The new standard would require employers to remove workers who have covid-19 from the workplace, notify workers of covid exposure at work and strengthen requirements for employers to report worker deaths or hospitalizations to the Occupational Safety and Health Administration.

“These are the workers who continue to go into work day in and day out to take care of us, to save our lives,” said Jim Frederick, acting assistant secretary of Labor for occupational safety and health. “And we must make sure we do everything in our power to return the favor to protect them.”

set to take effect immediately after publication in the Federal Register and are expected to affect about 10.3 million health care workers nationwide.

The government’s statement of reasons for the new the work of KHN and The Guardian in tallying health care worker covid deaths . Journalists documented far more deaths than the limited count by the Centers for Disease Control and Prevention, which through May tallied 1,611 deaths on case-reporting forms that were often incomplete.

The project documented for better respiratory protection for health care workers than loose-fitting face masks, noted serious complaints to OSHA from hospital workers that and revealed repeated employer failures of worker deaths. It also found that health care employers were in notifying workers about exposure to the coronavirus on the job.

The new standard would address some of those problems.

The rules require workers to wear N95 or elastomeric respirators when in contact with people with either suspected or confirmed covid. They strengthen employer record-keeping requirements, saying employers must document all worker covid cases (regardless of whether they were deemed work-related) and report work-related deaths even if they occur more than 30 days after exposure.

Until now, employers were required to report a hospitalization only if it came within 24 hours of a workplace exposure. Now all work-related covid hospitalizations must be reported. The rules also mandate notification about exposure to a sick colleague, patient or customer if the worker was not wearing a respirator.

There is a lot to like about the new rule ― except for the timing, according to Barbara Rosen, vice president of the Health Professionals and Allied Employees union in New Jersey.

“It’s a little late,” she said. “If we had had this in place at the beginning, it would have saved a lot of lives and a lot of suffering that has gone on with health care workers and probably patients in hospitals because of the spread.”

She said she was pleased with the requirement that workers be paid when they isolate with covid and that employers formulate a detailed covid plan with the input of non-managers.

The day after he took office, President Joe Biden issued an calling on OSHA to “take swift action to reduce the risk that workers may contract COVID-19 in the workplace.” The rule has been for coming late — about which Labor Department officials said on a press call that such standards typically take years, not months, to formulate. It has also been derided for failing to enact requirements on employers outside of health care.

“OSHA’s failure to issue a COVID-specific standard in other high-risk industries, like meat and poultry processing, corrections, homeless shelters and retail establishments is disappointing,” according to a statement from David Michaels, a former OSHA administrator and professor with the George Washington University School of Public Health. “If exposure is not controlled in these workplaces, they will continue to be important drivers of infections.”

The new rule also cites 67,000 worker complaints during the pandemic, with “more complaints about healthcare settings than any other industry.” The rule would protect workers from retaliation for staying home when sick with covid, alerting their employer about a covid hazard or exercising their rights under the emergency rule.

Through March 7, about half of health care workers said they had received at least their first dose of a covid vaccine, according to a . About one-third of those polled said they were unsure if they would get a vaccine. The issue has been controversial, especially in Houston, where workers staged a protest over their employer’s vaccine mandate.

The new rules exempt some office-based health care workplaces where all staff members are vaccinated and measures are taken to screen people with potential illness. The rule summary estimates the measures will prevent 776 deaths and 295,000 infections.

The new rule also will “enable OSHA to issue more meaningful penalties for willful or egregious violations, thus facilitating better enforcement and more effective deterrence against employers who intentionally disregard … employee safety.”

Kristin Carbone said the measure came too late for her mother, Barbara Birchenough, 65, a New Jersey hospital nurse who’d asked family members to gather gardening gloves and trash bags to serve as makeshift personal protective equipment before she fell ill and later died on April 15, 2020. Still, she said, it’s a necessary step.

“If there is a silver lining,” she said, “I’m glad that out of this tragedy come positives for the people that are left behind.”

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Senior KHN correspondent Christina Jewett spoke on Thursday with NPR’s “Morning Edition” and the PBS NewsHour about the yearlong project, “Lost on the Frontline,” in which KHN and The Guardian counted and profiled health care workers who have died of covid-19.

• Read “12 Months of Trauma: More Than 3,600 US Health Workers Died in Covid’s First Year” by Jewett and The Guardian’s Jane Spencer

Midwest correspondent Lauren Weber joined WAMU’s “1A” to discuss vaccination rates on April 2.

• Read Weber’s reporting on the covid-19 vaccine

Colorado correspondent Rae Ellen Bichell spoke with KUNC’s “Colorado Edition” about Durango’s covid cowboys enforcing mask mandates on April 1.

• Read Bichell’s “Durango’s Covid ‘Cowboy’ Rounds Up Spring Break Scofflaws, Lines ’Em Up for Shots”

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These health care workers were profiled in KHN and The Guardian’s yearlong “” project.

Dr. Reza Chowdhury was a with a private practice in the Bronx and a trusted voice in New York’s Bengali community. His daughter, Nikita Rahman, said that despite underlying health issues putting him at higher risk of developing covid complications, he saw patients through mid-March last year, when he developed symptoms. He died on April 9, 2020.

Nikita Rahman, Reza Chowdhury’s daughter:

My therapist says grief is the final act of love. Every time I miss him, I think about how that is my love for him, showing up again. I like that framing of it. I think I only recently realized just how much I loved him.

He was so beloved by the community for just being a general practitioner who did his job really well and cared and was honest. He was so present and could find life and enjoyment in the little things, like taking a walk. He loved his breakfast, even if it was the same breakfast every day.

In March, I flew home from California to be with my family. I was reading about covid cases spiking in Italy and was freaking out. My mom and I tried to convince my dad, who was immunocompromised, to stay home from work. He said: “No, it’s not a big deal.”

Then in mid- to late March he started to feel sick. At that time, everyone was so worried about hospitals being over capacity that the [guidance] was not to come in unless you’re insanely sick. We eventually took him to the hospital. He was there for about 10 days and then he had a heart attack.

I’ll sometimes visit my dad’s grave by myself and bring tea, because my dad always drank tea, and read letters my friends have written over the past year. He was into growing nice grass, so whenever [my mother, brother and I] go, we bring nice grass to make sure his plot is nicely manicured. He told really good stories. I would do anything for audio recordings of him telling stories. Now I’ve started recording conversations with family members.

When someone dies, the world carries on. You’ll take a walk and you’re so upset, but people around you may be laughing or carrying on with their lives. You want the world to reflect how you feel inside. You want it to rain. Because of the pandemic, everyone’s kind of miserable. Everyone’s at home, having to process a lot. It has been nice, in a way, to be forced to sit down and process it. There’s no running away from confronting your feelings.

Nueva Parazo was a and one of scores of health care workers from the Philippines who have died of covid-19. Her father, Chito Parazo, described her as a skilled and compassionate nurse and doting daughter. She died on Sept. 5, 2020.

Chito Parazo, Nueva Parazo Singian’s father:

It’s true, life has to go on, but it will never be the same. I’m 70 years old. I have maybe 10, 15 years left. Maybe less. Of course, I’m happy I’m still alive, but for me, we’re just going through the motions of living. We lost our 9-year-old son, Xerxes, years ago in an accident and I still cannot accept the fact that he died. My children were the priceless jewels in my life, and I lost both of them.

During the early days of the pandemic, I asked [Nueva] to file a leave of absence. She said, “I cannot just turn my back on these helpless people. This is the job that I chose.”

Her youngest son brought her to the hospital on Aug. 3 because she was complaining about difficulty breathing. She probably suspected that she had contracted the virus. When my wife was admitted to the same hospital in December with covid, the staff remembered Nueva. They said: “We tried to save her, Mr. Parazo, but we couldn’t. Her lungs were so badly damaged.”

I’m so proud of her. She did her best to save people despite all the dangers she faced.

I shaved my head after Nueva died and made a vow to let it grow after the first anniversary of her death. I’ve been taking medication to combat my depression. Despite the fact that I have psoriatic arthritis in both of my knees, a bone spur in my left foot and spinal stenosis, I still go bowling to forget what happened. It’s hard, but I have to be strong for the sake of my three grandkids and my wife.

Jessica Cavazos was a , and the family member everyone turned to for sage advice and a dose of optimism. Cavazos had not seen her son, Jayden Arrington, since 2013. After she died on July 12, 2020, Arrington, 19, reunited with her family.

Jayden Arrington, Jessica Cavazos’ son:

I called her Mamo. There were some family issues that kept me from having more time with her, and that is hard for me to live with. I hadn’t seen her since I was 10. When I was 17, I called her and we spoke for two or three hours, and I assumed after I turned 18 I’d start seeing her again. She passed without having her own son with her.

Some days I can’t function or accept that some people’s expiration dates are not what you want them to be.

I’ve learned that God’s not going to give it to you how you want it. He’s going to give it to you in a way to see how you’re going to bounce back. I’ve grown over the last several months. I’ve learned how to control my feelings, and be more open to what’s given to me in life. And also be more thankful for what I have.

I see things a little differently since [my mom died]. I try to find ways where every day is a good day, where I don’t regret anything or have a negative effect on anyone. I try to keep people around me who I know can help me get through my days.

Sometime this month, I’m hoping to receive an acceptance letter [to a nursing program]. I want to become a registered nurse, just like Mamo.

These conversations have been condensed and edited.

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“We rightfully refer to these people without hyperbole — that they are true heroes and heroines,” he said in an exclusive interview with The Guardian. The deaths of so many health workers from covid-19 are “a reflection of what health care workers have done historically, but putting themselves in harm’s way by living up to the oath they take when they become physicians and nurses,” said Fauci.

KHN and The Guardian have tracked health care workers’ deaths throughout the pandemic in the “. More than 3,600 health worker deaths have been tallied in the database, considered the most authoritative accounting in the country.

Personal protective equipment — including gloves, gowns and critical masks — have been in short supply since the pandemic began and heightened the toll. The U.S. is the importer of PPE, which made it especially vulnerable to the demand shock and export restrictions that hit the global market last spring.

“During the critical times when there were shortages was when people had to use whatever was available to them,” said Fauci. “I’m sure that increased the risk of getting infected among health care providers.”

Shortages were compounded by the federal government’s failure to maintain a national stockpile of personal protective equipment, and the Trump administration’s refusal to order more domestic manufacturing of PPE. That left health workers to use trash bags as gowns, reuse N95s for weeks and, at times, go totally without gloves.

The shortages led to protests by health workers, who said working amid the pandemic without equipment left them like “.” , a nurse at an assisted living facility, was forced to wear a trash bag at times, according to her daughter, and later died. A year into the pandemic, gowns and gloves remain in short supply, according to the .

Nearly in the covid pandemic, with many more experiencing long-term symptoms of covid.

Health workers have been especially vulnerable through the pandemic, as they have treated patients through early waves when the lack of personal protective equipment was especially acute, through summer surges and a disastrous peak in the winter.

A study of health workers in the U.S. and the United Kingdom in found health workers are three times more likely than the general public to become infected with the covid virus, with disproportionate impacts on minority health workers.

“It’s very clear when you just go to the media and see the images on television — the stress and the strain on the faces of health care providers, nurses, doctors, other people involved in the health care enterprise,” said Fauci.

Nevertheless, the U.S. government has failed to systematically count health worker deaths. Members of Congress, the Health and Human Services Department and academic reports The Guardian and KHN’s reporting as the most comprehensive. A growing chorus of policy experts and unions have called for a comprehensive count of health worker deaths.

“We certainly want to find an accurate count of the people who die,” said Fauci, without noting when the government should undertake such an effort. “Certainly, that’s something I think would fall under the auspices of the federal government.”

Even as the vaccine rollout picks up speed, health workers continue to be imperiled. More than between the time the rollout began and late February. Infections among vaccinated health workers have steeply declined, but because deaths are a lagging indicator of the spread of covid, some health workers will have been sickened before widespread vaccination.

At the same time, immunity to coronaviruses generally wanes over time and variants may blunt the efficacy of some vaccines. A global shortage of vaccines means dozens of poor nations have not inoculated a single person. Advocates argue this has led to a global “,” which will contribute to the continued emergence of variants. Both scenarios could imperil health workers anew and necessitate a new round of adult mass vaccination.

Studies into the duration of immunity for vaccines, and variants’ impact on vaccines, are ongoing. “If we’re going to need to do boosting with a variant-specific boost, [we] will be prepared for it because we’re already doing a study,” Fauci said, with such research taking place at the National Institute of Allergy and Infectious Diseases, which he leads. Even so, “it looks like our ability to protect against variants with the standard vaccine might be better than we anticipated.”

Regardless of how future vaccination campaigns play out, Fauci said, U.S. policymakers should learn from what has transpired over the past year.

“We better make sure the lesson we will learn is that we will never again be in a situation where people who are putting their health and their safety on the line don’t have the appropriate equipment to protect themselves safely,” he said.

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Health policy experts and union leaders are pressing the White House to move quickly to fill the gaping hole left by the Trump administration through its failure to create an accurate count of covid deaths among front-line workers. The absence of reliable federal data exacerbated critical problems such as shortages of personal protective equipment that left many workers exposed, with fatal results.

In the absence of federal action, “Lost on the Frontline,” a between The Guardian and KHN, has compiled the most comprehensive account of health care worker deaths in the nation. It has recorded 3,607 lost lives in the first year of the pandemic, with nurses, health care support staffers and doctors, as well as workers under 60 and people of color, affected in tragically high numbers.

The Guardian/KHN investigation, which involved more than 100 reporters, is drawing to a close this week. Pressure is now growing for the federal government to step into the breach.

Harvey Fineberg, a leading health policy expert who approved a recent that cited the “Frontline” project and recommended the formation of a national tracking system run by the federal government, backed the calls for change. He said his ideal solution would be a nationwide record.

“There would be a combination of a selective look backward to gain more accurate tabulations of the past burden, and a system of data-gathering looking forward to ensure more complete counts in [the] future,” he said.

Zenei Triunfo-Cortez, a president of National Nurses United, the largest body of registered nurses in the U.S., said it was unconscionable how many health care workers have died of covid-19. The found that almost a third of those who died were nurses — the largest single occupation — followed by support staff members (20%) and physicians (17%).

Triunfo-Cortez said the death toll was an unacceptable tragedy aggravated by the lack of federal data, which made identifying problem areas more difficult. “We as nurses do not deserve this — we signed up to take care of patients, we did not sign up to die,” she said.

Dr. Anthony Fauci, the nation’s top expert on infectious diseases, also sees a role for federal agencies in tracking mortality among front-line health care workers. In an interview with The Guardian, he expressed a desire for a definitive picture of the human toll.

“We certainly want to find an accurate count of the people who died,” he said. “That’s something that I think would fall under the auspices of the federal government, likely Health and Human Services.”

The lack of federal intelligence on deaths among front-line health care workers was one of the running failures of the Trump administration’s to the crisis. The main health protection agency, the Centers for Disease Control and Prevention, does curate some information but has itself acknowledged that its own record of — more than 2,000 fewer than the joint Guardian/KHN tally — is an undercount based on limitations in its data collection.

Overall, health care workers were revealed to be singularly at risk from the pandemic. Some studies have shown they were more than three times as likely to contract covid as was the general population.

To date, there is no sign of the Biden administration taking active steps to set up a comprehensive data system. An HHS spokesperson said the department has no plans to launch a comprehensive count. However, Triunfo-Cortez said there is a new willingness on the part of the White House and key federal agencies to listen and engage.

“We have been working with the Biden administration and they have been receptive to the changes we are proposing,” Triunfo-Cortez said. “We are hopeful that they will start to mandate the reporting of deaths, because if we don’t have that data how can we know how effective we are being in stopping the pandemic?”

The responsiveness of the new administration is likely to be heightened by the fact that Biden’s chief of staff, Ron Klain, has a track record in fighting infectious disease outbreaks. In 2014, President Barack Obama appointed him

In an last August, Klain drew on the findings of “Lost on the Frontline” to decry the ultimate price paid by health care workers: “Although America has applauded health workers, banged pots in their honor and offered grateful video tributes, we have consistently failed them where it mattered most.”

David Blumenthal, the national coordinator for health information technology under Obama, said a national tracking system is an important step in healing the wounds of the pandemic. “So many health care workers feel as though their devotion and sacrifice weren’t valued,” he said. “We must combat the widespread fatigue and disappointment.”

KHN senior correspondent Christina Jewett contributed to this report.

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Lost on the Frontline is the most complete accounting of U.S. health care worker deaths. The federal government has not comprehensively tracked this data. But 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 health care 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 health care 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 health care workers. Studies show that health care 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 . The covid deaths of so many are “a reflection of what health care 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 , 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, 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 health care workers in the database, it is only 59.
• More than a third of the health care 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 health care workers has slowed dramatically since covid vaccines were made available to them in December. A 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 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 filed by health care 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 health care employers were 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.

, 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 health care workers safe.”

Adeline’s father, Brant Fagan, wants the government to begin tracking health care 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.”

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Journalists from KHN and The Guardian have identified 3,607 workers who reportedly died of complications from covid-19 after they contracted it on the job. Reporters are working to confirm the cause of death and workplace conditions in each case. They are also writing about the people behind the statistics — their personalities, passions and quirks — and telling the story of every life lost.

Explore the  tracking those health worker deaths.

(Note: The previous total announced by The Guardian and KHN was approximately 1,450 health care worker deaths. The new number reflects the inclusion of data reported by nursing homes and health facilities to the federal and state governments. These deaths include the facility names but not worker names. Reporters cross-checked each record to ensure fatalities did not appear in the database twice.)

• Read more investigative stories

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She was not yet 13 when the Khmer Rouge seized power in Cambodia and ripped her family apart. The totalitarian regime sent her and four siblings to work camps, where they planted rice and dug irrigation canals from sunrise to sunset — each surviving on two ladles of rice gruel a day. One disappeared, never to be found.

Just a few months before the Khmer Rouge fell in January 1979, Lim’s father starved to death, among the nearly of Cambodians who perished from execution, forced labor, starvation or disease in less than four years.

For Lim, the indelible stamp of childhood anguish drove two of her life’s passions: serving people as a physician and cooking lavish feasts for friends and family — both of which she did until she died of covid-19 in January.

Within the week before her death at age 58, she treated dozens of patients who flooded the hospital during the deadly winter covid surge, while bringing home-cooked meals to the hospital for her fellow health care workers to enjoy during breaks.

“These experiences during the war made her humble and empathetic toward the people around her,” said Dr. Vidushi Sharma, who worked with Lim at Community Regional Medical Center in Fresno, California. “She always wanted to help them.”

Lim’s story is one of suffering and triumph.

During the Khmer Rouge’s brutal reign and the Cambodian civil war before it, Lim and her nine siblings attended school sporadically. The ravages of war forced the family first from its small town to the capital, Phnom Penh, and then into the countryside when the Khmer Rouge took power in 1975. As part of its vision to create a , the communist group split families and relocated residents to rural labor camps.

Lim survived the work camps because she was smart and resourceful, said her youngest brother, Rithy Lim, who also lives in Fresno. She dug ditches, hauled clay-like dirt on her back, built earthen dams in the middle of a river during monsoons — all with little food or rest, he said.

She also became a skillful hunter and fisher, and learned to identify plants that were safe to eat.

“You cannot imagine the horrible conditions,” he said. “Think of it as a place that you live like wild animals, and people tell you to work. There’s no paper, no pens. You sleep on the ground. We witnessed death of all sorts.”

Vietnamese troops liberated Cambodia from the Khmer Rouge in 1979. Later that year, Lim, her mother and siblings sneaked into Thailand. “The whole family walked through minefields,” Rithy Lim recalled. There, they waited and worked in refugee camps. At one camp, they met a dentist from California’s Central Valley who was on a medical mission.

When Lim and her family arrived in the U.S. in 1982, they landed in Georgia. But she and an older brother soon moved to the small town of Taft, California, about 45 minutes west of Bakersfield, at the invitation of the dentist they’d befriended at the Thai refugee camp.

When she hit the ground, the 4-foot-11 dynamo, then 19, was driven by “pure determination,” Rithy Lim said.

Within two years, Linath Lim learned English, earned her GED and graduated from Taft College — “boom, boom, boom,” her brother recalled. (She learned to make traditional, middle-America Thanksgiving dinners when she worked at the community college’s cafeteria, which she would later cook for scores of friends and family.)

She went on to attend Fresno State and then the Medical College of Pennsylvania, sleeping on friends’ couches, borrowing money from other Cambodian refugees and scraping by.

“Imagine not having any money, studying alone, sleeping in someone else’s living room,” Rithy Lim said.

Lim became an internal medicine doctor “because she always wanted to be really involved with a lot of patients,” Rithy Lim said. After her residency, she returned to the Central Valley to practice in hospitals and clinics in underserved communities, including Porterville and Stockton, where some of her patients were farmworkers and Cambodian refugees.

California has the largest Cambodian population in the country, with roughly 89,000 people of Cambodian descent in 2019, according to a Public Policy Institute of California analysis of data.

Twice, Lim joined the on weeklong volunteer trips to Cambodia, where she and other doctors treated hundreds of patients a day, said Dr. Song Tan, a Long Beach, California, pediatrician and founder of CHPAA.

“She was a kindhearted, very gentle person,” recalled Tan, who said he was the only member of his family to survive the Khmer Rouge. “She went beyond the call of duty to do special things for patients.”

Most recently, Lim worked the swing shift, 1 p.m. to 1 a.m., at Community Regional Medical Center. She admitted patients through the emergency room, where she was exposed to countless people with covid. She worked extra shifts during the pandemic, volunteering when the hospital was short-staffed, said Dr. Nahlla Dolle, an internist who also worked with Lim.

“She told me there were so many patients every day, and that they didn’t have enough beds and the patients had to wait in the hallway,” Tan said.

Colleagues said she was aware of the risks but loved her job. Lim, who was single and didn’t have kids, drew happiness from celebrating others’ joys. After getting home from work in the small hours, she slept for a bit, then got up to cook. Her specialties were Cambodian, Thai, Vietnamese and Italian food. She sometimes ordered a whole roasted pig that she transported to the hospital. Her memorable Thanksgiving dinners served 70 or more people.

“For any occasion that comes up — if it’s a birthday, if it’s a baby shower, if it’s Thanksgiving — she would cook, she would order food and bring everybody together,” Dolle said. “She loved to feed people because she experienced famine and lack of food.”

The week before she died, Lim cooked for her colleagues almost every day, and threw a baby shower for Sharma, complete with chicken calzones and blueberry cake.

“Every day, we were having lunch together,” Sharma said. “She did the shower, and then she’s gone.”

Lim, who had health problems including diabetes, had not been vaccinated.  Family and friends had urged her to take care of herself, and to check her blood sugar and take her medications. “She would care about everyone but herself,” Sharma said.

On Jan. 15, Lim told friends by phone that she was exhausted, achy and having trouble breathing. But she said that she would be fine, that she just needed to rest. Then she stopped responding to calls and texts.

When she didn’t show up for work a few days later, her brother went to check on her at home and found her on the couch, where she had died.

Now her brother and colleagues are haunted by what-ifs over the loss of a remarkable woman and doctor: What if I had checked on her sooner? What if she had been vaccinated? What if she had gotten care when she started feeling ill?

“To have someone who has been through all that in her childhood and then flourish as a physician, a human being, coming to a new country, learning English, going to school and college without having much financial support, it’s phenomenal,” Sharma said. “It’s unbelievable.”

This story is part of “Lost on the Frontline,” a project from  and Kaiser Health News that aims to document the lives of health care workers in the U.S. who die from COVID-19, and to investigate why so many are victims of the disease.

This story was produced by , which publishes , an editorially independent service of the .

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Espinoza died at age 36 of covid-19, just days after he got his first dose of a covid vaccine. He was a hospice nurse who put his life in danger to help covid patients and others have a peaceful death.

When covid hit, it was no surprise to his family that this “gentle giant,” as friends and family called him, stepped up to the plate.

“His attitude was like, ‘No, I’m not going to be scared,’” said Nancy Espinoza, his wife of 10 years. “This is our time to shine,” he told her. “I became a nurse for a reason.”

As a hospice nurse and chief nursing officer for Calstro Hospice in Montclair, California, Espinoza routinely made house calls, visited assisted living facilities and performed death visits — during which hospice nurses pronounce patients dead.

Hospice workers aren’t just doctors and nurses, but also include home health aides, social workers, chaplains and counselors. In the past year, they have frequented some of the highest-risk environments, such as nursing homes, assisted living facilities and patients’ homes.

Hospice requires intimate patient care, and the additional safety requirements and need for personal protective equipment made it challenging, said Alicia Murray, board president of the . But hospice workers adapted, she said, knowing they might be the only people who could comfort dying patients when family members were not allowed to visit medical and long-term care facilities.

“They’re taking care of dying people and, in particular, people dying of covid who may be spewing out the virus,” said Dr. Karl Steinberg, a geriatrician and palliative care specialist who is the medical director of Hospice by the Sea in Solana Beach, California, and several nursing homes.

A few months into the pandemic, when Calstro Hospice began caring for covid patients, Espinoza helped develop a covid unit. Part of his job was to make sure staff members had sufficient personal protective gear, including himself.

“Some people had a hard time getting a hold of all the PPE gear, but his office had adequate equipment,” his wife said. Right before he got sick, he was excited to receive a big shipment of gowns, N95 masks, booties and face shields from San Bernardino County, she said.

Espinoza fell ill a few days after his first dose of covid vaccine on Jan. 5, but went to work thinking it was vaccine-related. “He had kind of a sore throat and felt a little bit under the weather, but nothing major,” said Nancy Espinoza. His symptoms progressed to a fever and chills and he tested positive for covid on Jan. 10.

Seven other Calstro Hospice staff members also got covid during the pandemic, said Jennifer Arrington, Calstro Hospice’s director of patient care services.

Espinoza was a victim of bad timing, according to Dr. Lucy Horton, infectious disease specialist and associate professor at the University of California-San Diego School of Medicine.

The virus’s incubation period averages five to seven days, she explained. “If you test positive a few days after the vaccine, chances are you actually got exposed before you even got your first dose,” she said.

Horton said people aren’t fully vaccinated until at least 14 days after their second dose of a two-dose vaccine, or their first dose of a one-dose version. Early after the first dose, people don’t reap the benefit of the vaccine yet, she said.

“Even after you’re fully vaccinated, there still is a remaining risk,” said Horton, co-author of a letter to about post-vaccination infection rates among health care workers in California. “Even if it’s so much lower, it’s still present.”

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Espinoza knew he wanted to care for others and go into health care since he was in high school, and realized the Hispanic community needed Latino nurses in hospice care, his wife said. “He made it his purpose to help the Hispanic community understand hospice care and not be afraid of it,” she said.

On Jan. 15, Nancy Espinoza and the couple’s toddler, Ezekiel, spoke to Antonio over the phone for the last time. “I love you” were the last words she heard her husband say.

She was allowed to visit him right before he died on Jan. 25. He was intubated with an oxygen level of 25%.

Nancy Espinoza stood in the room alone with her husband for the last time. “I just wanted to be able to hold his hand and pray for him,” she said. “I wanted him to know that he wasn’t alone.”

This story is part of “,” an ongoing project from  and Kaiser Health News that aims to document the lives of health care workers in the U.S. who die from COVID-19, and to investigate why so many are victims of the disease.

This story was produced by , which publishes , an editorially independent service of the .

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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 Health Care 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  Wednesday allowing indoor visits in the facilities, even among unvaccinated residents and visitors, under most circumstances.

National figures on health care worker infections in other settings are hard to come by, but some statewide trends look promising. In California and Arkansas, health care 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 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,

, a yearlong data and reporting project by KHN and The Guardian, is investigating over 3,500 covid deaths of U.S. health care workers. The monthly number has been declining since December, but deaths often lag weeks or months behind infections.

Along with other health care 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 , 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, , 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 to get flu vaccines than other health care 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 . Hispanic adults are to say they will “definitely” get the covid vaccine, as are . Black adults have been 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 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 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.

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The new standard would require employers to remove workers who have covid-19 from the workplace, notify workers of covid exposure at work and strengthen requirements for employers to report worker deaths or hospitalizations to the Occupational Safety and Health Administration.

“These are the workers who continue to go into work day in and day out to take care of us, to save our lives,” said Jim Frederick, acting assistant secretary of Labor for occupational safety and health. “And we must make sure we do everything in our power to return the favor to protect them.”

set to take effect immediately after publication in the Federal Register and are expected to affect about 10.3 million health care workers nationwide.

The government’s statement of reasons for the new the work of KHN and The Guardian in tallying health care worker covid deaths . Journalists documented far more deaths than the limited count by the Centers for Disease Control and Prevention, which through May tallied 1,611 deaths on case-reporting forms that were often incomplete.

The project documented for better respiratory protection for health care workers than loose-fitting face masks, noted serious complaints to OSHA from hospital workers that and revealed repeated employer failures of worker deaths. It also found that health care employers were in notifying workers about exposure to the coronavirus on the job.

The new standard would address some of those problems.

The rules require workers to wear N95 or elastomeric respirators when in contact with people with either suspected or confirmed covid. They strengthen employer record-keeping requirements, saying employers must document all worker covid cases (regardless of whether they were deemed work-related) and report work-related deaths even if they occur more than 30 days after exposure.

Until now, employers were required to report a hospitalization only if it came within 24 hours of a workplace exposure. Now all work-related covid hospitalizations must be reported. The rules also mandate notification about exposure to a sick colleague, patient or customer if the worker was not wearing a respirator.

There is a lot to like about the new rule ― except for the timing, according to Barbara Rosen, vice president of the Health Professionals and Allied Employees union in New Jersey.

“It’s a little late,” she said. “If we had had this in place at the beginning, it would have saved a lot of lives and a lot of suffering that has gone on with health care workers and probably patients in hospitals because of the spread.”

She said she was pleased with the requirement that workers be paid when they isolate with covid and that employers formulate a detailed covid plan with the input of non-managers.

The day after he took office, President Joe Biden issued an calling on OSHA to “take swift action to reduce the risk that workers may contract COVID-19 in the workplace.” The rule has been for coming late — about which Labor Department officials said on a press call that such standards typically take years, not months, to formulate. It has also been derided for failing to enact requirements on employers outside of health care.

“OSHA’s failure to issue a COVID-specific standard in other high-risk industries, like meat and poultry processing, corrections, homeless shelters and retail establishments is disappointing,” according to a statement from David Michaels, a former OSHA administrator and professor with the George Washington University School of Public Health. “If exposure is not controlled in these workplaces, they will continue to be important drivers of infections.”

The new rule also cites 67,000 worker complaints during the pandemic, with “more complaints about healthcare settings than any other industry.” The rule would protect workers from retaliation for staying home when sick with covid, alerting their employer about a covid hazard or exercising their rights under the emergency rule.

Through March 7, about half of health care workers said they had received at least their first dose of a covid vaccine, according to a . About one-third of those polled said they were unsure if they would get a vaccine. The issue has been controversial, especially in Houston, where workers staged a protest over their employer’s vaccine mandate.

The new rules exempt some office-based health care workplaces where all staff members are vaccinated and measures are taken to screen people with potential illness. The rule summary estimates the measures will prevent 776 deaths and 295,000 infections.

The new rule also will “enable OSHA to issue more meaningful penalties for willful or egregious violations, thus facilitating better enforcement and more effective deterrence against employers who intentionally disregard … employee safety.”

Kristin Carbone said the measure came too late for her mother, Barbara Birchenough, 65, a New Jersey hospital nurse who’d asked family members to gather gardening gloves and trash bags to serve as makeshift personal protective equipment before she fell ill and later died on April 15, 2020. Still, she said, it’s a necessary step.

“If there is a silver lining,” she said, “I’m glad that out of this tragedy come positives for the people that are left behind.”

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Senior KHN correspondent Christina Jewett spoke on Thursday with NPR’s “Morning Edition” and the PBS NewsHour about the yearlong project, “Lost on the Frontline,” in which KHN and The Guardian counted and profiled health care workers who have died of covid-19.

• Read “12 Months of Trauma: More Than 3,600 US Health Workers Died in Covid’s First Year” by Jewett and The Guardian’s Jane Spencer

Midwest correspondent Lauren Weber joined WAMU’s “1A” to discuss vaccination rates on April 2.

• Read Weber’s reporting on the covid-19 vaccine

Colorado correspondent Rae Ellen Bichell spoke with KUNC’s “Colorado Edition” about Durango’s covid cowboys enforcing mask mandates on April 1.

• Read Bichell’s “Durango’s Covid ‘Cowboy’ Rounds Up Spring Break Scofflaws, Lines ’Em Up for Shots”

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These health care workers were profiled in KHN and The Guardian’s yearlong “” project.

Dr. Reza Chowdhury was a with a private practice in the Bronx and a trusted voice in New York’s Bengali community. His daughter, Nikita Rahman, said that despite underlying health issues putting him at higher risk of developing covid complications, he saw patients through mid-March last year, when he developed symptoms. He died on April 9, 2020.

Nikita Rahman, Reza Chowdhury’s daughter:

My therapist says grief is the final act of love. Every time I miss him, I think about how that is my love for him, showing up again. I like that framing of it. I think I only recently realized just how much I loved him.

He was so beloved by the community for just being a general practitioner who did his job really well and cared and was honest. He was so present and could find life and enjoyment in the little things, like taking a walk. He loved his breakfast, even if it was the same breakfast every day.

In March, I flew home from California to be with my family. I was reading about covid cases spiking in Italy and was freaking out. My mom and I tried to convince my dad, who was immunocompromised, to stay home from work. He said: “No, it’s not a big deal.”

Then in mid- to late March he started to feel sick. At that time, everyone was so worried about hospitals being over capacity that the [guidance] was not to come in unless you’re insanely sick. We eventually took him to the hospital. He was there for about 10 days and then he had a heart attack.

I’ll sometimes visit my dad’s grave by myself and bring tea, because my dad always drank tea, and read letters my friends have written over the past year. He was into growing nice grass, so whenever [my mother, brother and I] go, we bring nice grass to make sure his plot is nicely manicured. He told really good stories. I would do anything for audio recordings of him telling stories. Now I’ve started recording conversations with family members.

When someone dies, the world carries on. You’ll take a walk and you’re so upset, but people around you may be laughing or carrying on with their lives. You want the world to reflect how you feel inside. You want it to rain. Because of the pandemic, everyone’s kind of miserable. Everyone’s at home, having to process a lot. It has been nice, in a way, to be forced to sit down and process it. There’s no running away from confronting your feelings.

Nueva Parazo was a and one of scores of health care workers from the Philippines who have died of covid-19. Her father, Chito Parazo, described her as a skilled and compassionate nurse and doting daughter. She died on Sept. 5, 2020.

Chito Parazo, Nueva Parazo Singian’s father:

It’s true, life has to go on, but it will never be the same. I’m 70 years old. I have maybe 10, 15 years left. Maybe less. Of course, I’m happy I’m still alive, but for me, we’re just going through the motions of living. We lost our 9-year-old son, Xerxes, years ago in an accident and I still cannot accept the fact that he died. My children were the priceless jewels in my life, and I lost both of them.

During the early days of the pandemic, I asked [Nueva] to file a leave of absence. She said, “I cannot just turn my back on these helpless people. This is the job that I chose.”

Her youngest son brought her to the hospital on Aug. 3 because she was complaining about difficulty breathing. She probably suspected that she had contracted the virus. When my wife was admitted to the same hospital in December with covid, the staff remembered Nueva. They said: “We tried to save her, Mr. Parazo, but we couldn’t. Her lungs were so badly damaged.”

I’m so proud of her. She did her best to save people despite all the dangers she faced.

I shaved my head after Nueva died and made a vow to let it grow after the first anniversary of her death. I’ve been taking medication to combat my depression. Despite the fact that I have psoriatic arthritis in both of my knees, a bone spur in my left foot and spinal stenosis, I still go bowling to forget what happened. It’s hard, but I have to be strong for the sake of my three grandkids and my wife.

Jessica Cavazos was a , and the family member everyone turned to for sage advice and a dose of optimism. Cavazos had not seen her son, Jayden Arrington, since 2013. After she died on July 12, 2020, Arrington, 19, reunited with her family.

Jayden Arrington, Jessica Cavazos’ son:

I called her Mamo. There were some family issues that kept me from having more time with her, and that is hard for me to live with. I hadn’t seen her since I was 10. When I was 17, I called her and we spoke for two or three hours, and I assumed after I turned 18 I’d start seeing her again. She passed without having her own son with her.

Some days I can’t function or accept that some people’s expiration dates are not what you want them to be.

I’ve learned that God’s not going to give it to you how you want it. He’s going to give it to you in a way to see how you’re going to bounce back. I’ve grown over the last several months. I’ve learned how to control my feelings, and be more open to what’s given to me in life. And also be more thankful for what I have.

I see things a little differently since [my mom died]. I try to find ways where every day is a good day, where I don’t regret anything or have a negative effect on anyone. I try to keep people around me who I know can help me get through my days.

Sometime this month, I’m hoping to receive an acceptance letter [to a nursing program]. I want to become a registered nurse, just like Mamo.

These conversations have been condensed and edited.

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“We rightfully refer to these people without hyperbole — that they are true heroes and heroines,” he said in an exclusive interview with The Guardian. The deaths of so many health workers from covid-19 are “a reflection of what health care workers have done historically, but putting themselves in harm’s way by living up to the oath they take when they become physicians and nurses,” said Fauci.

KHN and The Guardian have tracked health care workers’ deaths throughout the pandemic in the “. More than 3,600 health worker deaths have been tallied in the database, considered the most authoritative accounting in the country.

Personal protective equipment — including gloves, gowns and critical masks — have been in short supply since the pandemic began and heightened the toll. The U.S. is the importer of PPE, which made it especially vulnerable to the demand shock and export restrictions that hit the global market last spring.

“During the critical times when there were shortages was when people had to use whatever was available to them,” said Fauci. “I’m sure that increased the risk of getting infected among health care providers.”

Shortages were compounded by the federal government’s failure to maintain a national stockpile of personal protective equipment, and the Trump administration’s refusal to order more domestic manufacturing of PPE. That left health workers to use trash bags as gowns, reuse N95s for weeks and, at times, go totally without gloves.

The shortages led to protests by health workers, who said working amid the pandemic without equipment left them like “.” , a nurse at an assisted living facility, was forced to wear a trash bag at times, according to her daughter, and later died. A year into the pandemic, gowns and gloves remain in short supply, according to the .

Nearly in the covid pandemic, with many more experiencing long-term symptoms of covid.

Health workers have been especially vulnerable through the pandemic, as they have treated patients through early waves when the lack of personal protective equipment was especially acute, through summer surges and a disastrous peak in the winter.

A study of health workers in the U.S. and the United Kingdom in found health workers are three times more likely than the general public to become infected with the covid virus, with disproportionate impacts on minority health workers.

“It’s very clear when you just go to the media and see the images on television — the stress and the strain on the faces of health care providers, nurses, doctors, other people involved in the health care enterprise,” said Fauci.

Nevertheless, the U.S. government has failed to systematically count health worker deaths. Members of Congress, the Health and Human Services Department and academic reports The Guardian and KHN’s reporting as the most comprehensive. A growing chorus of policy experts and unions have called for a comprehensive count of health worker deaths.

“We certainly want to find an accurate count of the people who die,” said Fauci, without noting when the government should undertake such an effort. “Certainly, that’s something I think would fall under the auspices of the federal government.”

Even as the vaccine rollout picks up speed, health workers continue to be imperiled. More than between the time the rollout began and late February. Infections among vaccinated health workers have steeply declined, but because deaths are a lagging indicator of the spread of covid, some health workers will have been sickened before widespread vaccination.

At the same time, immunity to coronaviruses generally wanes over time and variants may blunt the efficacy of some vaccines. A global shortage of vaccines means dozens of poor nations have not inoculated a single person. Advocates argue this has led to a global “,” which will contribute to the continued emergence of variants. Both scenarios could imperil health workers anew and necessitate a new round of adult mass vaccination.

Studies into the duration of immunity for vaccines, and variants’ impact on vaccines, are ongoing. “If we’re going to need to do boosting with a variant-specific boost, [we] will be prepared for it because we’re already doing a study,” Fauci said, with such research taking place at the National Institute of Allergy and Infectious Diseases, which he leads. Even so, “it looks like our ability to protect against variants with the standard vaccine might be better than we anticipated.”

Regardless of how future vaccination campaigns play out, Fauci said, U.S. policymakers should learn from what has transpired over the past year.

“We better make sure the lesson we will learn is that we will never again be in a situation where people who are putting their health and their safety on the line don’t have the appropriate equipment to protect themselves safely,” he said.

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Health policy experts and union leaders are pressing the White House to move quickly to fill the gaping hole left by the Trump administration through its failure to create an accurate count of covid deaths among front-line workers. The absence of reliable federal data exacerbated critical problems such as shortages of personal protective equipment that left many workers exposed, with fatal results.

In the absence of federal action, “Lost on the Frontline,” a between The Guardian and KHN, has compiled the most comprehensive account of health care worker deaths in the nation. It has recorded 3,607 lost lives in the first year of the pandemic, with nurses, health care support staffers and doctors, as well as workers under 60 and people of color, affected in tragically high numbers.

The Guardian/KHN investigation, which involved more than 100 reporters, is drawing to a close this week. Pressure is now growing for the federal government to step into the breach.

Harvey Fineberg, a leading health policy expert who approved a recent that cited the “Frontline” project and recommended the formation of a national tracking system run by the federal government, backed the calls for change. He said his ideal solution would be a nationwide record.

“There would be a combination of a selective look backward to gain more accurate tabulations of the past burden, and a system of data-gathering looking forward to ensure more complete counts in [the] future,” he said.

Zenei Triunfo-Cortez, a president of National Nurses United, the largest body of registered nurses in the U.S., said it was unconscionable how many health care workers have died of covid-19. The found that almost a third of those who died were nurses — the largest single occupation — followed by support staff members (20%) and physicians (17%).

Triunfo-Cortez said the death toll was an unacceptable tragedy aggravated by the lack of federal data, which made identifying problem areas more difficult. “We as nurses do not deserve this — we signed up to take care of patients, we did not sign up to die,” she said.

Dr. Anthony Fauci, the nation’s top expert on infectious diseases, also sees a role for federal agencies in tracking mortality among front-line health care workers. In an interview with The Guardian, he expressed a desire for a definitive picture of the human toll.

“We certainly want to find an accurate count of the people who died,” he said. “That’s something that I think would fall under the auspices of the federal government, likely Health and Human Services.”

The lack of federal intelligence on deaths among front-line health care workers was one of the running failures of the Trump administration’s to the crisis. The main health protection agency, the Centers for Disease Control and Prevention, does curate some information but has itself acknowledged that its own record of — more than 2,000 fewer than the joint Guardian/KHN tally — is an undercount based on limitations in its data collection.

Overall, health care workers were revealed to be singularly at risk from the pandemic. Some studies have shown they were more than three times as likely to contract covid as was the general population.

To date, there is no sign of the Biden administration taking active steps to set up a comprehensive data system. An HHS spokesperson said the department has no plans to launch a comprehensive count. However, Triunfo-Cortez said there is a new willingness on the part of the White House and key federal agencies to listen and engage.

“We have been working with the Biden administration and they have been receptive to the changes we are proposing,” Triunfo-Cortez said. “We are hopeful that they will start to mandate the reporting of deaths, because if we don’t have that data how can we know how effective we are being in stopping the pandemic?”

The responsiveness of the new administration is likely to be heightened by the fact that Biden’s chief of staff, Ron Klain, has a track record in fighting infectious disease outbreaks. In 2014, President Barack Obama appointed him

In an last August, Klain drew on the findings of “Lost on the Frontline” to decry the ultimate price paid by health care workers: “Although America has applauded health workers, banged pots in their honor and offered grateful video tributes, we have consistently failed them where it mattered most.”

David Blumenthal, the national coordinator for health information technology under Obama, said a national tracking system is an important step in healing the wounds of the pandemic. “So many health care workers feel as though their devotion and sacrifice weren’t valued,” he said. “We must combat the widespread fatigue and disappointment.”

KHN senior correspondent Christina Jewett contributed to this report.

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Lost on the Frontline is the most complete accounting of U.S. health care worker deaths. The federal government has not comprehensively tracked this data. But 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 health care 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 health care 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 health care workers. Studies show that health care 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 . The covid deaths of so many are “a reflection of what health care 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 , 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, 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 health care workers in the database, it is only 59.
• More than a third of the health care 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 health care workers has slowed dramatically since covid vaccines were made available to them in December. A 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 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 filed by health care 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 health care employers were 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.

, 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 health care workers safe.”

Adeline’s father, Brant Fagan, wants the government to begin tracking health care 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.”

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Journalists from KHN and The Guardian have identified 3,607 workers who reportedly died of complications from covid-19 after they contracted it on the job. Reporters are working to confirm the cause of death and workplace conditions in each case. They are also writing about the people behind the statistics — their personalities, passions and quirks — and telling the story of every life lost.

Explore the  tracking those health worker deaths.

(Note: The previous total announced by The Guardian and KHN was approximately 1,450 health care worker deaths. The new number reflects the inclusion of data reported by nursing homes and health facilities to the federal and state governments. These deaths include the facility names but not worker names. Reporters cross-checked each record to ensure fatalities did not appear in the database twice.)

• Read more investigative stories

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She was not yet 13 when the Khmer Rouge seized power in Cambodia and ripped her family apart. The totalitarian regime sent her and four siblings to work camps, where they planted rice and dug irrigation canals from sunrise to sunset — each surviving on two ladles of rice gruel a day. One disappeared, never to be found.

Just a few months before the Khmer Rouge fell in January 1979, Lim’s father starved to death, among the nearly of Cambodians who perished from execution, forced labor, starvation or disease in less than four years.

For Lim, the indelible stamp of childhood anguish drove two of her life’s passions: serving people as a physician and cooking lavish feasts for friends and family — both of which she did until she died of covid-19 in January.

Within the week before her death at age 58, she treated dozens of patients who flooded the hospital during the deadly winter covid surge, while bringing home-cooked meals to the hospital for her fellow health care workers to enjoy during breaks.

“These experiences during the war made her humble and empathetic toward the people around her,” said Dr. Vidushi Sharma, who worked with Lim at Community Regional Medical Center in Fresno, California. “She always wanted to help them.”

Lim’s story is one of suffering and triumph.

During the Khmer Rouge’s brutal reign and the Cambodian civil war before it, Lim and her nine siblings attended school sporadically. The ravages of war forced the family first from its small town to the capital, Phnom Penh, and then into the countryside when the Khmer Rouge took power in 1975. As part of its vision to create a , the communist group split families and relocated residents to rural labor camps.

Lim survived the work camps because she was smart and resourceful, said her youngest brother, Rithy Lim, who also lives in Fresno. She dug ditches, hauled clay-like dirt on her back, built earthen dams in the middle of a river during monsoons — all with little food or rest, he said.

She also became a skillful hunter and fisher, and learned to identify plants that were safe to eat.

“You cannot imagine the horrible conditions,” he said. “Think of it as a place that you live like wild animals, and people tell you to work. There’s no paper, no pens. You sleep on the ground. We witnessed death of all sorts.”

Vietnamese troops liberated Cambodia from the Khmer Rouge in 1979. Later that year, Lim, her mother and siblings sneaked into Thailand. “The whole family walked through minefields,” Rithy Lim recalled. There, they waited and worked in refugee camps. At one camp, they met a dentist from California’s Central Valley who was on a medical mission.

When Lim and her family arrived in the U.S. in 1982, they landed in Georgia. But she and an older brother soon moved to the small town of Taft, California, about 45 minutes west of Bakersfield, at the invitation of the dentist they’d befriended at the Thai refugee camp.

When she hit the ground, the 4-foot-11 dynamo, then 19, was driven by “pure determination,” Rithy Lim said.

Within two years, Linath Lim learned English, earned her GED and graduated from Taft College — “boom, boom, boom,” her brother recalled. (She learned to make traditional, middle-America Thanksgiving dinners when she worked at the community college’s cafeteria, which she would later cook for scores of friends and family.)

She went on to attend Fresno State and then the Medical College of Pennsylvania, sleeping on friends’ couches, borrowing money from other Cambodian refugees and scraping by.

“Imagine not having any money, studying alone, sleeping in someone else’s living room,” Rithy Lim said.

Lim became an internal medicine doctor “because she always wanted to be really involved with a lot of patients,” Rithy Lim said. After her residency, she returned to the Central Valley to practice in hospitals and clinics in underserved communities, including Porterville and Stockton, where some of her patients were farmworkers and Cambodian refugees.

California has the largest Cambodian population in the country, with roughly 89,000 people of Cambodian descent in 2019, according to a Public Policy Institute of California analysis of data.

Twice, Lim joined the on weeklong volunteer trips to Cambodia, where she and other doctors treated hundreds of patients a day, said Dr. Song Tan, a Long Beach, California, pediatrician and founder of CHPAA.

“She was a kindhearted, very gentle person,” recalled Tan, who said he was the only member of his family to survive the Khmer Rouge. “She went beyond the call of duty to do special things for patients.”

Most recently, Lim worked the swing shift, 1 p.m. to 1 a.m., at Community Regional Medical Center. She admitted patients through the emergency room, where she was exposed to countless people with covid. She worked extra shifts during the pandemic, volunteering when the hospital was short-staffed, said Dr. Nahlla Dolle, an internist who also worked with Lim.

“She told me there were so many patients every day, and that they didn’t have enough beds and the patients had to wait in the hallway,” Tan said.

Colleagues said she was aware of the risks but loved her job. Lim, who was single and didn’t have kids, drew happiness from celebrating others’ joys. After getting home from work in the small hours, she slept for a bit, then got up to cook. Her specialties were Cambodian, Thai, Vietnamese and Italian food. She sometimes ordered a whole roasted pig that she transported to the hospital. Her memorable Thanksgiving dinners served 70 or more people.

“For any occasion that comes up — if it’s a birthday, if it’s a baby shower, if it’s Thanksgiving — she would cook, she would order food and bring everybody together,” Dolle said. “She loved to feed people because she experienced famine and lack of food.”

The week before she died, Lim cooked for her colleagues almost every day, and threw a baby shower for Sharma, complete with chicken calzones and blueberry cake.

“Every day, we were having lunch together,” Sharma said. “She did the shower, and then she’s gone.”

Lim, who had health problems including diabetes, had not been vaccinated.  Family and friends had urged her to take care of herself, and to check her blood sugar and take her medications. “She would care about everyone but herself,” Sharma said.

On Jan. 15, Lim told friends by phone that she was exhausted, achy and having trouble breathing. But she said that she would be fine, that she just needed to rest. Then she stopped responding to calls and texts.

When she didn’t show up for work a few days later, her brother went to check on her at home and found her on the couch, where she had died.

Now her brother and colleagues are haunted by what-ifs over the loss of a remarkable woman and doctor: What if I had checked on her sooner? What if she had been vaccinated? What if she had gotten care when she started feeling ill?

“To have someone who has been through all that in her childhood and then flourish as a physician, a human being, coming to a new country, learning English, going to school and college without having much financial support, it’s phenomenal,” Sharma said. “It’s unbelievable.”

This story is part of “Lost on the Frontline,” a project from  and Kaiser Health News that aims to document the lives of health care workers in the U.S. who die from COVID-19, and to investigate why so many are victims of the disease.

This story was produced by , which publishes , an editorially independent service of the .

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Espinoza died at age 36 of covid-19, just days after he got his first dose of a covid vaccine. He was a hospice nurse who put his life in danger to help covid patients and others have a peaceful death.

When covid hit, it was no surprise to his family that this “gentle giant,” as friends and family called him, stepped up to the plate.

“His attitude was like, ‘No, I’m not going to be scared,’” said Nancy Espinoza, his wife of 10 years. “This is our time to shine,” he told her. “I became a nurse for a reason.”

As a hospice nurse and chief nursing officer for Calstro Hospice in Montclair, California, Espinoza routinely made house calls, visited assisted living facilities and performed death visits — during which hospice nurses pronounce patients dead.

Hospice workers aren’t just doctors and nurses, but also include home health aides, social workers, chaplains and counselors. In the past year, they have frequented some of the highest-risk environments, such as nursing homes, assisted living facilities and patients’ homes.

Hospice requires intimate patient care, and the additional safety requirements and need for personal protective equipment made it challenging, said Alicia Murray, board president of the . But hospice workers adapted, she said, knowing they might be the only people who could comfort dying patients when family members were not allowed to visit medical and long-term care facilities.

“They’re taking care of dying people and, in particular, people dying of covid who may be spewing out the virus,” said Dr. Karl Steinberg, a geriatrician and palliative care specialist who is the medical director of Hospice by the Sea in Solana Beach, California, and several nursing homes.

A few months into the pandemic, when Calstro Hospice began caring for covid patients, Espinoza helped develop a covid unit. Part of his job was to make sure staff members had sufficient personal protective gear, including himself.

“Some people had a hard time getting a hold of all the PPE gear, but his office had adequate equipment,” his wife said. Right before he got sick, he was excited to receive a big shipment of gowns, N95 masks, booties and face shields from San Bernardino County, she said.

Espinoza fell ill a few days after his first dose of covid vaccine on Jan. 5, but went to work thinking it was vaccine-related. “He had kind of a sore throat and felt a little bit under the weather, but nothing major,” said Nancy Espinoza. His symptoms progressed to a fever and chills and he tested positive for covid on Jan. 10.

Seven other Calstro Hospice staff members also got covid during the pandemic, said Jennifer Arrington, Calstro Hospice’s director of patient care services.

Espinoza was a victim of bad timing, according to Dr. Lucy Horton, infectious disease specialist and associate professor at the University of California-San Diego School of Medicine.

The virus’s incubation period averages five to seven days, she explained. “If you test positive a few days after the vaccine, chances are you actually got exposed before you even got your first dose,” she said.

Horton said people aren’t fully vaccinated until at least 14 days after their second dose of a two-dose vaccine, or their first dose of a one-dose version. Early after the first dose, people don’t reap the benefit of the vaccine yet, she said.

“Even after you’re fully vaccinated, there still is a remaining risk,” said Horton, co-author of a letter to about post-vaccination infection rates among health care workers in California. “Even if it’s so much lower, it’s still present.”

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Espinoza knew he wanted to care for others and go into health care since he was in high school, and realized the Hispanic community needed Latino nurses in hospice care, his wife said. “He made it his purpose to help the Hispanic community understand hospice care and not be afraid of it,” she said.

On Jan. 15, Nancy Espinoza and the couple’s toddler, Ezekiel, spoke to Antonio over the phone for the last time. “I love you” were the last words she heard her husband say.

She was allowed to visit him right before he died on Jan. 25. He was intubated with an oxygen level of 25%.

Nancy Espinoza stood in the room alone with her husband for the last time. “I just wanted to be able to hold his hand and pray for him,” she said. “I wanted him to know that he wasn’t alone.”

This story is part of “,” an ongoing project from  and Kaiser Health News that aims to document the lives of health care workers in the U.S. who die from COVID-19, and to investigate why so many are victims of the disease.

This story was produced by , which publishes , an editorially independent service of the .

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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 Health Care 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  Wednesday allowing indoor visits in the facilities, even among unvaccinated residents and visitors, under most circumstances.

National figures on health care worker infections in other settings are hard to come by, but some statewide trends look promising. In California and Arkansas, health care 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 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,

, a yearlong data and reporting project by KHN and The Guardian, is investigating over 3,500 covid deaths of U.S. health care workers. The monthly number has been declining since December, but deaths often lag weeks or months behind infections.

Along with other health care 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 , 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, , 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 to get flu vaccines than other health care 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 . Hispanic adults are to say they will “definitely” get the covid vaccine, as are . Black adults have been 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 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 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.

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