Speaker 1: Welcome to the state of health, San Antonio, I, Randy Bieber.

And over the next half hour, we're going to take a look at some of the big health concerns in our community.

Right now we're going to, of course, be talking COVID 19 and vaccinations, the longterm effects of COVID maternal health during this pandemic and diabetes, especially among our younger citizens who are, we are joined by four top doctors with university health, Dr. Jason bowling, the hospital epidemiologist and medical director for infection prevention.

Also an associate professor of infectious diseases with UT health.

Dr. Monica Gutierrez is the director of COVID-19 recovery clinics at university health and UT health.

Also chair of the department of physical medicine and rehabilitation at UT health.

And Dr. Patrick Ramsey is the medical director of inpatient OB at university hospital.

I'm a maternal fetal medicine specialist and professor at UT health.

And finally, Dr. Jane Lynch is a pediatric endocrinologist at university health, Texas diabetes Institute.

She is also the professor and interim chief of the division of endocrinology at UT health San Antonio.

Thank you all for coming in.

And first of all, since COVID is on everybody's mind right now, what are you seeing in terms of vaccinations?

And when people ask you who haven't been vaccinated yet, for whatever reason should I get the vaccine?

What do you tell them?

And how is that affecting the health system in San Antonio right now, our vaccinations Dr.

Bowling?

Well, Speaker 2: I'll say that, unfortunately, we're still seeing a lot of people vaccinated are getting infected, but more often we're seeing people that are unvaccinated in the hospital and our numbers have been fairly consistent.

We're about 90% of people in the hospital are unvaccinated or partially vaccinated.

And so it's really important that we get the rest of the people in the community that are only partially vaccinated or un-vaccinated to join our vaccinated cohort so that they get the protection they need.

So they don't end up in the hospital.

There's a lot of stress in the hospital right now with the number of people of COVID patients.

And that's putting a lot of strain on people that don't have COVID as well, because we're still really busy with patients that don't have COVID infection.

And a lot of services are being strained right now, trying to serve both of these groups.

Speaker 1: Now we were talking before we went on the air here about the stresses that each of you are seeing in your different specialties.

What is it like at university health, UT health, all the hospital systems here, where we are in COVID, people may not have heard that much about it recently and their particular lives.

What do you tell them?

Well, from my perspective, we see patients across the continuum as rehabilitation specialists.

So we see them in the hospital.

We see them.

Long-term also at our long COVID recovery clinic in the short term, patients will need rehabilitation after different injuries.

Of course, university health, the level one trauma center patients may have accidents, major strokes, and need rehab.

Well, when the numbers of COVID are so high in the city and in the hospital, then those rehab beds have to close down to be able to take care of patients with COVID-19.

And so therefore they're persons who are missing out on this critical rehabilitation after, you know, whether it be COVID or a car accident, a stroke spinal cord injury.

So it affects other, And now what we've got to also along COVID people don't realize that there has to be re habilitation for long COVID and what that's like that, that's just one of those things that's not on people's radar, I think, Right?

Some people may not realize, you know, think it's just kind of a little viral illness that you get, but it can be a very have major consequences that last long-term or the I've had some patients with symptoms for a year and a half with long, COVID still with fatigue, brain fog, shortness of breath.

Can't get back to work, having physical symptoms as well.

And so we're seeing that these patients are ones that need individualized rehab programs, and we have to be able to address those needs for them.

And also other, other groups of people that people might not think about as much.

Although I do as a soon to be grandfather is a pregnant women and whether they are getting the vaccine, whether they should get the vaccine, a lot of questions, what are you seeing here in San Antonio?

Speaker 2: I've seen it really a mix.

Some people are early adopters.

They want to get the vaccine right away.

They know that there's a good immune protection for mom to prevent her from getting sick, as well as providing protection to the baby when the baby's born.

But there's another group of patients that are just embedded in social media.

As ginger mentioned before we started this session, just all this misinformation, that's out there about the vaccine.

Is it safe?

Is it approved?

Is it going to cause birth defects?

And my baby is going to cause infertility.

If I'm thinking about getting pregnant and it's really taking a lot of work for us to overcome those, those myths and, uh, try to inform people that the vaccine is safe in pregnancy it's recommended at any gestational age and the advantages it provides mom protection, but also those antibodies that protect mom go into the baby and give baby protection for the first several months after birth.

So, um, it's kind of a mixed bag right now.

I think we're making some headway, but, uh, a lot of work to do Speaker 1: A lot of people also who want the third shot, you don't call it a booster.

You're calling it a third shot.

And there was a at least initially some confusion about whether that should be for all Americans or for some Americans.

And looks like now it's going to be, you know, the older Americans in the immunocompromised first, what do you tell people about that?

Whether they need it, they have to have it, or, Well, from our perspective, I think we were all vaccinated very early and there is some evidence out of Israel that perhaps there's some waning of the vaccine, and I'm a little bit of a later comer to the COVID boards because the children now are being so affected.

And the consults that we're getting for the babies born at 22 and 23 weeks to moms who weren't bats, inated where the moms are critically ill and ventilators.

And the babies are born with a lot of medical issues and extremely premature.

So our exposure to COVID is quite high right now with the ward.

So full of COVID and our perspectives, probably a little different, uh, because of our risks.

But I think that third shot likely is going to be approved for at least high-risk EMT and medical providers and elderly, or many of my patients who are immune suppressed.

And you're going to recommend that.

Speaker 2: Absolutely.

Yeah.

I think we're getting, you know, learning more information as this pandemic goes along.

And as Dr. Lynch mentioned, there's been some changes.

This Delta variant is more transmissible, it's causing more severe disease.

We're seeing a lot of younger people, pediatric patients in the hospital.

And it's the other thing we're seeing is we have a vaccine, but all vaccines have strengths and weaknesses over time, the protection can wane for certain groups, especially people that may not have as much of a response initially.

So immuno-suppressed people that's already been authorized and approved, but now we're looking at groups of people that tend to have less robust responses to the initial vaccine.

So people that are older or people that are more vulnerable that are at high risk because of their occupation, their frontline.

Um, so they're looking at healthcare workers, uh, potentially looking at school teachers because of their exposures in the classroom as well.

We're waiting for more information currently as of this taping, uh, there's supposed to be a meeting later this week to discuss which groups would benefit most from this third dose.

But absolutely we want to get people protected as much as possible.

Speaker 1: And as all this is going around, or we're dealing with this, the flu season is coming up last season.

And it wasn't a problem at all, probably because we're wearing masks largely and social distancing.

What do you expect this year?

What do you tell people about a flu vaccine?

Speaker 2: Well, I'll just say for flu activity and then I'll pass it on to others about what we will look for.

Um, as far as the vaccine, but we hadn't seen it.

We didn't see any flu last year.

We were very fortunate, historically low numbers for influenza, but this year, unfortunately we've already seen some flu isolates.

Uh, we saw 10 people with flu in August.

We hadn't seen any since March of 2020, and that probably reflects that people are starting to travel.

Now they're being less careful with the masking.

And so we're really looking at this flu season.

It's always hard to predict the flu season, but we're going to see flu and that's going to be a big difference.

The tricky part with that is that clinically, that looks very similar to COVID-19.

And so that's going to pose a real challenge.

We're talking about getting people vaccinated for COVID-19, but we also need them to still think about flu vaccines as well to provide that layer of protection.

So we don't want people to sleep on the flu because unfortunately this year it looks like we're going to have, Speaker 1: What about our immune systems in general?

Because we haven't been close to each other.

We haven't been exposed to as much we've been wearing masks as that, uh, lessened our immunity, or is it not going to be as strong as it would be in a normal year?

Or is that, is that a dumb question?

Speaker 2: It's not a dumb question.

I think that's something that we're going to look to see.

Fortunately, in some prior studies and influenza people tend to have protection for awhile from either natural immunity, uh, but more often from vaccines, they provide stronger immunity.

Um, it's, uh, we'll have to see what that means.

One of the things we worry about is people can get co-infection with viruses.

Um, we have actually already in August, one of the patients I mentioned had a co-infection with influenza and COVID-19 and if you have co-infections, you're going to be at higher risk for more severe disease, higher risk for more risk of respiratory failure ending up in the ICU.

And so another thing to think about is we want to keep people protected from COVID obviously, but the flu this year, since it's coming back, we need to look at getting people protected that way, too.

What about Speaker 1: The severity of the symptoms you're seeing in people, whether they're fully vaccinated, maybe have one shot or no shots that is, I believe a huge difference in what you're, what you're dealing with, right?

Whether or not you touch those people or not, or deal with those people, how much more severe is it likely to be when you are not vaccinated?

So I'll talk from my perspective and seeing patients who have long COVID and now there's data that's come out of the UK, that they've been able to see persons who are vaccinated versus ones who are not that if you're vaccinated, you're 50% less likely to have long COVID symptoms, which is very, you know, something that I really start to want to spread this news that get vaccinated half chance, less of getting long COVID.

And that's something that hopefully, uh, you know, I'm continuing to tell people, get the first dose, because there's a lot of people who are hesitant even for the first dose, but if it can decrease the chances of long COVID, which is happening in young persons, young women, we're seeing a lot and it isn't even the older, traditional at-risk population.

Wow.

And San Antonio really is this epicenter for type two diabetes in children and obesity.

And those are the highest risk morbidity mortality patients.

So adult literature gave us a clue that you're 30 to 40% more likely within six weeks to 12 weeks to develop type two diabetes post COVID.

If you've been sick enough to be in the hostel Developing diabetes, we're talking about the new onset.

Like people didn't have diabetes before until COVID right.

We're finding out more about that.

Why, why is that an issue?

I mean, why is that We know when they're very ill and there are all these inflammatory cytokines and, and reasons for illness to cause some insulin resistance.

It's probably really a stress on the pancreas for making insulin.

And then you add some steroids in.

So this was adult literature that we followed on these higher rates of diabetes in England and in the us and in other countries, Hong Kong.

And now we're seeing in children, this really escalated rate of children coming in with type two and a history, oh, I did have COVID three months ago and we don't have time to even have them.

Some of them are getting educated and treated in the emergency room because we have no beds.

There's such a huge pressure for managing anything, but COVID on the wards right now.

And to see this happening in kids who, uh, younger kids aren't even eligible for the vaccine is really scary.

And yeah, And as we're looking toward vaccinating kids five to 11 now, uh, parents want to know, I dunno, it still seems early.

What do you tell those parents?

I think all parents are always worried about their kids, probably more so for themselves.

I think the social media is hard to interpret.

I do trust these studies.

I think they're being done very carefully because the stakes are so high.

And for the population I see of kids who are overweight or at risk for diabetes are in families where parents have diabetes.

I just feel strongly that those children, I mean, this is really going to be important to potentially prevent some serious diseases.

They get older.

One of the things we wanted to mention, because we're talking about, you know, some of the biggest issues right now, even without COVID diabetes.

And I guess what you would call pre-diabetes is a huge issue in this community, especially with kids.

How big of a problem is it in general before COVID We have 50% of our new onset diabetes or in kids and our rates are triple their normal rates from two years ago.

Uh, probably one of the highest rates in the country here in San Antonio.

It used to be, it was juvenile diabetes or type one.

And then adult onset is type two, but type two.

Now is, is much more prevalent among your kids.

Why is that Infants born to mothers?

Who've had diabetes when they were in utero have now had methylated DNA.

Their DNA was changed and they're at risk for earlier onset obesity and earlier onset diabetes.

So we're probably a second generation into this cycle and it's not surprising for those reasons.

As we have younger moms who have diabetes, that we're going to see this trend worsen.

And then these kids who do develop, COVID have grandparents and parents at home with diabetes, and a lot of tragedy in our clinic of stress on families, where they've lost family members, The lifestyle that we've had to live during the pandemic, It didn't help.

We're seeing significant weight gain in adults and kids Speaker 2: And from the pregnant population, gestational diabetes, which can occur during pregnancy.

We, there has been some reports that that rate has went up during the COVID pandemic.

And some thoughts behind that is that they're a lot more sedentary.

They're not being active and not being healthy through reading poorly.

And that may be leading to that increased risk for gestational diabetes, which could lead to longterm harm for the baby.

Um, so a lot of work, Speaker 1: Are there other concerns about pregnant women, as well as just not coming in for any care San Antonio, a lot of women don't get in for any care before COVID and now what kind of Speaker 2: It's been kind of two-fold one is there's access to clinics.

There was a lot kind of a slow down of getting people into clinics.

If people were symptomatic, uh, they had to stay home or they tried to minimize the visit in person, try to use telemedicine for that.

Um, I think there's still a fear to come into the office.

They're going to be around there with other sick people.

You might get exposed there and maybe it's better to stay at home.

So people have missed appointments and skipped appointments, and it, depending on the state of the pregnancy and other complications that could be major concern for the pregnancy.

If mom has hypertension and it's poorly controlled, that could lead to the placenta, failing the baby growing poorly and some adverse outcome for the baby.

So it's really important to maintain that prenatal care, uh, when you're pregnant, just so that we can keep tabs on your pregnancy and help you have a healthy baby.

Speaker 1: Oh, it seems like all of this would help convince those people who are a little hesitant to get the vaccine.

If they heard about all these possible effects and especially long COVID, which is intriguing.

We heard a lot about it.

We heard some about it maybe a year ago, and we've heard some since then, but the more you find out about it, how severe, how long lasting, how long could this COVID last with some people we're talking to a lifetime of effects, It may be.

And so I think the numbers that we're seeing now is anywhere from 20 to 30%, if even people who had mild COVID can have ongoing symptoms.

And then for patients who are hospitalized, there's some studies from Wu Han that says, you know, if they were hospitalized one year later, 67% of patients were still having lasting symptoms.

So we don't know how long this will last.

And yes, it may seem like, well, fatigue, I get tired all the time.

Pregnant women get all tired all the time, but this is overwhelming.

This is someone who's told me, who's lived with cancer and said, this is a hundred times worse than my fatigue when I had cancer.

And these are people who, you know, their heart rate may shoot up.

When they try to do something, they have significant brain fog.

We're doing now more research as well, that there's some concern that this inflammation and, you know, the, the cytokines that cross into the blood-brain barrier is this gonna cause down the line, dementia or other more serious diseases, and we're looking at it and we know that other viruses have caused long-term effects or reactivated, you know, in my practice, I sometimes still take care of patients who have post-polio symptoms.

So they had polio and other virus that was from decades ago, and they're still having effects of it so long.

COVID may be that, But some in the health community are still skeptical as well.

And that's another thing I guess you have to have to fight against is some other physicians, even aren't convinced yet of all the effects of long COVID.

Is that, is that something you deal with?

There's sometimes.

Yeah.

There's, you know, my patients and I might see in my clinic, well, first it takes months to get in because there's not a lot of physicians who are focusing on this.

And then by the time they see me, they said, I've been blown off.

Some of my tests came back normal because a lot of them didn't have severe disease.

Maybe they didn't have the full COVID lungs, but they're still not breathing.

Right.

They still have headaches every day, feeling dizziness.

Can't concentrate, forget words all the time.

And so that's always hard to quantify on a test.

So these patients, they may have been blown off by other providers Because some of us have that and not realize until we get an antigen test to find out that we've actually had COVID.

I mean, that could be something else that possibly could show up as well down the road, They show up as well that, you know, may they have had such a mild disease that they didn't know that they were exposed to COVID until they get in an antigen.

And they see, oh, I've had antibodies that were two natural antibodies, not vaccination antibodies.

And so that's sometimes the case.

And some people may have gotten sick at a time when we didn't have great tests, right.

At the beginning of the pandemic, when there wasn't so much access to tests.

So then they don't even know, well, I was sick, but I don't know if it was really COVID.

We didn't have a test.

Their home test was negative, but yeah.

Do people come in with these preconceived notions and tell you doctor, this is what I have, or don't have, and you have to deal with that, or Speaker 2: Absolutely.

We have people that are concerned.

Um, there's some problems I should say, challenges with testing, right?

Um, there's home testing that's available, which is great, but it's an antigen test.

And so it helpful if you have a high viral load, but people that have my older illness could have a negative antigen test, but still have COVID.

And so I can understand that there's a lot of confusion about the testing and the approach to testing and then access to testing at the beginning was tough too.

Uh, I'll say that one of the things that's really important for people to recognize, even if they had a mild COVID infection, initially, uh, many people haven't gotten vaccinated because of that, but we've seen many people in the hospital that had an initial, mild infection, but with this new Delta variant, that's more virulent, more transmissible.

They've had severe illness.

Um, we've seen people in the ICU that had a prior infection, but never got vaccinated afterwards, but there's also these other things that we're just unpacking now.

And we're going to be learning about for years to come the impact on you of that long COVID some of the symptoms that you have with that.

How long does that last, how do we treat that diabetes have impacts on pregnancies and then the strain on the ripple effect on other health care services that have been kind of compressed or in this pandemic?

I think we're going to be learning about that impact for a while as well.

Speaker 1: The other variants out there, Delta Delta plus, which sounds like it's a bonus and you and others are S we're not seeing that much here yet, but are you concerned that that could be throwing wrenches and things in the future?

Speaker 2: And at this point they've seen some variants in some different areas of the world.

Aren't we fortunately have some sequencing here at UT health, San Antonio, and for our south Texas region right now, it's all Delta in our most recent batch, it's all been Delta, but there are some different variants within that Delta, that strain lineage.

And so we're going to learn more about those.

The issue is it's kind of a good news, bad news is, you know, the good news is we're not seeing those other variants.

The bad news is that's because this Delta variant is so transmissible and so efficient and infection.

These other variants, haven't been able to get a foothold, at least for now in the south Texas area.

So we'll need to keep an eye out for that.

What are Speaker 1: Losing out on in terms of healthcare overall, because we're so focused on COVID.

I mean, there's obviously so many different things, but what is your biggest concern, Nursing and retiring nurses and bringing in traveling nurses, which pulls down the morale for those hard working nurses who aren't paid at those high rates, exhausted doctors, trainees, who aren't getting to learn what they need to learn while they're here as residents it's on so many levels, very discouraging for us Speaker 2: And social isolation.

People are staying at home, doing web meetings all day and not even getting out to see the sunlight potentially.

So I think that's the long-term concern.

If this continues, Speaker 1: I think, access to care for other conditions.

And so, you know, since I see patients across spectrum of rehabilitation, diagnoses, by training, I take care of strokes and brain injuries.

And a lot of these patients during this time persons with disabilities, they don't get the same access to the therapy that they need.

And so they've declined during this period of pandemic time and they also don't get out and aren't able to participate in their community because of what's going on.

And, and also living in fear because of the virus, Yes, and missed diagnoses of late cancer and conditions where they would have had a screening visit or a pap smear or a mammogram, and they were missed and they're coming in with advanced disease.

Speaker 2: And then later I was talking with one of our gastroenterologists and he's seen a lot of cases now of polyps and cancers during the colonoscopies that they would have found earlier, it would have been more treatable.

Um, but because of delays and getting these preventative care measures, people are presenting with more advanced stage, but polyps tumors, things earlier on might be more treatable.

Speaker 1: Uh, obviously this is all frustrating for, for all of you, but we're talking about, okay, how do you move the needle in terms of COVID to get things back to where we're focused on everything, that's going to be a frustration for you.

Especially maybe if somebody heard a whole conversation like this as to how COVID can affect them, it would help.

But what, what are your thoughts in terms of when, uh, when you try to talk to one patient or someone about getting a vaccine, or She put together an amazing summary of pros, cons, and safety of the vaccine for pregnancy, which impacted three of our female physicians in our department this year that I work with.

And they were all very reluctant as soon to be mothers to take a vaccine.

And how did it affect the baby?

And they, you sat down and worked with them and they came out saying, oh, yes, I definitely want the vaccine.

They gave it a lot of thought.

They've all three had very healthy pregnancies.

Um, but it was not a small decision even for a physician until they really understood the science.

And, and I think then they felt very reassured.

Speaker 2: I think the science drives it all.

I think we have to believe in the science that's being done in the, the process that goes behind approval of vaccines when it's fully FDA approved.

It's just like the flu vaccine.

It's just like the RSV vaccine.

It's like the polio vaccine.

And we've almost eradicated polio with vaccines, which was a tragic illness for kids.

Um, and we can do the same with COVID-19.

It's going to be a moving target with all these variants.

Okay.

Speaker 1: Do you sometimes worry that it's your approach, maybe your literally your doctor's bedside manner in terms of how you approach somebody with a questions still about whether they should get the vaccine?

I just think that sometimes patients need a little encouragement or, you know, they may have heard things and done their own research, but they need to hear it from the medical professional who that they, they trust in.

And so I go with an open line.

What have you heard?

You know, what can I tell you?

What are you, you know, what is your concern right now?

And then just try to give them more medical facts because misinformation is hurting a lot of people.

And then also since I see these patients who have long COVID and have had the disease before some believe, well, my own antibodies, I'm fine now, but actually we know that getting a vaccine is going to help actually, That's what I've heard repeatedly.

Well, I've had it back then.

I should be okay.

Or they should be okay.

Yeah.

That kind of immunity isn't as strong Isn't as strong.

And also we know that people who've gotten COVID that thirty-five percent will never seroconvert.

So some may not even, you know, get those kinds of antibodies that they need.

So really the best combination is like, get your vaccinations if you've had COVID and then you're going to be like, wonder woman or Superman.

Thank you very much.

I, a great conversation.

I wish we had more time to thank you.

All of these wonderful top doctors from university health, Dr.

Bowling Ramsey Lynch.

Buscopan Gutierrez.

Thank you very much for joining us and thank you for watching this special half hour and our thanks to university health.

We're sponsoring this program until next time.

Good night.