West Virginia is currently the only state in the United States without a confirmed case of COVID-19. Yet as the pandemic continues to spread, there could be a flood of casualties in store for the rural Appalachian state, as a recent study suggests that West Virginia may have the highest at-risk population in the nation.

West Virginia Gov. Jim Justice acknowledged his state’s vulnerability in a press conference on Monday as he declared a state of emergency for all 55 West Virginia counties.

“We should really be concerned because we’re an elderly state, and those of us that aren’t elderly, a high percentage of those have health issues,” Justice said.

Currently, West Virginia’s status as the lone state with no reported cases of the coronavirus is more indicative of a lack of available testing than lack of casualties.

“This virus is without question in West Virginia — probably somewhere right now,” Justice said.

As of Monday, 84 people in West Virginia had been tested for the coronavirus, with 80 negative results and 4 pending results.

“Here’s the reality. Currently, I have enough tests and supplies and everything else to do maybe 500 people,” Cathy Slemp, commissioner and state health officer at the West Virginia Bureau for Public Health, said at Monday’s press conference. “I would love to be able to test everybody. We’re currently testing folks that are seriously ill in hospitals ... vulnerable populations in hospitals and then also those that have high risk of actually having been exposed.”

The Centers for Disease Control and Prevention website says that “older people and people of all ages with severe underlying health conditions — like heart disease, lung disease and diabetes, for example — seem to be at higher risk of developing serious COVID-19 illness.”

And in West Virginia, vulnerable populations make up a considerable chunk of the state’s inhabitants. A study released Friday by the Kaiser Family Foundation found that 51 percent of West Virginia adults age 18 and older would be at a higher risk of serious illness if infected with COVID-19 — more than any other state, and 20 percentage points higher than neighboring Washington, D.C. And a quarter of adults below the age of 60 were also considered higher risk — again, more than any other state.

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“We have an older population here in West Virginia. We also have a large number of people that have morbid health conditions — heart disease, diabetes, lung problems,” Anna Allen, associate program director for the West Virginia University occupational medicine residency program, told Yahoo News. “In general we do have a large number of people — even in the younger age groups — that have disabilities or other health care issues.”

Allen also points to the ongoing opioid crisis, which further complicates how West Virginia’s older population would deal with the coronavirus pandemic.

“What might be a little bit of a unique issue is we have a large number of elder parents in West Virginia,” Allen said. “They’re taking care of their grandchildren. We’ve had a lot of children that are in the foster system because of opioids and drug issues. And so we have a lot of elder parents, and they’re the primary caregivers of children who could be asymptomatic carriers.”

West Virginia also has a large coal mining community with many cases of black lung disease, which can be caused by inhaling coal dust.

“They can have obstructive lung patterns,” Susie Criss, a counselor at New River Health Breathing Center, told Yahoo News of patients with black lung. “It does make them more susceptible for respiratory illness.”

The center, which includes a black lung clinics program, is one of nine black lung clinics in the state, and Criss says its clinic alone treats close to 500 patients. She says that although there aren’t any confirmed cases of COVID-19 in West Virginia, the center is encouraging patients to practice social distancing.

“This morning, we had a pulmonary rehabilitation class scheduled, and we met everyone at the door. If anybody had any respiratory symptoms such as runny nose, cough, fever, or if they had someone at home who had symptoms, we ask that they not come,” Criss said.

“We’re hoping that we can at least slow the progression by educating everyone,” Criss continued. “A lot of the area churches are doing services where people can call in from home and participate. And we’re definitely encouraging our patients to call in any time they can, and not to go out in group settings.”

West Virginia has closed schools, yet restaurants and bars remained open on Monday.

“Go to the grocery stores. For crying out loud, go to the grocery stores. If you want to go to Bob Evans and eat, go to Bob Evans and eat,” Justice said during Monday’s press conference. “If we get to the point in time where we’ve got to close the grocery stores and drive a truck around and whatever and bring groceries to people, we’ll do that. But today, don’t have a mad rush trying to buy all the toilet paper in the store. We’ll get by.”

Brenda Marion, director of New River Health Breathing Center, said the center doesn’t currently have access to coronavirus testing.

“We have a health department within 10 miles that we can send someone if we truly suspect a case,” Marion told Yahoo News.

West Virginia does have a higher ratio of beds to population than most other states. But some hospitals have recently closed in the region, meaning smaller clinics and health care facilities may need to step up and help if hospitals become overwhelmed by coronavirus patients.

“This area is rural, probably poorer, elderly, a lot of disabled people in this area,” Marion said. “And so if it did for some reason start affecting a lot of our population, it would be very difficult for our rural hospitals to handle that. So I would say a lot of the clinics and other health care facilities in the area would have to kick in and figure out how we can help the county health departments and the hospitals.”

“I think that’s a concern across the United States,” Criss said of hospitals being overwhelmed. “Everyone has talked about that. Everyone knows that that’s a possibility. So we know that it can happen here.

“I just hope that we’re being proactive enough that we don’t hit that peak all at once.”

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