestones she never had the chance to experience. "Falling in love, buying a home, sharing your family and your life with your siblings," said Mary Jane Abt-Fagan. "It's all those things she missed that break a parent's heart."

Christina Jewett: ChristinaJ@kff.org, @by_cjewett

California's overall progress masks huge variations in senior vaccination rates among the state's 58 counties, which largely are running their own vaccine rollouts with different eligibility rules and outreach protocols.

This article was published on Wednesday, April 7, 2021 in Kaiser Health News.

By Jenny Gold

Even as California prepares to expand vaccine eligibility on April 15 to all residents age 16 and up, the state has managed to inoculate only about half its senior population — the 65-and-older target group deemed most vulnerable to death and serious illness in the pandemic.

Overall, nearly 56% of California seniors have received the full course of a COVID vaccine, according to the latest data from the federal Centers for Disease Control and Prevention. That's about average compared with other states — not nearly as high as places like South Dakota, where almost 74% of seniors are fully vaccinated, but also not as far behind as Hawaii, which has reached 44%. The data, current as of Tuesday, does not include seniors who have received only the first dose of the Pfizer-BioNTech or Moderna vaccine.

But California's overall progress masks huge variations in senior vaccination rates among the state's 58 counties, which largely are running their own vaccine rollouts with different eligibility rules and outreach protocols. The discrepancies notably break down by geographic region, with the state's remote rural counties — generally conservative strongholds — in some cases struggling to give away available doses, while the more populous — and generally left-leaning — metropolitan areas often have far more demand than supply.

In San Francisco Bay Area counties like Marin and Contra Costa, for example, more than two-thirds of seniors are fully vaccinated. Meanwhile, in the far northern reaches of the state, encompassing some of California's most dramatic and rugged terrain, rural counties like Tehama, Shasta and Del Norte have fully vaccinated only about a third of senior residents, according to the CDC data.

"We definitely share one thing in common and that is that we have a fairly high percentage of people who are vaccine hesitant. And that even spreads into the seniors," Dr. Warren Rehwaldt, health officer for Del Norte County, said of the Northern California counties with relatively low vaccination rates. Del Norte, which is 62% white and voted solidly for Donald Trump in the 2020 election, has vaccinated 36.6% of residents age 65 and older.

The county, population 28,000, has spotty internet service, leaving the health department reliant on phone appointments for its twice-weekly clinics, which have the capacity to give out 300 doses in a day.Bottom of Form

"I don't think we have filled any of them completely, and they are tapering off," Rehwaldt said. Often, 100 or more appointment slots go unused, even after the county expanded eligibility to age 50 and up. "We expected that, but we didn't expect it this fast," he said.

Every Thursday morning, Rehwaldt joins a local public radio broadcast to encourage people to get their shots, and the department regularly airs public service announcements. "But it's a really high hurdle to overcome serious misgivings about the vaccine itself," Rehwaldt said.

Asked what resources might help bolster vaccination rates, Rehwaldt said he'd opt for a mobile van to travel to remote areas of his county. But moments later, he sighed and said he wasn't sure a van would help much after all. "What kind of resources are going to overcome hesitancy? It's not a resource problem," he said.

Shasta County, whose population is about 80% white and voted in even stronger numbers for Trump, is also struggling to reach the 65-plus group, with just 36.6% of seniors fully vaccinated. Public information officer Kerri Schuette acknowledged health workers were encountering some hesitancy among residents but said their efforts also were hampered by early supply issues.

On the other end of the spectrum are counties like Marin, a largely suburban and affluent stretch of communities just north of San Francisco where 71.4% of seniors are fully vaccinated.

"There's a thread of privilege that does lead to ease of access to vaccines that needs to be acknowledged," said county public health officer Dr. Matt Willis. Many seniors in the county have access to computers and cars, he said, and have been able to access vaccine appointments with relative ease.

Still, the county made an aggressive plan to vaccinate seniors even before the first doses arrived, he said. Rather than waiting for the federal government's program that relied on pharmacies to vaccinate residents in long-term care facilities, for example, the health department sent in workers as soon as it had vaccines.

The county also kept its eligibility rules tightly focused on seniors age 75 and older through the middle of February, while other counties were expanding to younger age groups and a broad array of occupations. At one point, the county briefly expanded eligibility to teachers, but pulled back just one week later when doses grew scarce.

"We showed that a dose offered to someone 75 and older in Marin was 320 times more likely to save a life than a dose offered to someone younger than 50," Willis said.

Contra Costa County, a more diverse area on the other side of San Francisco Bay, has done nearly as well: 70.9% of seniors are fully vaccinated. Add in those who have received at least one dose, and the numbers are far higher: 90% of people ages 65-74 and 97% of those 75 and older, according to the county's vaccine tracker.

To reach vulnerable seniors, Dr. Ori Tzvieli, Contra Costa's deputy health officer, said the county worked with nonprofit groups to make lists of residential care facilities and low-income senior housing, then sent mobile clinics to each one. "For people who were literally homebound, we send someone inside. Otherwise, we set up a station in the lobby or right outside," he said.

The county also set up mobile clinics at farms and places of worship. It gave community health workers dedicated appointments to sign up older residents directly. And rather than have residents track down their own appointment slots online, the department had people fill out forms and then scheduled appointments for them, prioritizing those who lived in low-income ZIP codes with high rates of disease.

With a population of just over 1 million, Contra Costa now is able to vaccinate 100,000 people a week, Tzvieli said, and has recently opened eligibility to everyone over 16. But even within the county, inequalities remain. In Bay Point, for example, a largely working-class Latino community, vaccination rates are still just half of those of some wealthier communities, Tzvieli said.

Farther south, in California's agricultural Central Valley, Fresno County falls somewhere in the middle on vaccination rates. About 54% of seniors 65-plus are fully vaccinated, just under the state average. Just more than half the county's residents are Latino, many of them farmworkers. And about a fifth of the population lives in poverty, which presents its own hurdles to a vaccination campaign.

"Poverty immobilizes, physically and mentally," said Joe Prado, community health division manager in Fresno County. "For a wealthier population, going 3 to 5 miles away [to a vaccine clinic] is simple; you hop in the car and go. But if you're living in poverty, that's a big barrier."

There are community pockets that have not engaged with the county health system, meaning health officials are coming up against vaccine hesitancy and distrust, Prado added. "Our health literacy is nowhere near where it should be, and now there's a digital literacy problem, too," he said. "We're trying to deal with all this in the middle of a pandemic."

At this point in the campaign, Prado said, most seniors eager for the vaccine have received at least an initial dose: "The final 25% is going to be the most resource-intensive, the most difficult to reach."

Dr. William Schaffner, an infectious-disease specialist at Vanderbilt University, calls this public health's "low-hanging fruit phenomenon." As the proportion of people who are vaccinated grows, he said, "we'll have to work proportionally harder to keep advancing these numbers, because the eager beavers go first." In rural counties from California to Tennessee, he added, supply is already outpacing demand.

So far, just more than 75% of seniors in the U.S. have received at least one dose of vaccine, according to the CDC.

"You can look at that as the glass is half-empty or half-full," said Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota, during a recent episode of his weekly podcast. That still leaves more than 13 million seniors unprotected despite facing the highest risk of death; 8 in 10 deaths from COVID reported in the U.S. have been among adults 65 and older.

It is crucial, Osterholm said, that states continue to direct efforts toward reaching and vaccinating vulnerable seniors who are homebound or hesitant.

"When we say we're going to open up eligibility to everybody 16 or 18 years and older, that seems like a victory," he said. "In many states, that is an admission of defeat."

Jenny Gold: jgold@kff.org, @JennyAGold

Some music-streaming platforms like Apple Music don't allow third-party playlist curation. So, without a direct connection to their editorial team or partners, landing a spot on these lists isn't likely. 

This article was published on Tuesday, April 6, 2021 in Kaiser Health News.

By Chaseedaw Giles

When the pandemic hit, Debórah Bond, like many artists, was caught off guard. “I thought I’d be juggling gigs and touring,” said the independent R&B/soul musician.

A full-time artist, Bond, 44, made a living through a patchwork of vocal gigs — performing live at weddings, bars and theaters, recording jingles, teaching vocal lessons and hosting events.

But the coronavirus pandemic found her burning through her savings and struggling to make ends meet in a tiny rental accessory dwelling unit above the tree-lined garage of a home in Hyattsville, Maryland. According to a 2020 report from the Rand Corp., artists were more likely than others to have lost their main source of income — music-related or not — due to the pandemic.

So with few other obvious options, and the world at a standstill for the foreseeable future, she set out to write her first solo album in the small rental she fondly referred to as her “treehouse.”

But cut off from family, friends and other nearby musicians, she devised a way to bring together out-of-work musicians from around the world, people who felt just as abandoned and stuck as she did. What resulted is an extraordinary transnational album — “compass: I,” released March 5 — that connected her with a far broader musical community and buoyed their collective spirits during a year of isolation.

The new album is a pandemic-fueled collaboration of musicians such as Chelsey Green, PhD. a violinist and acting chair of the strings department at Berklee College of Music in Boston; two-time Grammy-nominated drummer Nate Smith in Nashville; and a percussionist from the British acid jazz band Incognito, who sent in his recordings from London. “Everyone jumped on board from wherever they were,” Bond said. And most, she said, “didn’t even stress me for money. We all wanted to create.” She was even able to work with Gordon Chambers, a songwriter who has written for several artists from Beyoncé to Anita Baker and likely would not have been accessible to her or available pre-pandemic.

They were up against the challenges of not just a pandemic, but also a music industry that has come to rely heavily on curated playlists like Apple Music’s “New Music” or “From Our Editors” to promote new releases. Mainstream artists who have released music during the pandemic have teams of industry professionals ensuring their tunes end up on the most highly trafficked playlists.

Some music-streaming platforms like Apple Music don’t allow third-party playlist curation. So, without a direct connection to their editorial team or partners, landing a spot on these lists isn’t likely. Without being able to perform live at clubs and events this past year, Bond says, some independent artists may feel financial pressure to focus less on the quality of their music and more on finding ways to go viral on social media to tip the scales.

How does an independent artist find new listeners at a time when performing for a crowd isn’t allowed, and they’re battling against more than 50 million and 60 million songs already on Spotify and Apple Music, respectively?

Bond was not naïve about how the music world works, having been a performer for decades. She and her band, Third Logic, had been performing together since they were in their early 20s, but as time passed and adulthood — marriage, children, increased work responsibilities — set in, finding the time to write music together became nearly impossible. They hadn’t released a new album since “Madam Palindrome” in 2011. Time and distance from her bandmates meant that gigs were few. So, in 2019, she decided to embark on a solo career. Then covid hit.

At first, she despaired about how she would be able to pay for things like rent and food without the hope of recurring live gigs. “The pandemic relief money was really helpful,” she said, because independent artists can sometimes go weeks without making any money even without a global pandemic. Between her stimulus check and unemployment, Bond budgeted $600 a week to live on. She had affordable health insurance through Kaiser Permanente, “thanks to Obamacare,” she said. She cut expenses, stuck to her budget and received modest payments from booking a few covid-friendly, livestreamed events for Washington, D.C.’s Kennedy Center and the Music Center at Strathmore in North Bethesda, Maryland.

She was able to improvise a home-recording studio with mics, speakers, her MacBook and ProTools software and the help of music engineering friends over video conferences. Bond writes song lyrics and performs but doesn’t herself compose music. So, she put out a call to the musicians in her network and found many of them were also at home tinkering with new tunes and willing to share. Bond would “wait until late at night, turn on colored bulbs, blast things through my monitors and write,” she said.

After a rough draft of the album was completed in September, she and independent producer Brandon Lane put out a broader call for help for more live instrumentation. Their pleas circulated and produced a village of talent, as musicians from all over the world sent the singer their high-quality home recordings. “It showed me how many musicians were in the same boat,” Bond said.

Lane, who lived nearby and became part of Bond’s pandemic bubble, would come to her home studio — fully masked-up — as technical support and to co-produce the album. The title “compass: I” reflects an appreciation of the importance of trusting your own internal compass, she explained. The project showed Bond “who has my back,” she said, and that in a time of global crisis musicians — many of whom Bond considers friends — would come together to co-create with her.

Bond, who describes herself as having an eclectic Bohemian style and devil-may-care attitude, said she doesn’t want to change herself to jockey for a spot on the Billboard charts or playlists — even in the post-pandemic world.

The music industry is notoriously youth-obsessed and male-dominated, she said. The third annual report on the industry, “Inclusion in the Recording Studio?” from professor Stacy Smith and the USC Annenberg Inclusion Initiative found that in evaluating gender across eight years of Grammy nominations for Record of the Year, Album of the Year, Song of the Year, Producer of the Year and Best New Artist, 21.7% — or about 1 in 5 artists — were women.

“This is who the f*** I am,” she said. “I’m not 18, but I’m not ‘old’ either.” She wants listeners to have the chance to discover diverse musical options for female entertainers, at different ages, with different sounds and styles to match. By dint of necessity, the pandemic opened new types of doors for performers like her — through which she hopes new types of music will continue to be heard.

“You have to be smart,” she said. “It’s not hard to find new music.” Manually searching streaming apps like SoundCloud and Spotify take no more effort than scrolling through Instagram, she said. Bond hopes that listeners will take a break from the algorithms that sneakily sway our musical interests toward those artists pushed to the top of the charts and follow their own compass.

Without definitive data, concerns arose that returning to play too soon could expose thousands of athletes to serious cardiac complications.

This article was published on Tuesday, April 6, 2021 in Kaiser Health News.

By Markian Hawryluk

For sports fans across the country, the resumption of the regular sports calendar has signaled another step toward post-pandemic normality. But for the athletes participating in professional, collegiate, high school or even recreational sports, significant unanswered questions remain about the aftereffects of a COVID infection.

Chief among those is whether the coronavirus can damage their hearts, putting them at risk for lifelong complications and death. Preliminary data from early in the pandemic suggested that as many as 1 in 5 people with COVID-19 could end up with heart inflammation, known as myocarditis, which has been linked to abnormal heart rhythms and sudden cardiac death.

Screening studies conducted by college athletic programs over the past year have generally found lower numbers. But these studies have been too small to provide an accurate measure of how likely athletes are to develop heart problems after COVID, and how serious those heart issues may be.

Without definitive data, concerns arose that returning to play too soon could expose thousands of athletes to serious cardiac complications. On the other hand, if concerns proved overblown, the testing protocols could unfairly keep athletes out of competition and subject them to needless testing and treatment.

"The last thing we want is to miss people that we potentially could have detected, and have that result in bad outcomes — in particular, the sudden death of a young athlete," said Dr. Matthew Martinez, director of sports cardiology at Atlantic Health's Morristown Medical Center in New Jersey and an adviser to several professional sports leagues. "But we also need to look at the flip side and the potential negatives of overtesting."

With millions of Americans playing high school, college, professional or master's level sports, even a low rate of complications could result in significant numbers of affected athletes. And that could prompt a thorny discussion of how to balance the risk of a small percentage of players who could be in danger against the continuation of sports competition as we know it.

Limited Impact on Pro Sports

Data released from professional sports leagues in early March provided at least some reassurance that the problem may not be as great as initially feared. Pro athletes playing football, men's and women's basketball, baseball, soccer and hockey were screened for heart problems before returning from COVID infections. The players underwent an electrical test of their heart rhythms, a blood test that checks for heart damage and an ultrasound exam of their hearts. Out of 789 athletes screened, 30 showed some cardiac abnormality in those initial tests and were referred for a cardiac MRI to provide a better picture of their heart. Five of those, less than 1% of athletes screened, showed inflammation of the heart that sidelined them for the remainder of their seasons.

The researchers compiling the data did not name the players, although some have disclosed their own diagnoses. Boston Red Sox pitcher Eduardo Rodríguez returned to the mound this spring after missing the 2020 season following his COVID and myocarditis diagnoses. Similarly, Buffalo Bills tight end Tommy Sweeney was close to returning from a foot injury when he was diagnosed with myocarditis in November.

In the college ranks, many assumed Keyontae Johnson — a 21-year-old forward on the University of Florida men's basketball team who collapsed on the court in December, months after contracting COVID — might have developed myocarditis. The Gainesville Sun reported that month he had been diagnosed with myocarditis, but his family issued a statement in February saying the incident was not COVID-related and declined to release additional details.

Consequences Still Unclear

Doctors still don't know how significant those MRI findings of myocarditis may be for athletes. Tests looking for rare medical events often generate more false positives than true positives. And without comparing the results with those of athletes who didn't have COVID, it is hard to determine what changes to attribute to the virus — or what may just be an effect of athletic training or other causes.

Training significantly changes athletes' hearts, and what might look concerning in another patient could be perfectly normal for an elite athlete. Many endurance athletes, for example, have larger than average left ventricles and pump out a lower percentage of blood with each contraction. That would be a warning sign for patients who aren't highly trained athletes.

"You can definitely have what we call the gray zone, where extreme forms of athletic cardiac remodeling can actually look a little bit like pathology," said Dr. Jonathan Kim, a sports cardiologist at Emory University in Atlanta. "COVID has introduced a new challenge to this. Is it because they're a cross-country runner or is it because they just had COVID?"

Moreover, myocarditis is generally diagnosed based on symptoms — chest pain, shortness of breath, heart muscle weakness or electrical dysfunction — and then confirmed by MRI. It isn't clear whether MRI findings that look like myocarditis in the absence of those symptoms are just as concerning.

"They have normal physical exams. They have normal cardiograms. Nothing else is going on," said Dr. Robert Bonow, a cardiologist at Northwestern University and editor of JAMA Cardiology. "But when you order an MRI as part of a research study, you start seeing very subtle changes, because the MRI is very sensitive."

Were they finding "abnormalities" simply because they were looking? Even in patients who die of COVID, the rate of myocarditis is very low, Bonow said.

"So what's going on with the athletes? Is it something related to the fact that they had an infection, or is it something which is very nonspecific, related to COVID but not damage to the heart?" he said. "There's still a great deal of uncertainty."

Sports cardiologists involved in the pro sports data collection and in writing screening guidelines for athletes said the fact that players were able to resume their seasons without serious heart complications suggests the initial concern was overblown. Of the players who had mild or asymptomatic cases of COVID, none was ultimately found to have myocarditis, and none experienced ongoing heart complications through 2020. Many completed their 2020 season and have already started their next one.

"We overcalled it," Martinez said. "It shows what our guidelines reflected: The prevalence of cardiac disease in this condition is unusual in the athletic population."

Falling Through the Cracks

Those screening guidelines, published by a group of leading sports cardiologists in October, call for cardiac tests only for athletes with moderate or severe COVID symptoms. Athletes with asymptomatic cases or those with mild symptoms that have gone away can return to play without the additional testing. The National Federation of State High School Associations and the American Medical Society for Sports Medicine have put out similar guidelines for high school athletes.

But that approach would not flag players such as Demi Washington.

Washington, a 19-year old sophomore on Vanderbilt's women's basketball team, had a rather mild case of COVID. She had shared a meal with two teammates, one of whom later turned out to be infected. Seven days into a two-week quarantine in a hotel off campus, Washington also tested positive, and had to isolate with a stuffy nose for an additional 10 days. She waited for her symptoms to get worse, but they never did.

"It felt like allergies," she said.

But when her symptoms cleared and she returned to practice, the university required her to undergo several tests to ensure the virus had not affected her heart. The initial tests raised no concerns. An MRI, though, showed acute myocarditis.

Her season was over, but, more importantly, Washington, an athlete in prime physical condition, faced the possibility of losing her life. She learned about Hank Gathers, a 23-year-old Loyola Marymount basketball star who collapsed during a game in 1990 and died within hours. His autopsy confirmed an enlarged heart and myocarditis.

"That really put me on the edge of my seat," Washington said. "I was like, 'OK, I have to take this seriously, because I don't want to end up like that.'"

For months, she had to keep her heart rate under 110 beats per minute. Before, she ran 5 miles a day. With the myocarditis diagnosis, she had to wear a heart monitor, and even a brisk walk could push her above that threshold.

"One time I was walking to the gym and I might have been walking a little fast," Washington recalled. "My chest got really, really tight."

By mid-January, however, another MRI showed the inflammation had cleared, and she has since resumed working out.

"I'm so grateful that Vanderbilt does the MRI, because without it, there's no telling what could have happened," she said.

She wondered how many other athletes have been playing with myocarditis and didn't know it.

Cases like Washington's raise questions about how aggressively to screen. Her condition was found only because Vanderbilt took a much more conservative approach than that recommended by current guidelines: It screened all athletes with cardiac MRIs after they had COVID, regardless of the severity of their symptoms or their initial cardiac tests.

Of the 59 athletes screened post-COVID, the university found two with signs of myocarditis. That's just over 3%.

"Is the current rate of myocarditis that we're seeing high enough to warrant ongoing cardiovascular screening?" asked Dr. Daniel Clark, a Vanderbilt sports cardiologist and lead author of an analysis of the school's screening efforts. "Five percent is too much to ignore, in my opinion, but what is our societal threshold for not screening highly competitive athletes for myocarditis?"

Even though myocarditis is rare, studies have found that nonCOVID-related myocarditis causes up to 9% of sudden cardiac deaths among athletes, said Dr. Jonathan Drezner, director of the University of Washington Medicine Center for Sports Cardiology, who advises the NCAA on cardiac issues. Thus COVID adds a new risk. The NCAA alone reports more than 480,000 athletes. To provide a sense of scale: If all of them got COVID and even 1% were at risk of heart problems, that's 4,800 athletes.

Waiting for More Data

Doctors are now waiting for the release of data pooled from thousands of college athletes screened after having COVID last year. The American Heart Association and the American Medical Society for Sports Medicine have created a national registry to track COVID cases and heart disease in NCAA athletes, with more than 3,000 athletes enrolled, while the Big Ten conference is running its own registry.

That registry data may eventually help parse who is most at risk for heart complications, target who needs to be screened and improve the reliability of the tests. Doctors may discover that some symptoms are better indicators of risk than others. And down the road, genetic testing or other types of tests could identify who is most vulnerable.

But will smaller schools have the resources and know-how to screen all their athletes?

"How about all the junior colleges, all the Division III programs, the Division II programs?" Martinez said. "A lot of them are saying, 'Look, forget it. If we have do all this extra testing, we can't do it.'"

He said the new pro sports data should reassure those colleges and even high schools, because the vast majority of young, healthy athletes who contract COVID generally have mild or asymptomatic infections, and won't need further testing.

The same guidelines apply to recreational athletes. Those with mild or asymptomatic COVID can slowly resume exercising once their symptoms resolve without much concern. Those with moderate or severe cases should talk to their doctors before returning to sports.

Concerns for Small Schools

Large, wealthy universities like Vanderbilt have cutting-edge medical facilities with the resources and expertise to properly interpret cardiac MRIs. Smaller schools could struggle to get their athletes screened.

"There's only a small number of centers around the country that have the true expertise to be able to effectively do cardiac MRIs on athletes," said Dr. Dermot Phelan, a sports cardiologist with Atrium Health in Charlotte, North Carolina. "And the reality is that those systems are already stretched trying to deal with normal clinical data. If we were to add a huge population of athletes on top of that, I think we would stretch the medical system significantly."

Some schools with limited resources for testing could decide to bench athletes recovering from moderate or severe COVID rather than risk a devastating event. Others could allow athletes to resume playing once they've recovered, and then monitor them for signs of cardiac complications. Many NCAA schools added automated external defibrillators after Gathers' death in case an athlete collapses during a game or practice.

"You think about all the 100,000 high school athletes out there whose parents are concerned: Do they even have access to anyone who knows something about this? On the other hand, they're younger people who don't get really sick with COVID," said Dr. James Udelson, a cardiologist with Tufts Medical Center in Boston. "There's a concern about how much we don't know."

Legal Issues

Some schools may also worry about the liability of allowing players to return after a COVID infection if they can't get the proper cardiac screening.

"No matter what precautions a college or university takes in that regard, they can always be sued," said Richard Giller, an attorney with the Pillsbury Winthrop Shaw Pittman law firm in Los Angeles. "The real question is, do they have liability? I think that's going to depend on a number of factors, not the least of which is who recommended that student athletes who contracted COVID-19 return to play."

He recommends that colleges not rely solely on doctors affiliated with the university but have student athletes see their own private physicians to make return-to-play decisions. Teams may also ask players to sign waivers to the effect that if they return to play after a COVID infection, they might face cardiac complications.

Some colleges asked students to sign waivers absolving the school if a player contracted COVID. But the NCAA ruled that schools couldn't make those waivers a requirement to play.

Doctors don't know what might happen over the long run. With barely a year's worth of experience with COVID, it's not clear whether the myocarditis seen on MRIs will resolve quickly, or whether there might be lingering effects that cause complications years later.

That leaves many concerned about what we still don't know about COVID and the athlete's heart, as well as the handful of cases that might elude detection.

"You can take a cohort of athletes and put them through every single cardiac test and come out the other end, and one of them will die someday," Phelan said. "The reality is there's nothing we can do to be 100% guaranteed."

ESPN's Paula Lavigne and Mark Schlabach contributed to this report.

Markian Hawryluk: MarkianH@kff.org, @MarkianHawryluk