Publisher Health

People discharged from hospital after covid-19 appear to have increased rates of organ damage (“multiorgan dysfunction”) compared with similar individuals in the general population, finds a study published by The BMJ today.
The increase in risk was not confined to the elderly and was not uniform across ethnic groups, prompting the researchers to suggest that the long-term burden of covid-19-related illness on hospitals and broader healthcare systems is likely to be substantial.
Although covid-19 is most well known for causing serious respiratory problems, it can affect other organs and systems within the body, including the heart, kidneys, and liver.
Several unexplained symptoms that continue for more than 12 weeks after covid-19 are said to be part of post-covid syndrome (also known as “long covid”), but the long term pattern of organ damage after infection is still unclear.
To investigate this, a team of UK researchers from the Office for National Statistics, University College London and University of Leicester set out to compare rates of organ dysfunction in individuals with covid-19 several months after discharge from hospital with a matched control group from the general population.
Their findings are based on 47,780 individuals (average age 65, 55% men) in hospital in England with covid-19 who were discharged alive by 31 August 2020.

A manufacturing subcontractor in Baltimore mixed ingredients from the coronavirus vaccines of Johnson & Johnson and AstraZeneca, setting back U.S. production of the “one-and-done” shot.WASHINGTON — Workers at a plant in Baltimore manufacturing two coronavirus vaccines accidentally conflated the ingredients several weeks ago, contaminating as many as 15 million doses of Johnson & Johnson’s vaccine and forcing regulators to delay authorization of the plant’s production lines.The plant is run by Emergent BioSolutions, a manufacturing partner to both Johnson & Johnson and AstraZeneca, the British-Swedish company whose vaccine has yet to be authorized for use in the United States. Federal officials attributed the mistake to human error.The mix-up has delayed future shipments of Johnson & Johnson doses in the United States while the Food and Drug Administration investigates what occurred. Johnson & Johnson has moved to strengthen its control over Emergent BioSolutions’ work to avoid additional quality lapses.The mistake is a major embarrassment both for Johnson & Johnson, whose one-dose vaccine has been credited with speeding up the national immunization program, and for Emergent, its subcontractor, which has faced fierce criticism for its heavy lobbying for federal contracts, especially for the government’s emergency health stockpile.The error does not affect any Johnson & Johnson doses that are currently being delivered and used nationwide, including the shipments that states are counting on next week. All those doses were produced in the Netherlands, where operations have been fully approved by federal regulators.Further shipments of the Johnson & Johnson vaccine — projected to total tens of millions of doses in the next month — were supposed to come from the giant plant in Baltimore. Those deliveries are now in question while the quality control issues are sorted out, according to people familiar with the matter.Federal officials still expect to have enough doses from the three approved coronavirus vaccine makers to meet President Biden’s commitment to provide enough vaccine to immunize every adult by the end of May. The two other federally authorized manufacturers, Pfizer-BioNTech and Moderna, are continuing to deliver as expected.Pfizer is shipping its doses ahead of schedule, and Moderna is on the verge of winning approval to deliver vials of vaccine packed with up to 15 doses instead of 10, further bolstering the nation’s stock.The problems arose in a new plant that the federal government enlisted last year to produce both Johnson & Johnson’s and AstraZeneca’s vaccines. Both use similar technology in which genes unique to the coronavirus are shuttled into human cells, where they cause the immune system to produce antibodies.In less than a year, Emergent hired and trained hundreds of new workers to produce millions of doses of both vaccines that were supposed to be ready by the time that clinical trials showed whether they actually worked. In late February, one or more workers somehow confused a key ingredient for AstraZeneca’s vaccine with Johnson & Johnson’s, raising questions about training and supervision.Vaccine production is a notoriously fickle science, and errors are often expected to occur and ruin batches. But Emergent’s mistake went undiscovered for days until Johnson & Johnson’s quality control checks uncovered it, according to people familiar with the situation. By then, up to 15 million doses had been contaminated, the people said.None of the doses ever left the plant, and the lot has been quarantined. There is no indication that production of AstraZeneca’s vaccine, which has yet to be authorized for emergency use by the Food and Drug Administration, was affected.Johnson & Johnson reported the mishap to federal regulators, who then started an investigation that has delayed the authorization of that plant’s production lines. The company has beefed up the number of its own staff members who monitor Emergent’s work and instituted a variety of new checks intended to protect against future lapses.Johnson & Johnson already faced a lag in its manufacturing that has caused the company to fall behind on its commitments to the federal government, but it seemed on track to catch up. It delivered 20 million doses by the end of March, and has pledged to deliver about another roughly 75 million by the million doses by the end of May.White House officials hedged their projections in a phone call with governors on Tuesday, forecasting certain deliveries from Pfizer and Moderna but warning that Johnson & Johnson’s shipments would fluctuate.In a statement late Wednesday, the company said it expected the steps it was now taking with Emergent would enable it to deliver 24 million doses by the end of April, or about what the federal government expected. But that depends on whether Johnson & Johnson satisfies Food and Drug Administration regulators.The agency last week cleared a bottling facility that Johnson & Johnson uses in Indiana, allowing the release of more doses made in the Netherlands. But that facility cannot send out doses produced in the Emergent plant until the Food and Drug Administration authorizes it.Nearly seven million doses of the vaccine have been delivered so far, and about half of those have been administered, according to the Centers for Disease Control and Prevention.

A drug that unleashes the immune system offers a rare glimmer of hope for those with a cancer that resists most treatments.For decades, esophageal cancer has defied scientific attempts to discover a therapy that extends patients’ survival, year after year claiming the lives of such illustrious people as Humphrey Bogart, Christopher Hitchens and Ann Richards, the former governor of Texas.Now a large clinical trial offers hope, finding that a drug that unleashes the immune system to attack cancer cells can double the disease-free survival times in patients from 11 months to 22 months. The study was published on Wednesday in the New England Journal of Medicine.“It is a game changer,” said Dr. David Ilson, an esophageal cancer expert at Memorial Sloan Kettering Cancer Center in New York, who wrote an editorial accompanying the research. “We’ve waited a long time for this.”In the trial, sponsored by Bristol-Myers Squibb, 794 patients in 29 countries were randomly assigned to receive infusions of the drug, nivolumab, or a placebo.The patients had all had chemotherapy and radiation followed by surgery to remove their cancers. As usually happens, pathology reports showed that the surgery did not remove all of the cancer cells, which still lurked in lymph nodes and elsewhere, setting the stage in these patients for their cancers to return as incurable metastases.Nivolumab is approved for some patients with other cancers, like Hodgkin’s lymphoma, melanoma and colorectal cancer. With the new study, experts expect the drug will readily win approval for treatment of early-stage esophageal cancer.Dr. Ronan Kelly, director of the Charles A. Sammons Cancer Center at Baylor University Medical Center and lead author of the new study, said he and the other researchers urgently wanted to help the 75 percent of patients who go through extraordinarily difficult sequences of radiation, chemotherapy and surgery that disfigures the digestive system, only to learn that cancer is still present or has a high likelihood of recurring.Without some other form of treatment, “we knew many would recur quickly,” Dr. Kelly said. Additional chemotherapy not only was difficult for patients to tolerate, but it also did not seem to help. Nivolumab has few side effects and seemed worth a try.Esophageal cancer is rare in the United States, accounting for 1 percent of all cancers; about 15,000 patients die each year. But it is the seventh most common cancer globally, and frequently seen in East Asia, although it is not clear why, Dr. Ilson said.Smoking is a risk factor, but researchers do not think the high smoking rates in China, for example, explain the high incidence. “We don’t think it’s environmental,” Dr. Ilson said.Other risk factors include alcohol consumption and acid reflux disease.Because the cancer is so rare in the United States, it has not gotten much research attention. While new treatments have revolutionized prospects for other cancer patients, those with esophageal cancer could only look on longingly.That has weighed heavily on people with the disease, said Mindy Mordecai. Her husband, John, died of esophageal cancer in March 2008. She started an advocacy group called Esophageal Cancer Action Network.“You can’t even imagine how demoralizing it is to see all the progress around you. ‘Please sir, may I have some more gruel?’” she said, quoting Oliver Twist, the Charles Dickens character in the eponymous novel, asking for a pittance.The new findings must be seen in the context of what patients go through when they develop esophageal cancer, experts said. Most learn they have the cancer after it has progressed to a point where they are unlikely to survive.But every patient hopes to be one of the lucky ones. “Our patients are always waiting for the other shoe to drop,” Ms. Mordecai said. “You have to understand what it’s like to live with that every day.”The first step for most is chemotherapy and radiation. The treatment is so harsh that an oncology nurse told Mr. Mordecai it “brings Navy Seals to their knees,” Ms. Mordecai recalled.The chemotherapy has difficult side effects, and the radiation causes a burning sensation that makes it difficult to swallow. “Food won’t go down,” Ms. Mordecai said. “You just feel rotten.”The next step is major surgery. A doctor takes out most of the patient’s esophagus, the tract leading from the mouth to the stomach, and then grabs the stomach and pulls it up, attaching it to a stump of esophagus left behind.The result is a stomach that is vertical, not horizontal, and lacks the sphincter muscle that normally keeps stomach acid from spilling out. For the rest of their lives, patients can never lie flat — if they do, the contents of their stomach, including acid, pours into their throats. They can choke, cough and aspirate.Recovery is difficult, and morbidity and mortality are high. But most patients go through with the operation once they weigh their options. To refuse the treatment means giving up and letting the cancer close off the esophagus to the point where some cannot even swallow their own saliva, said Dr. Paul Helft, a professor of surgery and an ethicist at Indiana University School of Medicine.The treatment is so long and harrowing that Dr. Helft often uses it to teach medical students and other trainees about informed consent — about how patients must be fully informed before they start any given treatment. Esophageal cancer patients in particular must be told that they are likely to have a recurrence within the first year.Ms. Mordecai said her husband had his surgery at the end of September 2008. By Dec. 6, he had untreatable metastases in his liver. Now, she said, patients may have a glimmer of hope.Dr. Ilson, who has spent his career trying to develop therapies to help patients with esophageal cancer, said that he did not expect this treatment to succeed: “We all get nihilistic when faced with years of negative studies.”“This is really a landmark paper,” he added, and the drug “will become a new standard of care.”

Clinicians using a new viral screening test can not only diagnose COVID-19 in a matter of minutes with a portable, pocket-sized machine, but can also simultaneously test for other viruses — like influenza — that might be mistaken for the coronavirus. At the same time, they can sequence the virus, providing valuable information on the spread of COVID-19 mutations and variants. The new test, dubbed NIRVANA, was described online today by a multi-institution team of scientists in the journal Med.
“This is a virus detection and surveillance method that doesn’t require an expensive infrastructure like other approaches,” says Juan Carlos Izpisua Belmonte, co-corresponding author and a professor in Salk’s Gene Expression Laboratory. “We can accomplish with one portable test the same thing that others are using two or three different tests, with different machines, to do.”
Around the world, more than 100 million people have been infected with SARS-CoV-2, the virus that causes COVID-19. A staggering 500,000 Americans have died from COVID-19 to date. Testing the population is key to stopping the spread of the virus. In addition, tracking the spread of new SARS-CoV-2 variants — some of which could respond differently to treatments or vaccines — is critical.
Today, the standard approach to determining whether a nasal swab is positive for COVID-19 is to run a polymerase chain reaction (PCR) test to detect genetic material from the SARS-CoV-2 virus. If the sample is negative, however, patients and clinicians don’t get any information on what might be causing the coronavirus-like symptoms — unless they run separate PCR tests, using different swab samples, for other viruses. And if the sample is positive for SARS-CoV-2, they don’t learn which COVID-19 variant a patient is infected with unless another set of tests is run; those require a large and expensive next-generation gene-sequencing machine.
Last summer, Mo Li, an assistant professor of bioscience at King Abdullah University of Science and Technology in Saudi Arabia, was pondering ways he could lend his expertise in genetic engineering and nanopore sequencing to combatting the COVID-19 pandemic. Li, who previously spent six years as a Salk postdoctoral researcher in the Izpisua Belmonte lab, wondered whether a gene-detection approach called isothermal recombinase polymerase amplification (RPA) coupled with real-time nanopore sequencing might be more useful — and faster, cheaper and more portable — than the current COVID-19 testing approach. He teamed up with Izpisua Belmonte to find out.
Unlike PCR, which cycles through lower and higher temperatures to separate DNA strands and copy them, RPA uses proteins — rather than temperature changes — to accomplish the same thing in only 20 minutes. The technology lets researchers copy longer stretches of DNA, and probe for multiple genes at the same time.

New findings from a Michigan Medicine study reveal that antibody testing is predictive of prior COVID-19 infection, and rapid screening methods — even from finger pricks — are effective testing tools.
Researchers analyzed antibody tests conducted on more than 500 subjects in patient care settings. They found that people who had COVID, including those with mild symptoms, produced antibodies.
“For a long time, people were very worried that people with mild COVID did not make immune responses,” says Charles Schuler, M.D., a clinical assistant professor of allergy and immunology at Michigan Medicine. “This should give people confidence that the tests that are available to them aren’t just random number generators. They’re actually giving them something useful.”
The findings also indicate that rapid screens can predict infection with nearly the same precision as antibody tests conducted in a lab. Schuler, who led the research team, says the results could prove very useful for providers.
“I was actually surprised at how well some of these tests did because it’s a very different experiment,” Schuler says. “[If you have] a patient at a clinic that does not have a lab on site, we can find out if you had COVID before and we can do it now and we can do it at low cost.”
The team examined lateral flow assays, which Schuler describes as modern litmus tests: A drop of blood or serum is placed on filter paper that changes color to indicate whether antibodies are present.

Emerging technologies can screen for cervical cancer better than Pap smears and, if widely used, could save lives both in developing nations and parts of countries, like the United States, where access to health care may be limited.
In Biophysics Reviews, by AIP Publishing, scientists at Massachusetts General Hospital write advances in nanotechnology and computer learning are among the technologies helping develop HPV screening that take the guesswork out of the precancer tests. That could mean better screening in places that lack highly trained doctors and advanced laboratories.
Cervical cancer is the world’s fourth-most common cancer, with more than 500,000 cases diagnosed every year. Almost all cases of cervical cancer are caused by HPV, or human papillomavirus. Detecting precancer changes in the body gives doctors a chance to cure what could otherwise become a deadly cancer.
Pap smears, which were introduced in the 1940s, are subjective and not always reliable. The tests, which can detect about 80% of developing cervical cancer if given regularly, require high-quality laboratories, properly trained clinical doctors, and repeated screenings. These test conditions are not widely available in many countries or even in low-income and remote parts of wealthier nations.
“The Pap smear has done wonders in terms of reducing mortality from a cancer that is very treatable when caught early and almost invariably fatal when it is caught late,” said author Cesar Castro, an oncologist at Massachusetts General Hospital and associate professor at Harvard Medical School. “And it is not even a great test. Part of its imperfection is that there is subjectivity to it. The trained eye is the limiting step in the process. The untrained eye, or relatively untrained eye, can miss cancers.”
The subjectivity of the test has led to a much higher death rate from cervical cancer in lower-income countries. The authors highlight a list of existing and emerging technologies that can be used to close the testing gap in those areas. They range from existing DNA testing and other Pap smear alternatives to next-generation technologies that use recent advances in nanotechnology and artificial intelligence.
One technique involves screening with tiny beads made of biological material that form a diamond shape when they contact HPV. Those shapes can be detected with powerful microscopes. When those microscopes are not available, a mobile phone app, built through machine learning, can be used to read them.
“Similar to COVID-19 testing, we have great technology in places like the United States that does not work well enough in other countries,” said author Hyungsoon Im, a biomedical engineer at Massachusetts General Hospital and assistant professor at Harvard Medical School. “This is why there is great motivation to find next-generation, affordable technology to address this problem.”
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For many parents, the COVID-19 pandemic has made life’s everyday juggling act — managing work, school, extracurricular, and household responsibilities — much, much harder. And according to a new study led by Penn sociologists, those extra burdens have fallen disproportionately on mothers.
The research, shared in the April issue of the journal Gender and Society, investigated how shifts in work and school that arose due to the pandemic triggered changes in the division of labor in families. Using data on two-parent households from a nationwide survey conducted in April 2020, the researchers found that gender disparities in unpaid labor were most apparent when a mother was the only parent working from home, or when neither parent was able to work remotely.
“It turns out that when the mother is working remotely and her partner isn’t, she ends up taking on a ton more responsibilities,” says Jerry Jacobs, a sociology professor in Penn’s School of Arts & Sciences and one of the paper’s authors. “When a father is working remotely and his partner isn’t, somehow he doesn’t take on as much extra work. This seems to be a deeply gendered issue.”
As the pandemic has worn on, the toll on women has been hard to ignore. Each month, hundreds of thousands of women lost their jobs or dropped out of the workforce to meet new demands at home.
Yet remote work also seemed to open the possibility of greater equity between the genders in domestic responsibility, as two parents would be at home and accessible.
To tease out the effects of a shift to remote work on domestic labor during the pandemic, Jacobs, Penn doctoral student Allison Dunatchik, and colleagues turned to data from a New York Times survey, conducted by marketing research firm Morning Consult. Of 2,200 respondents, 478 were partnered parents, and 151 were single parents.

The Centers for Disease Control and Prevention and the National Institutes of Health announced a new initiative on Wednesday to help determine whether frequent, widespread use of rapid coronavirus tests slows the spread of the virus.The program will make rapid at-home antigen tests freely available to every resident of two communities, Pitt County, N.C., and Hamilton County, Tenn., enough for a total of 160,000 people to test themselves for the coronavirus three times a week for a month.“This effort is precisely what I and others have been calling for nearly a year — widespread, accessible rapid tests to help curb transmission,” said Michael Mina, an epidemiologist at Harvard University who has been a vocal proponent of rapid, at-home testing programs.He added, “Taking 30 seconds out of your day three times a week to perform the test is something any person can do.”Antigen tests are cheaper and faster than P.C.R. tests, which are the gold standard for diagnosing Covid-19, the disease caused by the virus, but they are less sensitive and more prone to false negatives. Mathematical models have suggested that if these tests are used frequently, they can still reduce transmission of the virus.The tests can help identify people who may not realize that they are infectious, prompting them to self-isolate before they are able to transmit the virus to others. But real world data has been limited, and with virus case numbers still high across the country, testing remains essential, public health experts say.“We have all hypothesized that testing at home, at scale could stop the chain of transmission of the virus and allow communities to discover many more cases,” said Bruce Tromberg, who directs the National Institute of Biomedical Imaging and Bioengineering and leads its rapid acceleration of diagnostics program, which is supplying the tests for the initiative. “All the mathematical models predict that. But this is a real world, real life example.”Residents who decide to participate in the program can have the tests delivered to their homes or pick them up at local distribution sites. An online tool will guide participants through the testing process and help them interpret their results. Residents can also volunteer to complete surveys that will assess whether frequent testing has changed their behavior, knowledge about Covid-19, or opinions on vaccination.Researchers at the University of North Carolina and Duke University will compare the test positivity, case and hospitalization rates in these two communities to those in other similar communities that are not participating in the program.A. David Paltiel, a professor of health policy and management at Yale School of Public Health, called the launching of a real-world study of the effectiveness of rapid, at-home screening “just great news.” But he cautioned that the results will need to be interpreted carefully, especially if the residents who choose to participate in the initiative are not representative of the community at large.“We know that self-selection tends to bring out the worried well and a disproportionate number of people who are already Covid-conscious or Covid-conscientious,” he said.“It’ll be great to see how it works when in the hands of people who really care,” he added. But, he said, the results may not be widely generally applicable to screening programs in which participation is mandatory, as may be the case with some workplace and school programs.

Germany has suspended the use of the AstraZeneca vaccine for under-60s, after the German medicines regulator found 31 cases of a type of rare blood clot out of 2.7 million people who had received the jab. The European Medicines Agency and the UK’s regulatory body, MHRA, have said there is no indication that the vaccine is linked to blood clots.Despite this, Angela Merkel has insisted that Germany will still offer every adult a vaccine by the end of the summer. They’re largely relying on the Pfizer/BioNTech vaccine, with a new factory in the town of Marburg aiming to produce one billion doses a year. Jenny Hill went to see how the vaccine was made.

Prime Minister Mario Draghi issued a decree requiring that workers in health care facilities be vaccinated, a move that will test the legal limits of his government’s efforts to stem coronavirus outbreaks.ROME — Giulio Macciò tested negative for the coronavirus and spent weeks receiving treatment for emphysema in a sealed-off hospital under the care of doctors and lung specialists — and a nurse who had refused to be vaccinated. On March 11, he unexpectedly died. A post-mortem swab found that he had contracted the virus, as had 14 other patients and the unvaccinated nurse who spent her shifts in his midst.“It makes no sense that a person whose job is to heal the sick gives them Covid and kills them,” said Mr. Macciò’s son, Massimiliano Macciò, who filed a complaint against the San Martino hospital in the northern Italian city of Genoa. He believes that the nurse, one of an estimated 400 who have refused vaccination against Covid-19 at the hospital, infected his father, who died unvaccinated at 79.As vaccination rollouts build momentum, businesses everywhere are grappling with whether they can require the inoculation of their employees, raising thorny ethical, constitutional and privacy issues around Europe and the United States. But that quandary becomes all the more urgent when the person is your health care worker.In Italy, the original Western front in the war against Covid, a rash of outbreaks in hospitals where medical workers have chosen not to be inoculated has raised fears that their stance is endangering public health. It has also prompted a forceful response from an Italian government that is struggling to get vaccinations on track.On Wednesday, Prime Minister Mario Draghi tested the legal limits of his government’s ability to address the problem by issuing a decree requiring that workers in health care facilities be vaccinated. It also allowed hospital employers to suspend without pay any health care workers who refuse to do so.Some legal analysts have said that requiring Covid-19 inoculation for health workers could violate Italy’s privacy laws, and that firing or forcing any who decline it to take unpaid leave could be unconstitutional because of a specific article that protects people who refuse health treatments.A coronavirus ward at the Papa Giovanni XXIII hospital in Bergamo in March last year.Fabio Bucciarelli for The New York TimesBut recent court rulings have interpreted the law differently, and Mr. Draghi has made clear that for a country that has suffered more than 100,000 Covid deaths, the breach of safety cannot be tolerated.“It is absolutely not OK that unvaccinated workers are in contact with the sick,” he said at a news conference last week while announcing his government’s intention to “intervene” when asked about the reports of unvaccinated health care workers.For much of the pandemic, nurses and doctors stood as national heroes who sacrificed their waking hours, safety and sometimes lives to protect their compatriots. It has shocked Italians that in some major hospitals up to 15 percent of those medical professionals — who were given preference in the vaccination rollout ahead of older people — have shunned inoculation.“It’s really humiliating for the medical and health worker class that you have to force people to vaccinate themselves,” said Roberto Burioni, a virologist at San Raffaele University in Milan.He added that while firing workers is exceedingly difficult in Italy, he hoped the decree will bite into the salaries of any vaccine skeptics, especially considering the large amount of data demonstrating that the vaccines’ efficacy is worth the risk. He also worried that the high number of health professionals refusing to get vaccinated had troubling implications.“Unfortunately there is huge part of doctors who are deeply ignorant,” said Mr. Burioni, who suggested that perhaps “the selection process for bringing people to gain a medical degree and then the medical license is not effective enough.”Transporting coffins in Bergamo last year. Italy has had more than 100,000 Covid-19 deaths.Fabio Bucciarelli for The New York TimesWhile Italy’s populists, including the Five Star Movement and League parties, exploited vaccine skepticism for political gain in recent years, the country is not even considered the most vaccine-skeptic in Europe, a dubious distinction that usually falls to France. Italy also had a fast start in vaccinations at the beginning of the year precisely because the previous government prioritized medical workers.In January, the health minister, Roberto Speranza, said on television that Italy, like its European partners, believed it was better to persuade people to get vaccinated than to require them to. “Those who had to deal with the virus, our health care workers, are even more aware than the others,” he said. “I think willingness will be enough.”But Italy’s vaccination program has hit speed bumps. First, the pharmaceutical company AstraZeneca failed to make good on millions of promised doses. The previous government, led by the Five Star Movement, fell, and Mr. Draghi came in promising to help accelerate vaccinations and the country’s economic recovery.He has pushed for bans on vaccine exports from the European Union to contend with the shortages. He has sought to mobilize new categories of vaccinators and centralize Italy’s response to make up for the failure of some of the country’s hardest-hit regions to inoculate the most vulnerable, older citizens. On Tuesday, Mr. Draghi himself received an AstraZeneca dose after joining a temporary Europe-wide suspension of the vaccine amid concerns about its safety.“It is absolutely not OK that unvaccinated workers are in contact with the sick,” said Prime Minister Mario Draghi, center.Angelo Carconi/EPA, via ShutterstockBut the anti-vax health workers have struck a deep nerve.In a nursing home outside Rome, nearly all of the health care workers chose not to be vaccinated, and a cluster erupted around three workers and 27 out of the 36 older guests. Roberto Agresti, the home’s owner, feared the worst for them. “If we had a law forcing everyone to get vaccinated, the virus would have passed without us even noticing it,” he said.In the southern city of Brindisi, the local health authority has opened disciplinary proceedings against 12 health care workers who expressly refused vaccination. It is also investigating why about 140 health care workers, including doctors, nurses, pediatricians and specialists, declined shots of the Pfizer vaccine.“We don’t want to punish workers — we need them,” said Giuseppe Pasqualone, who leads the local health authority. “But the risk of contagion not only for them but for fragile patients is very high.”Officials at the San Martino hospital, where Mr. Macciò died, said it was not clear whether the unvaccinated nurse was the source of the cluster, but they acknowledged that it was a problem.Salvatore Giuffrida, the director of the hospital, Europe’s fourth largest, said he favored a vaccination requirement because it would also keep medical workers healthy and would strengthen defensive lines as a brutal third wave spreads through northern Italy.“We cannot afford not having them on the job,” he said. “The objective is not to lose soldiers during a war in a nation that complains about not having health care workers.”He estimated that 15 percent of his nursing staff, about 400 nurses, was unvaccinated. Simply removing those nurses from the wards, or redirecting them to switchboards as some have proposed, would be “a cure worse than the disease,” he said, because it would result in the reduction of 250 beds.He and other directors said that Italy’s strict privacy laws kept the hospitals from knowing which doctors and nurses were unvaccinated.Paolo Petralia, the director general of the Lavagna hospital in Chiavari, the site of another outbreak this month, said 90 percent of his doctors were vaccinated, along with about 80 percent of nurses and aides.“They are protected by privacy laws,” he said, citing a recent pronouncement by Italy’s data protection authority that the vaccination status of health workers should be unknown. “But this right exists until it does not limit another person’s right,” Mr. Petralia said.Lining up at a drive-through vaccination center in Milan this month.Alessandro Grassani for The New York TimesSome Italian courts have agreed. In 2017, Italy made some vaccinations compulsory for children, including for measles, and barred the unvaccinated from attending school — a decision backed by Italy’s constitutional court because it also safeguarded public health. In the northern city of Belluno, a court ruled in mid-March that a nursing home that employed several health care workers who chose not to get vaccinated could force them to take paid leave.Mr. Macciò, whose father died in Genoa, said it made no sense that the people entrusted to care for his father were allowed to potentially harm him. He said he had complained to the doctors, who told him their hands were tied because the nurses were protected by privacy rules.But amid Italy’s frustration, and the new decree, something appears to be changing. Mr. Macciò said the police had asked for his help in identifying the nurses he saw when going to pick up his father’s belongings.“I hope some good comes of it,” he said of his father’s death. “These people should change their job.”Emma Bubola