♪ ♪ Gavin: Welcome to This Week in South Carolina.

I'm Gavin Jackson.

With cold and flu season heating up state epidemiologist Dr. Linda Bell breaks down what we should expect this winter.

But first, Dr. Eugene Chang and maternal fetal medicine specialist at MUSC discusses the rising issue of maternal mortality.

Dr. Chang, thanks for joining me.

Dr. Chang: Yeah, happy to be here.

Gavin: So Dr. Chang, I want to ask you about maternal mortality rates in our state.

In 2019 there were 66 Pregnant Women Who died 22, of which those deaths were determined to be pregnancy related 70% of pregnancy related deaths occurred during the postpartum period.

Can you tell us about why that's always the case?

and what's driving this?

Dr. Chang: Yeah, that's a great question.

I think It's a lot of factors.

I think the first thing and something that I've learned by participating in review of all these mortalities is that, you know, most of the time for an obstetrician, when you hear about a maternal death, you know, the things that most of us pictures a patient who has severe bleeding, or something like a heart attack or stroke right around the time of delivery, and certainly those things can happen.

But thankfully, to be honest, I think we're making a lot of headway, particularly in the area of hemorrhage.

And so what's happening is now we're recognizing if we spread out sort of looking at pregnancy as a factor in a patient's passing away, and we, we take patients a year out from their pregnancy and kind of look and see what happened that led to their to their death.

and then we do see pregnancy as an issue.

And so in the postpartum patients, certainly things like uncontrolled blood pressure issues can lead to death.

But a big chunk of what we see is related to psychiatric disease and substance abuse, and so a lot of overdoses.

Unfortunately, and you know, those are all things where the the question is really, is pregnancy a driver of that death?

No, but his pregnancy, something that was a big stressor on the patient that led them to that point?

The answer is probably yes.

Gavin: Yeah.

So you're saying the top underlying causes of these maternal deaths are cardiomyopathy, mental health and hemorrhage.

When you do cardiomyopathy, and cardiovascular conditions together, that counts for one in four deaths, according to some reports from DHEC.

So how do you get those numbers down?

Is that more when it comes to comorbidities with the patient?

Dr. Chang: Yeah, so the the cardiomyopathy part is, is tough, because there are patients who develop cardiomyopathy.

And I don't know that we have any way of predicting who the patient is, It's going to develop that, where I think, you know, we struggle is patients will develop something called a peripartum cardiomyopathy.

and a lot of times, they'll have recovery and actually get better.

The problem becomes when they get better, and they get pregnant, again, they have a risk of recurrence.

So, you know, I think addressing, you know, in a sensitive and an honest way with patients like what their childbearing you know, plans are in that particular group is important.

And then in general, you know, just addressing cardiovascular disease, before pregnancy is the most ideal thing we could do in practice, it doesn't work is in practice, what we typically see as patients show up pregnant, you take a history, and then you find they've got some cardiac issues, most commonly, hypertension, so high blood pressure.

and, again, the good news with that is that can be treated.

So you know, the challenge, really, with respect to heart issues is identifying the patient.

And, you know, there are definitely patients we feel like should never be pregnant with certain heart conditions.

There are patients with heart conditions that we see that we feel like if they can get tuned up, if you will, prior to pregnancy, they would do better.

And so that that's the issue is kind of seeing the patient before It's a hard thing to do.

Honestly, if you're a cardiologist following these patients, your focus is on the heart and understandably, not always on the patient's desires for childbearing.

So It's just something that that we're trying to do is to raise awareness across the board on these issues.

Gavin: I was gonna say is that your message to women who are maybe thinking about becoming pregnant if they do have some, you know, hypertension issues, cardiovascular issues, that they should really be aware of that before going forward with, you know, a complicated thing such as pregnancy?

Dr. Chang: Yeah, I think I think the best thing to do if you're a woman contemplating pregnancy and you have any sort of medical condition, the first thing to do is always bring it up with your doctor, you know, hey, I'm thinking about getting pregnant.

And so there are a lot of patients that have fairly straight forward medical problems that can be addressed by their primary care physician or their, you know, specialists that don't necessarily need to involve a visit to a maternal fetal medicine specialist right away.

But as long as It's addressed, they'll do well.

and there are other women who actually need to be sent to us and our minds and and yeah, getting those patients to the right place is really important.

And so the only way to do this is to communicate.

Gavin: Yeah, because it can lead to complications later on.

I mean, you know, my cousin, for example, she was pregnant.

She had preeclampsia during delivery, and was touch and go there for a little bit.

Now.

She's talking about having wants to have another baby.

What's the advice for folks like that?

Should they be having another baby if there's complications in one pregnancy?

Dr. Chang: Yeah, it all depends on the complication and the situation.

The one true as in obstetrics is if It's happened before, you're at risk for having it happen again.

So that's sort of the bad news.

The good news is for a lot of conditions like preeclampsia, even whenever occurs, it tends to be less severe.

There are things we can do to reduce the risk of preeclampsia.

But yeah, I think the interesting thing with women who have complications, like preeclampsia is the pregnancy for the most part is, is something that occurs in healthy young people, right?

And so you go through pregnancy, you do all the right things, and then they get really sick, and then your sense of well being actually just evaporates, you know, because all of a sudden, you went from being well, to not well, and, you know, that can be traumatic for lots of patients.

And I think, again, communication is important in understanding, you know, the questions to ask, and I think if you're pregnant, you've ever had a complication with pregnancy, that, you know, the conversation, you know, with your OBGYN should be like, Hey, I'm thinking about getting pregnant again.

Is that a good idea?

Bad idea?

You know, what's the chance of whatever complication I had recurring and what can I do about it?

Gavin: Yeah, Dr. Chang, you're just talking about there about how that well being Shre... that transition there for some of these complications.

So is that maybe what also leads to some of these mental health issues that we see postpartum?

That?

I mean, a lot of these deaths were also mentioned to be preventable, too.

So is it maybe just a whole patient approach to especially after birth?

Dr. Chang: Yeah, I do think It's a whole patient approach has It's really important, but I don't think so I think a lot of the mental health related deaths, and the substance abuse disorder related deaths are patients who came into pregnancy with those issues, long less common for a patient otherwise healthy without those diagnosis.

develop those diagnoses?

Can it happen, yes, but those are a little bit different.

And you know, that that those patients are a special population, because they're hard to take care of, in the sense that resources in the state and the community aren't as as robust as we'd like.

You know, thankfully, at MUSC, we have a group of psychiatrists that are very interested in women's behavioral health and reproductive behavioral health and recognize the strain that pregnancy puts on someone and, you know, they they've done a lot of outreach and really have provided a remote like a telemedicine platform for patients.

and really, they reach patients across the state now, that's been good.

Gavin: and Dr. Chang, you've been practicing for many years in South Carolina, I want to ask you about the the six week abortion ban law that got upheld by the state Supreme Court, I don't want you to get too political.

I know that's not your job.

but I just want to ask you what you're seeing.

It's been two months now, are women nervous?

I know, there's some exceptions for Fatal fetal anomalies in there.

but that takes a lot of hurdles to clear in terms of whether someone has to give birth to a child with birth defects.

What's what's it like right now on the front lines, two months into this?

Dr. Chang: Yeah, I think It's difficult, I think, you know, none of us really know how to navigate what's going on now.

And, you know, I think that, you know, the problem for as a physician is understanding, you know, what is really lethal, you know, for baby and, you know, what are the things that are, you know, problematic for moms to the point where the termination of pregnancies, okay.

You know, It's I think the legal world and the way a law is written is inherently very different from you know, how we think in medicine and I think marrying the two is presents a challenge and, you know, obviously, the threat of being charged with a felony is something that weighs on all physicians.

So I think it is tough.

We're all trying to figure it out.

It's frustrating in the sense that, you know, you feel like you kind of understand.

I mean, I feel like I understand where the legislature's coming from, you know, in the ban.

But I do think they're just things that were a little bit more poised to understand seeing these problems day in and day out.

And, you know, I wish, I don't know really what the solution is, you know, I do think somehow, physicians need to be more involved.

Because, you know, like I said, the laws are written with lawyers in mind, but not physicians in mind, and it makes it really hard to provide care.

Gavin: Have you had any complicated situations in the past few months due to the law?

Dr. Chang: Um, I have not personally.

But yes, I mean, you know, part of my job is, you know, fielding a lot of questions, and then we, you know, we get a lot of questions about, you know, just what in like I said, I think defining lethal is, is tough, you know, and that's probably the question that comes up the most, you know, I've seen a baby with this problem, is this lethal?

And the answer is, well, you know, It's a complicated answer.

So it makes it for a tough, tough discussion.

Gavin: and Dr. Chang, I just want you to maybe, you know, forecast or maybe estimate, I mean, there were 416 infants who die within the first year of birth, that's our infant mortality rate in the state that's 7.3 per 1000 live births.

Do you think that that rate might go up as a result of this law?

Can you even guess that?

Dr. Chang: Yeah, I, there's no way of knowing because, you know, the, I would anticipate the number would go up.

Because what, what I would think would happen is that, you know, patients with babies with anomalies that were really severe, who would have formerly terminated the pregnancy, would be carrying those pregnancies deliver those babies, and then they would pass away.

So, you know, that number may change.

Patients Still can leave the state.

So the part we don't know about is, you know, how many patients will leave the state to have a procedure done?

So I would think the answer is sort of yes or no.

And, you know, It's tough.

I think, probably this, like, little question points out one of the big flaws with the way we we track things, you know, if that truly represents an increase in infant mortality, you know, it sucks that the number is going up.

but It's, you know, I think the biggest question is, are we as healthcare providers not doing our job?

You know, I think the the way I think about this is if I see maternal mortality rates are going up, I think, well, what can I do to make things better, right?

I think if you're a pediatrician, you see an increase in infant mortality going up?

Your thought is what what am I not doing?

What can I make better?

The truth is, if you see an increase, and It's related to this particular group of patients, patients with fetal anomalies that pass away, I don't know what to do about it.

You know.

Gavin: It's also kind of... Dr. Chang: Right, It's not actionable, really, right, from a pediatrician perspective.

Gavin: And it comes at a time too, when there's a lot of counties in our state that don't even have access to OBGYN like yourself to so that kind of compounds this entire situation.

Dr. Chang: Yeah, yeah, yeah, I think, you know, like, trying to be a little bit stuck about all of these things, you know, we tried to control the things we can and understand that part.

And I think there are a lot of things that, you know, as an OBGYN or maternal fetal medicine specialists, we can do I mean, the the challenge of healthcare deserts in this state is tough, you know, I think smaller counties, you know, probably don't have enough in terms of population to support a hospital.

So It's, I don't know, how realistic is to have a hospital in every county.

I do think, you know, we need to figure out ways to get health care to patients a little bit better now that, you know, they still probably will have to travel to a hospital.

But you know, I think that the thing that COVID showed us is that we can do a lot more with teleconferencing tele video tele visits, if you will, that, you know, would be beneficial to patients.

Gavin: And Dr. Chang, we're gonna leave it there.

That's Dr. Eugene Chang.

He's an OBGYN at MUSC.

Thank you so much, sir.

Dr. Chang: Yeah, you're welcome.

Gavin: Joining me now to discuss the respiratory virus season is state epidemiologist, Dr. Linda Bell, Dr. Bell, welcome to This Week in South Carolina.

Dr. Bell: Thank you for having me.

Yeah, I mean, I appreciate it.

Gavin: Great.

Well, let's we have a lot to talk about, obviously with respiratory viruses.

but let's start with the flu.

Everyone knows about the flu.

It's always here every season.

But the 2024 season is officially underway right now.

And it comes on the heels of a really bad 2023 season.

but first, just tell us what folks can be doing in preparation for the flu season.

And what your what the trend is looking like so far.

Dr. Bell: Yes, thank you.

We do want to make sure that people are informed of the potential increase activity of the flu virus.

And as you said, we've already started in the flu season, which officially sort of kicks off the beginning of October.

But we know that flu activity can be unpredictable.

So it can increase as we saw last year, a huge surge in the very first week of flu season.

And flu activity can vary in its intensity, anytime between October and actually flu season ends in May, we generally see the highest activity in December through February, I would say.

but because It's unpredictable, we really encourage people to get their flu vaccine and annual flu vaccine, well in advance of when flu activity is expected to increase to make sure that they're protected before they're exposed.

And what we want to inform people about with the flu vaccine is that it actually takes your body about two weeks to mount a full strong response.

And so that's what we mean about what people can do to be prepared.

People often ask, Well, why do I need to get a flu vaccine every single year.

And that's because the virus changes a little bit from year to year.

And we want to make sure that people receive the vaccine that is best matched to the currently circulating strain.

That's one reason.

And the other reason is that a protection against the flu is not really durable.

So it wanes, it decreases over time.

So It's very important for people to get an annual flu vaccine to make sure that they're best protected against the currently circulating strain, and that they have the strongest possible protection in advance of being exposed is really the best, the best option.

Gavin: So doctor about when we look at this year's flu vaccine, do we know how effective it is yet, have we any studies any ideas when it comes to these strains.

Dr. Bell: So we have some indication that the way vaccine manufacturers designed the flu vaccine from year to year is that they actually conduct surveillance for flu activity in the southern hemisphere.

So in the southern hemisphere, their flu season is April through October.

So they monitor the most common circulating strains in the south in the southern hemisphere.

and then they develop vaccines to be what is best well matched to what's circulating in the southern hemisphere, because that's generally what we see in the northern hemisphere by the time it gets around to us.

and so what we've seen so far from that surveillance in the southern hemisphere, is that the vaccines that are currently available in the United States are pretty well matched to those that are circulating in the southern hemisphere.

So we think that it will offer good protection.

Another thing that we did see in the Southern Hemisphere was that they actually saw higher rates of children being affected with the flu.

But we believe that's primarily because many children do not get vaccinated in the last flu season.

So from one year to the next, even though we do recommend an annual flu vaccine, you do get some immunity from previous exposure.

And and that did not happen.

For many reasons, actually, the protective measures that we took against COVID prevented people from being exposed to other respiratory viruses, including the flu.

So a lot of people don't have strong natural immunity.

But we think that this the current flu vaccines that will be offered in the US this year, this flu season will be a pretty good match.

Gavin: Yeah Dr. Bell that kind of goes back to a question I have about the last flu season, we saw with about 3400 hospitalizations and 162 deaths.

Those were those metrics were far above their five year averages.

and that was for the 2023 seasons.

Do you think that was more of a result of folks coming out from COVID?

And, you know, kind of going back to daily life was in the post COVID era that we're in right now.

Is that what you attribute to that spike to?

Dr. Bell: We do in part, and also we want to remind people that when we were in the throws of the COVID pandemic, in those three years prior we actually had very mild flu seasons.

So that natural immunity that I mentioned to you that comes from exposure didn't occur.

Because they were it was just very mild flu season.

So for those reasons, a lack of natural immunity.

Lower uptake with flu vaccines, we believe are strong contributors to the that really alarming surge that we saw with the beginning of the flu season last year.

It did taper down pretty quickly.

But I want to take every opportunity to remind people that one flu season to the next, they all look different.

We have seen rapid increases in declines only to be confronted with a second surge in a flu season.

That that often occurs with the type B influenza strain.

So the the underlying message is as best as possible, let's just be prepared with with coverage with the flu vaccine instead of trying to rely on how severe the flu season will be, or taking chances on the risks of exposure.

Gavin: And when you look at DHEC data, its pivot to COVID really quick COVID-19 right now is a little bit more prevalent than the flu circulating.

Would you say we have like hospital missions, I think around 250 a week and hundreds of ER visits weekly too.

Dr. Bell do you think COVID is the biggest respiratory virus threat for the state right now?

Dr. Bell: So it is currently because as I know we'll get to this looking at flu and also RSV.

The the most common hospitalizations that we're seeing are attributed to COVID.

We also do surveillance for outbreaks in congregate settings.

So we are monitoring flu activity COVID activity and RSV activity in schools in nursing homes and other settings.

And the most, the highest number of outbreaks reported in those settings is also due to COVID at this time.

We are seeing a little bit of an uptick in flu but not not really significant.

But we are we really need to be monitoring that because we anticipate it will increase.

Gavin: We were talking about the effectiveness of the flu vaccine talk to us about this new COVID vaccine and how effective that is and and who should get that vaccine?

Dr. Bell: Yes, thank you.

The uhm, as most people know, the FDA has recently approved and updated COVID booster and the CDC is recommending that now for everyone six months of age and older.

The reason for that update is because the predominant circulating strains or variants of the COVID virus have changed pretty significantly from the previously available vaccines.

The updated booster is pretty well matched to the predominant strains that are we refer to these as variants for COVID that are most commonly circulating now.

So we are seeing that that gives very good protection against severity of illness.

So people may still get an infection, but It's very good at preventing hospitalizations and preventing deaths.

And so our goal now really is to reduce the severity of the impact of COVID by reducing hospitalizations and deaths.

And people who are most likely to have those severe complications are people who are unvaccinated.

Gavin: You have talked about me and I've had COVID before I've been vaccinated before, but now we're saying to lessen the severity of any potential infection, I should get the shot again.

Dr. Bell: That's correct, because people do question Well, I got the vaccine and I still got COVID Well, It's not 100% protection.

No vaccine offers 100% protection and what we really bank on is our goal is to avoid severe illness.

And and that is what what those vaccines really are best at.

Gavin: And Dr. Bell.

We have about two minutes left and I ask you about RSV because there's a vaccine for that too.

But that's for different age groups kind of talk to us about what RSV is and why folks should be getting that shot.

Dr. Bell: Sure, quickly RSP something we haven't paid as much attention to in previous years "respiratory syncytial virus" is what RSP stands for.

And many people don't know that RSP is responsible for a significant number of hospitalizations in older adults each year and deaths.

So there's a new vaccine that's been approved that is recommended for people over the age of 65.

Additionally, young children are severely impacted and are at highest risk.

So there is a new vaccine for children.

And there is actually a monoclonal antibody that is recommended for very young children who cannot yet be vaccinated.

So that is from birth, up until six months in the first RSV season.

And then the the other exciting thing that I'd like to add is that there is actually vaccination recommended for pregnant women.

So if they received the vaccine, in the last weeks of pregnancy between 32 and 36 weeks of pregnancy, those maternal antibodies will protect those young babies in the earliest weeks of life and have been shown to prevent hospitalizations and those babies.

And so these vaccines are available and then that monoclonal antibody, which gives antibodies to offer protection for those, those very young babies and and so that's what I really want people to know About for RSV it is an unrecognized cause of severe respiratory illness.

Gavin: A really quick 30 seconds about what should people be doing right now wrapping up for preparation for this season?

Dr. Bell: Sure, well, let's not forget about other measures that protect people against illness, simple things like washing your hands.

If you are sick, stay away from others prevent protect others don't send your kids to school don't go to work, get tested so that people are aware of which specific agent they may be affected by because there are treatments for each of those separate treatments.

And so we want people to just be vigilant about hygienic practices.

Stay home if you're sick.

And please, the final message that I would like to offer is, is please consider vaccination against all these illnesses because it can really significantly change people's lives.

Gavin: Very good.

Yeah, I'm always washing my hands, especially now more than ever in this cold and flu season.

That's state epidemiologist Dr. Linda Bell, thank you so much for joining us.

and thank you for all you do to keep our state safe.

Dr. Bell: Thank you for this opportunity.

Gavin: To stay up to date with the latest news throughout the week.

Check out the South Carolina Lede.

It's a pod cast that I host on Tuesdays and Saturdays that you can find on (southcarolinapublicradio.org) or wherever you find pod casts.

For South Carolina ETV.

I'm Gavin Jackson.

Be well South Carolina.

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