Host:

Hello, and welcome to the podcast. In the coming weeks, we'll be learning more about coronavirus, not just about the virus itself, but of the response to the global pandemic that has shut down cities, forced people into their homes, and started a race to find effective treatments and therapeutics. In this week's episode, we are joined once again by Dr. Lisa Costello, an assistant professor of pediatrics at the West Virginia University School of Medicine. She's also the president of the West Virginia chapter of the American Academy of pediatrics. Dr. Costello discusses some of the unanticipated health consequences of living during the global pandemic, not only for children, but for adults and those with special health considerations. Since March, coronavirus has been on the forefront of all of our minds. It's been impossible to avoid, but as we focused on keeping our families and ourselves safe, we may have turned our attention away from other health concerns.

Dr. Lisa Costello:

In the beginning of the pandemic, certainly there's no playbook for this. This is something that has impacted the entire world. In the beginning of the pandemic or early on, there was the movement to really err on the side of safety, and we needed to provide doctors offices, hospitals the opportunity to prepare to be able to safely deliver care. That may look like acquiring more personal protective equipment, or PPE, to be able to wear, to be able to see patients so that not only are we protecting patients, but we're also protecting staff. We needed to make sure that we were conserving that PPE for the individuals on the frontline because there is still a shortage, but there was a more severe shortage in the beginning of this pandemic.

            We're continuing to see more PPE being made and acquired, and we've seen a lot of innovative ways, including at WVU, where we've jumped into to make face shields or respirators, so PPE, as well as changing how we typically practice medicine, so reducing wait times, screening individuals before they come, having individuals wait in their car, and some would even have their full visit in their car in order to limit the interactions with other individuals because we have known from the beginning, and we still know, that we really need to be physically distant from one another, we need to have good hand washing, and more recently, the importance of wearing face cloth coverings, so whether you're wearing a mask, and there's different types of masks, for healthcare personnels versus everyone wearing a face cloth covering.

            Really, in the beginning of this pandemic, we saw delays in care delivery because we as a healthcare system needed to respond, and we looked at, "What are considered to be more urgent care items that need to be addressed?" Then over time, we realized that there's more and more important items that need to be addressed. Many individuals didn't seek care because they were afraid to go out, and there were orders to stay at home. We saw people not go to their routine health or preventative health visits.

Host:

The Vanderbilt Child Health COVID-19 Poll conducted in June 2020 surveyed parents of children under 18 about their experiences since coronavirus began to spread in the United States. One in three families reported cancellations or delays in their children's healthcare. The most commonly delayed visits were well child visits, but subspecialty visits and behavioral health visits were also delayed. The Centers for Disease Control and Prevention's morbidity and mortality weekly report found immunization rates among children have fallen between 60% and 80% during the pandemic.

Dr. Lisa Costello:

What I think is very concerning to pediatricians and healthcare professionals across the board is that vaccines are one of the most effective public health interventions ever introduced. We are seeing right now what the world is like when we don't have a vaccine for a communicable disease with COVID, and there are ongoing efforts to develop a safe and effective vaccine for COVID. Vaccines really have become this fabric of our society and is a significant medical intervention because they prevent life-threatening illnesses, including types of cancers, and really we see vaccines keep communities safe. If we're able to protect us all, we're able to prevent the spread of that disease in a more effective fashion. When we see immunization rates falling, we can see those diseases creep back into our communities. We were seeing this before the pandemic in certain areas where vaccination rates were low for, say, measles, which is a very highly contagious virus disease.

            We were seeing in areas where we had lower vaccine rates... We were seeing those diseases creep back into our communities and have impact on children. As we progress through this pandemic, we need to make sure that we're protecting individuals from the diseases that we already have the capability to prevent, so these vaccine-preventable diseases, as the way vaccines work is that we need to have a certain percentage of a community be vaccinated so that we can keep those diseases out. These diseases haven't gone away. We just have become better at preventing them through safe, effective vaccines. That's why we have been encouraging individuals to make sure that their children stay up to date, and adults need to stay up to date too. As we progress into the fall and we enter flu season, it's going to be really important that individuals get their flu vaccine as that is the best way that we know to prevent severe illness with the flu.

            As we continue to battle COVID, we need to make sure that we are not seeing a very significant flu season, and vaccination is going to be one of the key factors in making sure that we keep communities healthy. It's vitally important that individuals continue to get their vaccines at all ages of life, but certainly for our children when they're getting that primary series of vaccines to prevent against those diseases that we are currently able to prevent against. Hopefully, in the near future, we'll have a vaccine that's safe and effective to fight COVID as well.

Host:

Dr. Costello says preventative medicine is incredibly important at all ages, but especially for children. Regular well child visits are necessary to evaluate a child's height, weight, growth, and developmental milestones.

Dr. Lisa Costello:

There's different screenings that happen to determine if a child is developing on time. Many times, it can be very subtle developmental challenges when it comes to speech or maybe movement, and there are various questionnaires that parents fill out with their healthcare provider that look at the development of their child. The pediatrician or the family practitioner is able to look at the development of that child in addition to evaluating them through examination and then determine if they see a developmental delay. We know that the earlier we're able to intervene, the better outcomes we will see when it comes to some of those developmental challenges. We can get that early intervention, whether it's physical therapy, speech therapy, occupational therapy, and work with children so that they can catch back up. That is really, really important to make sure we're detecting early because the earlier we're able to intervene, the better outcomes that we will see, same thing when it comes to growth.

            Perhaps someone is slipping off of the growth curve. They're not growing as well as they should be. Those are measurements that we find through these preventative checks, and we can intervene. Also, the other end of the spectrum, perhaps we're noticing that individuals are gaining too much weight or they may be overweight and that we need to have an intervention because we know what obesity or being overweight can have in regards to longterm health implications, such as high blood pressure or diabetes. It's really important that we continue these preventative checks so that we're making sure that children are growing, developing appropriately, as well as making sure they stay up to date on their vaccines. The other thing that really I think is important when we talk about preventative healthcare visits is anticipatory guidance that healthcare providers give. For instance, in the summertime, we talk about drowning prevention or fire injury prevention or car seat safety. There's many different items that pediatricians and family healthcare providers educate families on based upon the developmental age of the child. We know that it's really important that we are educating individuals on how to keep their children safe.

Host:

While some education, guidance, and medical care can be delivered remotely through telehealth, Dr. Costello says sometimes an in-person visit is necessary even during a pandemic. Many safety measures have been implemented at doctor's offices across the country, including organizing office visits into well care and sick care blocks and instituting infection control measures, from removing seats and toys in the waiting room to conducting drive through testing and vaccinations.

Dr. Lisa Costello:

We've seen healthcare providers, whether it's private practice or larger institutions like WVU Medicine, really making sure the priority and safety of patients remain at the forefront. I think even before the pandemic, our clinics and our offices and our hospitals were always striving to improve the safety and delivery of care to patients. But when it comes to COVID, we know that there needs to be certain strategies implemented to really increase our efforts to prevent disease spread, so instituting protocols that we maintain six feet apart.

            When I have been in the waiting room, I've seen different tape markings saying, "Maintain physical distance," increasing capabilities to wash hands, whether that's having more hand sanitizer units or making sure that we're encouraging hand washing and just advertising it more to remind people of the importance of hand washing, wearing a face cloth covering or a mask and making sure that we're having individuals wear masks and making [inaudible 00:11:07] people when they come in. I was working at one of our branch hospitals in Moundsville, and they were checking when you came in and giving you a mask in case you didn't have one, so having protocols like that in place and doing screening, so if you do feel I'll, calling them ahead of time or having a patient identify themselves, "Have you been feeling ill?" or, "Have you been in contact with someone who was diagnosed with COVID?"

            Then we can take even further measures to ensure that those individuals are either maybe participating in a telehealth visit and not being seen in person, or if they absolutely need to be seen in person, what are we doing from the beginning to make sure that we are protecting everyone? There have been many new protocols implemented from screening of patients, maintaining six feet, physical distancing, wearing masks or face cloth coverings, having hand washing to ensure that we are doing all that we can to deliver safe care. Other strategies I've seen deployed are cohorting visits, so seeing the maybe well visits in one part of the day and then those individuals who may be sick in another part of the day so that we're trying not to intermix individuals who may be sick versus those well preventative visits that we talked about earlier.

Host:

Even beyond childhood and adolescence, Dr. Costello says preventative medicine and routine healthcare remains important. Depending on age, sex, and medical history, specialty care is also something people should consider.

Dr. Lisa Costello:

I think it's important when we're talking about prevention that it's all ages. Certainly in pediatrics there might be more frequent visits, particularly in the early ages of life, but really, as we progress through adulthood, we need to make sure that we are seeing a physician, seeing a primary care provider so that they can touch base and determine if there needs to be any intervention, so if we're talking about high blood pressure or diabetes, but also, there are screenings as we get older, so whether that's getting your mammogram or getting a colonoscopy, doing routine female healthcare, as a few examples, are really important that we identify these conditions early so that we can intervene early. Perhaps it's making lifestyle changes, or maybe it does require a medication or another intervention. I also think it's really important that we're seeing and participating in routine preventative healthcare to make sure that we're evaluating our mental health and having those discussions with our providers.

            This pandemic has had stress on people of all ages. It's a stressful situation. It's a situation that we have never had to deal with in our lifetimes when you're talking about the last pandemic in 1918. Really, this is nothing, I think, to this magnitude as people have spoken about, and so there has been a lot of added stress as we've become more isolated for good reason, to try to prevent the spread of COVID, but these isolation and the separation that we've been promoting can lead to mental health challenges. Individuals who may have already suffered from depression or anxiety or substance use disorder, we can see that getting worse in the pandemic. When we are able to have routine visits with our healthcare professional, we can have those discussions to make sure that we are also assessing someone's mental health, as well as their physical health. We know that health is all-encompassing, physical, mental, emotional, and it's important that we're assessing all of those. That's what that routine check-ins with your doctor can help promote as well.

Host:

Based on parent responses, the Vanderbilt poll found that mental and physical health worsened for parents and children during the COVID-19 pandemic. It's been an incredibly stressful time as we all figure out how to navigate the uncharted territory in which we find ourselves.

Dr. Lisa Costello:

I certainly think, and I have seen it, that the stress, fear, uncertainty that we've seen from the pandemic, it really wears anybody down. We know that there are certain individuals who may be even having a tougher time, so teens or children. I've seen children just have the change to their routines. Children love routines. When we disrupt routines, which we've seen with the pandemic, that can be to added stress. It can be hard to cope with that, especially when it's been for such a long period of time. We can see there's stages of grief that we talk about. When we're talking about a pandemic, there's also those similar stages in that in the beginning, we have a lot of adrenaline that we're going to address the pandemic, but then over time, we can see things such as denial and anger and depression set in as we're coping with this pandemic.

            When we're talking about children and teens, it's important that we stay in touch with them, whether it's their pediatrician screening for depression, as we talked about the importance of those visits, but then also to encourage parents to discuss with their children or their teens. We know it's normal for teens to feel sad. They could maybe cry because they're missing their friends or missing sporting events or missing other activities that they would typically be engaged in. You want to be, as a parent, on the lookout for, "Are you noticing any changes in your teen, their mood swings are more, they're having more behavior, so they're stepping back or regressing from things that they had done previously? Maybe they don't have a lack of interest in activities anymore?"

            Those type of things could alert a parent to say, "I think I need to have a discussion with my child or teen about how they're coping with this," and also talk with their healthcare professional to see if they may need additional resources to help. I think that it's important that when we're talking about children and teens that parents really kind of set the tone. We want to make sure that we are being cognizant of how our interactions are. If parents or the adults around are showing a lot of fear or anxiety when we're talking about items addressing the pandemic, our children and teens pick up on that, and they can pick up on the fear that we as adults have.

            We want to try to remain positive and relay consistent, calm, reassuring messages that we're going to get through this, we're going to make it through it together, and that it's important that we continue to communicate with one another, and that many of the feelings that we may be having are normal in this time, but we need to be careful to make sure if they become too intense, we may need additional help to get us through to cope with the changes that we're seeing happening. I think it's important that there's that open line of communication, that you're checking in with your child or teen to be able to make sure that you're checking in on their mental health, just like we check in on someone's physical health as well.

Host:

It's important to consider routines, especially for children and teens, but Dr. Costello also encourages families to include fun activities in their schedules, such as going for a hike, playing a board game, or even trying a new recipe together. She also encourages everyone to be cognizant of how much non-education or non-work-related screen-time we're consuming for our mental and physical wellness.

Dr. Lisa Costello:

Another way that we can work to remain active or an activity that we can do with our families is making sure that we stay physically active. We may not be able to go to a gym or a congregate care setting or... Let me restart that. We may not be able to go to a gym or a public place that we can engage in physical activity, but we could do a workout at home. We could create a workout. I've seen different activities, whether it's creating a challenge course for children to go through in the yard that involves hopscotch and jumping over a maybe a log or something of that matter, and so we know that physical activity is an important part of our overall health. We need to make sure that we're still engaging in activities of exercise and physical activity during the pandemic as well.

Host:

People who have mental health issues or struggle with substance use disorder may have felt the impact of the pandemic more than others. The American Association of Medical Colleges says that anxiety, grief, isolation, financial worries, changes at home and work, and an ongoing sense of uncertainty can all threaten people with substance use disorder, as well as those at risk of developing it.

Dr. Lisa Costello:

The pandemic certainly has been stressful on individuals of all ages. If you talk to, I think, most people, they will say, "We've never really experienced anything like this in our lifetime." Certainly we know that it impacts individuals of all ages. As we get older, we also have feelings of depression or anxiety that we have to deal with. In our state of West Virginia, where we have a high amount of substance use disorder and addiction, when we institute strategies as a community to try to reduce the spread of a communicable disease like we have with COVID, that leads to more isolation, and that can lead to more feelings of despair and really potentially lead to relapse if individuals were maybe battling their substance use disorder, and then they kind of can slip into relapse or increase their use as a way that they're trying to cope with the pandemic and what we're seeing going on around us.

            We know that there are healthy ways to cope with stress, and we need to make sure that we're providing resources to individuals so they don't go to the unhealthy ways to cope with stress such as drug or many different types of drug abuse, whether that's IV drug use or alcohol abuse. In addition, we also worry about increase in suicide, and we have seen individuals and seen numbers of suicide go up as we're looking at these mitigation strategies, again, leading to more isolation and individuals feeling like they're not able to get help, but help is out there. Help is available. There are various suicide hotlines to call, that it's important that individuals seek out help if they're feeling hopeless or that they may be contemplating injuring themselves, hurting themselves, or killing themselves. Whether it comes from your substance use disorder or your depression, anxiety, we can see an increase in mental health disease during times of stress.

            There are certainly resources out there available for individuals to seek out. The West Virginia Department of Health and Human Resources has frequently been sharing information as to where individuals can seek help, whether it's for their substance use disorders. The different health departments have been very busy when it comes to managing the pandemic, but they also have their rapid response teams staying operational. Throughout the state, there have been ongoing behavior therapy sessions, different clinics that continue to meet in different means, many times virtually, to continue those services to help address that the epidemic we were seeing before the pandemic, which was substance use disorder.

Host:

The AAMC report said it's too soon to have definitive data on the pandemic's effects, but early numbers are concerning. Alcohol sales have risen more than 25%, and an analysis of 500,000 urine drug tests by Millennium Health showed increase of 32% for non-prescribed fentanyl, 20% for methamphetamine, and 10% for cocaine for mid-March through May. Suspected drug overdoses climbed 18% in that same period according to a national tracking system from the University of Baltimore. The report said that some patients were fearful of seeking treatment in the early days of the pandemic for fear of contracting COVID-19. For those looking for inpatient care, they struggled to find available services or open facilities. In West Virginia, the Department of Health and Human Resources' Office of Drug Control Policy recently launched an interactive map of the state's treatments and recovery resources. The map allows residents to search resources by county, program type, gender, and by the American Society of Addiction Medicine levels of care. The map is available under dhhr.wv.gov under the Office of Drug Control Policy and then under Get Help. Those who prefer an offline option can call the number [1-844-HELP-4WV 00:24:47] or text 1-844-435-7498.

Dr. Lisa Costello:

Throughout the pandemic, we have seen that it's important to maintain connectiveness. We talk a lot about social distancing. I tend to call it physical distancing because I think it's still important that we have meaningful connections with individuals. When we're talking about children or teens, well, I really think anyone, we talk about having one caring adult or one caring person so that they can be there for others, particularly in children and teens, and I think it's important that we continue to reach out to individuals, whether it's picking up the phone to check in on someone, whether it's checking in on a neighbor.

            Maybe it's writing someone a letter, or now that we have other different technological ways of connecting, whether it's FaceTime or through a virtual meeting, we can still keep in touch with individuals and check in with one another to just see how everyone is doing. I know that my group of friends, we tend to check in. It's usually someone different every day just kind of saying, "How's everyone doing today? How are we doing to cope with what's going on?" Those little moments are really impactful so that someone knows that you're being thought of and that we're going to get through this together and we're coping with the stress of the pandemic together.

Host:

It has been a challenging year for so many. Everyone is adjusting as best they can to the, quote, new normal. "We will get through this," Costello says, "but we cannot let our guard down just yet. The fight against COVID-19 is not over, and we must be as safe as possible. There will be some bumps in the road, but every day is a step closer to a treatment, therapeutic, or vaccine that can help get us back to where we were."

Dr. Lisa Costello:

As we journey through the seasons of the year, there's always a little bit of a change of... whether it's going from spring to summer to fall to winter. There's always different excitement that comes with the change of the season. I really love the energy of the college atmosphere. We know that things are going to be a little bit different, but there are certain things that can never be taken away, and that can be our interactions that we have with others, whether it's a call or a text to say, "Hey, how are you doing? I'm thinking of you," and just reminding individuals that we're all in this together and that we are going to get through this day by day. We are going to have to make some different changes that need to happen to make us all be safer.

            I think President Gee has talked about these as acts of kindness, and that's really what I think they are, that we're being kind to our fellow Mountaineer or our fellow West Virginian or our fellow human, and just making sure that we all check in together. As we continue to progress through this pandemic, we'll learn more, things may change, and that is okay. That's showing that we're making progress. But at the end of the day, we're all in this together, and we've made great strides. We have seen a lot of positive things come from this. In addition to my ability to better run a Zoom session, we've seen many different things, whether it's telemedicine. I heard of a colleague seeing a patient when they were on a job site in a bulldozer because the patient was able to connect through telehealth when typically they wouldn't be able to get off work to come in to be seen.

            There have been those little areas of progress that we've seen being made because of the pandemic, that we've had to kind of push or accelerate things that we've done, and I think in the end, we just have to remember that we have should take it one day at a time, if that seems like too much, just take it a moment at a time, and that we're going to get through this. Keep washing those hands, wearing those masks, staying physically distant, but we can still certainly socialize in other capacities and maintain our safety. We can do this. As Mountaineers, we're in it together, and we just have to keep taking one step at a time. Since football season's coming up, I think we just have to trust the climb. When it's coming to the pandemic, this is a big mountain that we've had to climb before, and we'll get through it if we keep climbing together.

Host:

If you're interested in learning more about West Virginia University's response to the COVID-19 pandemic, visit.wvu.edu, follow us on social at @WVUHealth on Facebook, Twitter, and Instagram. Make sure you subscribe to this podcast on your favorite podcast app to get the latest episodes as they're released.