Much of the conversation around reopening colleges in the fall has focused on mitigating the risk of outbreaks and creating policies to keep the campus community safe as a whole. While these conversations are necessary and constructive, it is critical that colleges and universities put a particular focus on students who are vulnerable to serious illness as a result of the coronavirus.
The College Diabetes Network (CDN) is a non-profit organization that advocates for and supports young adults living with diabetes. Its network of campus peer support groups, and guidelines for college leaders, address both physical, emotional and behavioral health for students on campus. Since COVID-19, the organization has supported its vast network of students living with T1D virtually via Zoom meetings, leadership development opportunities, social media posts, blogs, and text message groups.
CDN has a strong message for higher education leadership: students with T1D and other chronic illnesses have unique concerns about the return to campus, and colleges must take their needs into account when creating plans for reopening.
Challenges for Returning to Campus
Students returning to campus this fall will likely be under strict guidelines – keep a six-foot distance from others, avoid crowded areas and events, wear masks in public. But there is a growing concern among higher ed stakeholders that many college students, a group known for taking risks, will not abide by the guidelines laid out by their college or state. Additionally, some institutions may not even require the bare minimum social distancing guidelines.
The University System of Georgia recently reversed a decision not to require masks on their campuses after public criticism, but Arizona President Robert C. Robbins recently said that while he would encourage everyone to wear a mask, he can’t require it. It is reasonable that students with chronic illnesses would fear exposure to the coronavirus from other students who aren’t following social distancing guidelines, which could have drastic health consequences.
Mental health is a heightened consideration. In its recent annual young adult survey, the College Diabetes Network (CDN) included a sub-section specifically on the impacts of COVID-19 and how it was influencing young adults with diabetes. Preliminary data analysis has reinforced the increasing need for mental health support from colleges and universities this fall. (CDN’s annual survey continues to be the largest study cohort providing data of this population. In an effort to make this data as actionable as possible, through CDN’s REACH™ initiative, Reducing Risk through Education, Advocacy, and Collaboration in Higher Education, CDN is currently in the process of publishing a white paper on its findings which will be available this summer.)
The limits on social interaction in the coronavirus era have increased feelings of depression, loneliness and stress among college students. And while many are looking forward to their return to campus as a light at the end of the tunnel, students with chronic conditions, whether they return to campus or not, are likely still facing months more of social isolation.
Staying home from school while others return to campus life is sure to elicit feelings of loneliness and despair. But, for students vulnerable to COVID-19, returning to campus will also include some measure of social isolation - turning down plans that may put them in a vulnerable position and avoiding friends who act recklessly, all while worrying about contracting a virus that could be disastrous for their health. Students with chronic illness are already statistically more likely to suffer from depression, anxiety, and isolation than their peers. These mental health challenges will be further compounded by the pandemic, and the increased risk it poses to their mortality. The potential for exacerbated mental health issues among vulnerable students is concerning.
If they contract the coronavirus, students with chronic diseases will need specialized medical care that college health centers are not set up for, or may have limited knowledge about. And at some schools, particularly those in rural areas, the local hospital may not be equipped to meet the specific health needs of those with chronic conditions who are infected with COVID.
While 20% of youth in the United States live with a chronic illness, students with type 1 diabetes are an obvious concern. David Walton, Chief Executive Officer of the T1D Exchange, noted that research from various organizations has demonstrated that COVID-19 initially led to reduced glucose testing by some staff in the inpatient setting and as a result, glycemic control was adversely impacted.” It has been widely documented that achieving well-controlled blood glucose levels is correlated with improved outcomes for hospitalized patients, including those with COVID-19. However, managing diabetes in the inpatient setting is challenging.
“High blood glucose levels can compromise the immune system and impair the body’s ability to fight infection, thus leading to susceptibility of complications of COVID-19, therefore, optimal blood glucose management in the context of COVID-19 is urgently needed, especially in the hospital setting.” said Dr. Daniel DeSalvo, MD Director of Strategic Collaboration at Texas Children’s Diabetes and Endocrine Center, Texas Children’s Hospital, and Assistant Professor at Baylor College of Medicine.
Walton also shared that “based on early data from the T1D Exchange national surveillance study examining COVID-19 and Type 1 Diabetes, the outcomes of those with T1D who contracted COVID-19 correlated with the level of their glycemic control.” These findings are critical for the higher education community, as young adults with diabetes have been shown to have the highest glycemic averages of any other demographic with type 1 diabetes.
The surveillance study also found that patients with diabetes were more likely to delay seeking treatment in an effort to manage illness from home and reduce additional covid-19 exposure, resulting in higher rates of more advanced Diabetic Ketoacidosis (DKA) when finally admitted to the hospital, and subsequently were more challenging to regain glycemic control management upon hospitalization due to this delay. Due to limited clinical education on symptoms and treatment, DKA has continued to be an ongoing risk of complications and mortality for young adults with diabetes on college campuses prior to the pandemic. These risks are now further compounded.
Finding Solutions for At-Risk Students
What can be done to address the unique needs of students with chronic conditions in the COVID-19 era?
First, higher education institutions must develop academic and residential accommodations for college students with chronic conditions that make them more vulnerable to COVID-19 complications. Some universities have begun publicizing their plans for the changes to campus life, including limits on roommates, mask requirements, altered schedules and more. Annie Tulkin, Founder and Director of Accessible College, an educational consulting firm that supports students with health conditions and physical disabilities with the transition to college, says this is both critical and as yet not guaranteed. this, saying "all of the students I work with who have health conditions (POTS, lupus, asthma, cancer, etc.) are in a high risk group. Most of the various plans from colleges they are attending do not directly address the needs of students with health conditions”.
Whenever possible, high-risk students should be permitted remote access to all classes to ensure greatest possible safety. The safest place for high-risk students is off-campus; but in situations where they must return to campus for academic (e.g. to take a class with a required in-person component) or personal reasons (e.g. an unstable life at home), the same remote access to classes should be permitted from on-campus residence. Schools should be prepared to provide academic accommodations (e.g. extensions on assignments and flexibility with attendance in the event of complications related to their condition or COVID-19 infection) for all classes regardless of whether the class can be accessed remotely. For students that must return, schools should also be prepared to provide high-risk residential students adequate housing accommodations (e.g. a ground floor single room and private bathroom) and dining accommodations (e.g. access to takeaway options).
As an adjunct to the accommodations themselves, disability support offices should prepare themselves for an influx of students that they are serving and supporting and make efforts to encourage students to contact their offices for support. As Annie Tulkin notes, “many students with health conditions may not be registered with the college's disability support office, either because they did not realize that their health condition could qualify them for accommodations, or they did not need accommodations in the past, prior to COVID-19. Students with health conditions should not assume that remote access or other accommodations will be provided unless their college says that explicitly. Accordingly, students in need should start the process of requesting accommodations now”.
Significant planning and consultation with experts will be needed to create and adjust these accommodations. In a recent call, Chief Executive Officer of the American College Health Association (ACHA), Devin Jopp reiterated that “remote learning options are strongly encouraged to be made available to all students with comorbidities and chronic conditions, given the risks they face.” Jopp also encouraged institutions to refer to the recently published ACHA Guidelines- Considerations for Reopening Institutions of Higher Education in the COVID-19 Era, ACHA Guidelines- Preparing for COVID-19, and the Center for Disease Control (CDC) Considerations for Institutions of Higher Education.
College and university leaders must provide education and training for health center personnel on conditions, including diabetes, that compound the effects of the coronavirus. They should also partner with local hospitals to share information and education. Critical to these efforts is the effort to update specific treatment protocols for students with at-risk conditions, both for their health center, and in collaboration with local or city hospitals, based on covid-19 frontlines data being collected in real-time.
According to Dr. DeSalvo, “Recently, the FDA made continuous glucose monitors (CGM) temporarily available for in-hospital use with COVID-19 patients. Use of CGM devices in the hospital setting allows the healthcare team to remotely monitor their patient’s glucose levels and receive timely alerts for glucose excursions, while also reducing staff exposure to the infected patient and preserving personal protective equipment.” Use of this technology provides an extra layer of safety to both the patient and the hospital staff, however, requires intentional training that has not historically been available prior to the pandemic.
Finally, due to the increases in mental health concerns across the board, colleges and universities should be prepared for heightened demand for treatment in the fall. And to ensure the safety of students with chronic illness, colleges should put a specific focus on providing care while maintaining social distancing. Precautions like telehealth and online treatment options will be necessary to treat students vulnerable to the effects of the virus.
Christina Roth is the Chief Executive Officer of the College Diabetes Network. Dana Humphrey is the Program Director of the Mary Christie Foundation.