The woman in the San Antonio intensive care bed was on a ventilator, her lungs ravaged by COVID-19. After the staff tried everything they could to help her beat the virus, there was nothing else to be done but try and make her comfortable as her life slipped away.
"I'm sorry," she kept telling Maria Manzanilla, the young ICU nurse at her bedside at University Hospital.
Manzanilla, 27, asked why she was apologizing.
The video above is from previous reporting.
"She kept saying she wished she'd gotten the vaccine," Manzanilla recalled.
About two weeks later, sometime in August, the woman died. She was in her mid-40s.
She is among more than 9,000 Texans who have died from COVID-19 in August and September, nearly 40% of them under the age of 60, part of an alarming upswing in reported daily deaths that threatens to overtake last summer's deadly surge in average weekly numbers.
The dramatic and sudden increase in deaths - which jumped nearly tenfold over two months this summer - comes in spite of tens of thousands of vaccine doses being administered to Texans every day.
Experts say it's being driven by the highly contagious delta variant of the virus that is preying on the 14 million Texans who remain unvaccinated. Some 96% of cases in Texas are the delta variant, state health officials said.
Since the first death linked to the coronavirus in Texas - on March 15, 2020, in Matagorda County - 62,033 people have died from the virus statewide as of Sept. 23. About half of them have occurred since vaccinations began in Texas in mid-December.
Just over 50% of the Texas population is fully vaccinated. Health officials say that the state's high rate of unvaccinated people contributed to a surge in hospitalizations last month, which preceded the spike in deaths that soon followed.
Of the nearly 19,000 Texas deaths attributed to COVID-19 since early February, 119 were fully vaccinated according to preliminary data from the state health department.
Scientists are still researching whether the delta variant is more deadly than earlier versions of the virus, but it is known to be much more contagious, and some data suggest that it makes people much sicker, much faster than the previous versions. The COVID-19 vaccines are extremely effective in preventing serious illness or death, scientists say.
"We shouldn't be surprised," Dr. David Lakey, vice chancellor for health affairs, chief medical officer at the University of Texas System and a member of the Texas Medical Association's COVID-19 task force, said of the death numbers. "The main reason the fatality rates are as high as they are is there's a lot of COVID in a lot of people that have underlying conditions and are not immunized."
Delta brings age shift in deaths
Manzanilla, who finished nursing school just weeks before the pandemic began, said that after a year and a half on the front lines as an ICU nurse, she noticed several big differences between this summer's delta surge and the previous surges in January and during the summer of 2020.
"This is the wave where they are a lot sicker," she said. "This is the wave where we're seeing them come in and they're dying a lot faster. It's pretty sad. And they are younger. The ones that are dying are a lot younger than they were last summer."
Statistics provided by the state back up her observations. Compared to earlier surges, a larger proportion of the deaths during the most recent surge are people younger than 60, according to state numbers.
The deadliest month of the pandemic so far was January - before vaccines were widely available - when 9,914 people died from COVID-19, according to state data. That month only 15% of the COVID-19 deaths were among Texans under age 60. Last month during the height of the delta surge, they accounted for 38% of deaths.
More Texans younger than 60 died in August than at any other point in the pandemic. Deaths of Texans in their 40s, for example, jumped to 679 - nearly double the previous peak for that age group in January 2021. For Texans in their 30s, deaths in August were 33% higher than the winter peak, while deaths of those younger than 30 - 124 in August - were 77% higher than the previous peak for that age group, which was 70 in July 2020.
Older people are still dying in the largest numbers, even as their vaccination rate has reached 98% in some areas and 79% of Texans ages 65 and older are fully vaccinated statewide. That's because they are still more vulnerable to the illness and much more likely to die from an infection than their younger counterparts, said Spencer Fox, associate director of the University of Texas COVID-19 Modeling Consortium.
While deaths in that age group also increased in August, they were far below their peaks over the winter and last summer.
Hospitalizations peaked in August statewide - nearly reaching the record numbers from the January surge - and more hospitals reported ICUs at or over capacity than at any other time in the pandemic. Those numbers are starting to level off or decline, along with the positivity rate, which measures the percentage of COVID tests that are positive.
It's an encouraging sign that the delta surge may finally be cresting, although that's not a certainty, Fox said.
Millions of Texas students returned to school in person in August and September, many of them in districts with no mask mandates as Gov. Greg Abbott battles with districts in high-transmission areas over how much authority they have to enforce behaviors that can help lower infection rates.
Fox said that he would expect a back-to-school bump in cases to show up this fall, if there is one.
"Right now, we're projecting overall declines in the state over the next few weeks, which is a very promising trend," Fox said. "We don't quite have enough data yet to understand the impact that school reopenings might have on the trends."
Deaths are a trailing indicator: They rise after COVID-19 cases and hospitalizations rise, then fall after those indicators fall.
"We'll have to have a dose of humility and caution as we look at these numbers and not be surprised that deaths are going to be elevated for a while after we get past this peak of hospitalizations," Lakey said.
"Angry and frustrated" by new wave of COVID-19
Last summer, Manzanilla said she and her fellow nurses were afraid of the new virus and heartbroken for the patients whose deaths they witnessed. Often, the nurses would sit with them so they would not pass away alone while their devastated loved ones could only look on through windows or smartphones because of COVID-19 visitation restrictions.
This summer, Manzanilla said, she mostly feels "angry and frustrated." And conflicted.
"We started out worried but we transitioned into anger," she said. "These people were not dying prior to COVID, and now they're coming in and getting this virus and they're dying, and it's something the community could have prevented.
"But at the same time, you feel compassion toward the patient because ... they're still human beings," she added. "They're still here. They're sick and we're here to take care of them."
Manzanilla said she, like others in her profession, is burned out and looking at a career change after the pandemic subsides. Last year held too much grief, too much death. She's decided she'd like to become a nurse practitioner, working in a doctor's office instead of on the front lines of tragedy.
"It's very heavy work," she said of being an ICU nurse. "I'm going to go back to school within a year. I don't think I can stick with bedside for a long time. I thought I could, but I don't think I can."
Disclosure: Texas Medical Association and University of Texas System have been financial supporters of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune's journalism. Find a complete list of them here.
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