Respiratory Viruses in Winter 2023-2024: Vaccination Against RSV
In this video roundtable episode, Jaspal Singh, MD, MHA, MHS, interviews Lisa Davidson, MD, Katie Passaretti, MD, and Amina Ahmed, MD, about the recently approved vaccines to protect against Respiratory Syncytial Virus (RSV), including prevention of lower respiratory tract infection in the older population, recommendations for women who are pregnant, and the impact of the vaccine in babies after a pregnant woman receives the vaccine. This is part one of a three-part series on respiratory viruses in winter 2023 to 2024.
For more respiratory syncytial virus content, visit the disease state hub.
Watch part two of the three-part series on respiratory viruses in winter 2023 to 2024 here.
Watch part three of the three-part series on respiratory viruses in winter 2023 to 2024 here.
TRANSCRIPTION:
Jaspal Singh:
Welcome everyone to another webcast series with Consultant360. I'm your host, Jaspal Singh for pulmonary critical care. I'm at Atrium Health in Charlotte, North Carolina, and with me today, I have three esteemed guests from our own organization who helped us last year with respiratory infections. Back with us today to help us, and I'm going to ask them to introduce themselves. I'll start on my screen clockwise. Dr Katie Passaretti.
Katie Passaretti:
I'm the Vice President and Chief Epidemiologist for Atrium Health, an infectious disease provider, and also a clinical professor with Wake Forest and Infectious Diseases.
Jaspal Singh:
Awesome. Great. Dr Amina Ahmed?
Amina Ahmed:
I'm Amina Ahmed. I am the medical director for pediatric infectious diseases and immunology, and I'm the hospital epidemiologist at Levine Children's Hospital and also a clinical professor at Wake Forest University.
Jaspal Singh:
Great. And then we have Dr Lisa Davidson.
Lisa Davidson:
I am Dr Lisa Davidson. I'm the Medical Director for the Antimicrobial Stewardship Network of Atrium Health. I'm the Chief Quality Officer for the Adult Medical Specialty Service Line, and I'm a clinical associate professor at Wake Forest University School of Medicine in the division of infectious diseases.
Jaspal Singh:
Great. Well, it's obviously great to have all three of you again, because this is ... will be another interesting winter for me in the ICU, or in my pulmonary clinic, actually, there are a lot of questions going around this year. I think a lot more questions about these ... about the three different viruses we're going to hit in different parts of our webcast series.
We'll start first of all talking about RSV, which RSV for a lot of us was ... I mean, it's a nuisance in the ICU. It wasn't something we thought a lot about, except for the immunocompromised people. And maybe I'll start with Amina because I associate this mostly with kids. Talk to us a little bit about what you see this year as RSV and talk to us about the virus, if you don't mind.
Amina Ahmed:
Sure. So yeah, I do claim that as a pediatric disease, although the vaccines this year have definitely garnered the attention towards the elderly, but RSV is a very common respiratory virus and it's a rite of passage, so to speak. Everyone has had the virus by the time they're two or three years of age, so young babies are getting it for the first time. So, then they're most severely impacted because they have no immunity to it the first time that they get it.
And then once you do have the infection, the immunity is not complete. So, you continue to have infections for the rest of your life, but they're just more mild as you get older. And I think I said this before, last year, the worst illness I've ever had was when I gave mouth-to-mouth resuscitation to a baby with RSV. So, I obviously hadn't built up very much immunity.
But it's very common and impacts babies, definitely more so because of their immune system. And then also high-risk babies. So, babies under six months of age are high risk themselves, but any baby that's born prematurely, or has any lung disease, or has congenital heart disease tends to be more severely impacted and therefore more likely to be hospitalized. And really, until these vaccines came out for the elderly, we thought about it, we're trying to target these babies, keep them out of the hospital. But it does definitely impact the other end of the spectrum, the age spectrum, with the elderly resulting in as many hospitalizations, if not more for the elderly, and definitely more mortality for those over 65 years of age in terms of absolute numbers compared to the babies.
Jaspal Singh:
That's very helpful. Dr Passaretti, any comments you want to add to that?
Katie Passaretti:
No, I think Amina summarized it. It's exciting that we now have a tool that we can use to prevent and protect those individuals that are at risk in the adult population as well as the neonatal. So really, the world of RSV protection, both in vaccines and protective antibodies for the most at-risk infant population has changed the landscape tremendously.
Jaspal Singh:
Yeah. Talk to us a little bit about those vaccines actually, it's really been sort of the hot topic in my clinic actually, if you don't mind.
Katie Passaretti:
Yeah. So, two different vaccines, one from GSK and one from Pfizer have been approved here very recently by the FDA, I think in the spring around May, and then approved by the ACIP, Immunization Council, CDC more recently the RSV vaccines, which are protein-based vaccines. So, that traditional mechanism that we've used for flu vaccines and whatnot, in the past is now approved and recommended in shared decision-making for individuals over the age of 60 on the adult side of things.
And those vaccines have been shown to do a really good job at reducing lower respiratory tract infection, which is what we ... That can settle in and cause more severe disease. So, the prevention of lower respiratory tract infection is important, especially in the older population.
Jaspall Singh:
No, that's great. So Dr. Davidson, do you think we should get the vaccine, and encourage our patients to get it?
Lisa Davidson:
Absolutely. Particularly in the older population, we still have to really educate people about viruses and that we have very few, if any viral treatment options. So, really the best way to treat these illnesses is through prevention and vaccination. Unlike the flu vaccine. I believe, and I don't know if Katie just said this, we think that the RSV vaccine will last for more than one season, so that's a benefit as well. And really, particularly because the most at-risk patients are the most vulnerable for being hospitalized, I would highly recommend it.
Jaspal Singh:
So, even if you're fairly healthy, and I guess Amina, you were mentioning that you didn't ... probably weren't immunized as properly as would've been hoped with the early exposure with childhood exposures. So, pretty much all adults above 60, or above 50, is there an age range?
Amina Ahmed:
So, the trials were done mostly in those over 65 years of age, and they did not select anyone that's ... they didn't purposefully select people that were at higher risk within that age group, people that were more frail or tended to have underlying disorders such as diabetes, [inaudible 00:06:32] disorders. So, it benefited the general population over 65 years of age, including some of those at higher risk.
Then there were a couple of concerns about some neurological disorders being seen, and some inflammatory conditions, but they were seen both in the placebo group and the vaccine group. And so, because of that, it's really what prompted the shared decision part of this vaccine. So, they're saying adults should be at least informed of these potential risks, although there were very few of them, and as I said, they were in both groups. And then you come to a shared decision from that.
So, it's over 60 years of age and you come to the shared decision model and then keep in mind as a healthcare provider, that those that are at higher risk, those that have diabetes or chronic lung conditions, may stand to benefit even more. So, when you're weighing the risk benefits, that's how you would come to that shared decision model.
Jaspal Singh:
That shared decision-making. I love that term. I think it's great. It's been an interesting word I would say these days within the vaccine space, the vaccine hesitancy, the misinformation. Any particular tips or tricks you might have in that space?
Amina Ahmed:
I've been telling people it's always been a shared decision model. We've labeled it this year, but there's never ... certainly, we've had more vaccine hesitancy in the last 20 to 25 years. Having said that, it's always been, I would think as pediatricians, family medicine doctors, and internists, that we would inform our patients of the pros and the cons and not just blindly say, "Of course, I'm an ID doctor, I want you to get a vaccine."
But we think about that and we think about the potential risks. And even with COVID vaccines, we were all aware these were new. And then you do the risk-benefit analysis for yourself and for your patients, and you come to that shared decision model. I think it will be hard to explain to people these numbers, but I think it's important to remember that those very few inflammatory conditions that occurred, or the atrial fibrillation that was noticed, those things are seen with every vaccine. It's just that we're now because of the COVID vaccine, we're more aware of them and we're making other people more aware of them. But I think just giving them those facts and saying it happened in both groups, there's no way to know and what's your risk? What's the risk-benefit for you? And then make that decision.
Jaspal Singh:
Thank you for that.
Katie Passaretti:
Oh, can I just say one thing on vaccine hesitancy, because there is a lot of concern that vaccine hesitancy stemming out of COVID is going to impact the flu vaccine, which we've had for a million years, and this new RSV vaccine? So, just on the topic of dealing with what we're all going to have to deal with probably for the next five to 10 years, which is increased vaccine hesitancy, there isn't one solution that works for everyone. It's often an iterative discussion like Dr. Ahmed was referring to. You give them the data that you have, you continue the discussion, you see where people are at and meet them there, and don't shove it down their throat. I personally have found to be more successful in dealing with vaccine hesitancy and directing towards trusted resources for information.
Jaspal Singh:
No, that's great. Dr. Davidson, anything to add?
Lisa Davidson:
I echo what Katie said. I think it's also really important to emphasize another point that was brought up, which is to say that there's not ... The risks are the same in both groups, and I don't think don't that that's really emphasized enough. And also to say, and there's ongoing studies and we've seen COVID vaccine is a great example. There was concern about myocarditis, but the most recent publication on the long-term data has shown that that has not really borne out. And that sometimes the early risks, the signal of risk because it's not a true risk, in the long term when we have more data is ... shows really that signal does not play out in the long term. So, I think it's also very important to not be defensive with your patients because then they won't come back to you. But also to remember in the years that come that you can revisit this information with patients to really, I think the most important thing is to ask them why they're concerned. Start with, "Well, what's your concern?" And really focus on addressing, those concerns most of all.
Jaspal Singh:
That sounds great. So, it sounds like for RSV we should be vigilant, but there's actually some hope here this year, that there are vaccines coming out and basically we obviously want to think about shared decision-making, want to make sure we build trust with our patients, look at the updated guidelines for the inclusion criteria, for who might be eligible. Those are available on the cdc.gov or other sites and then ... But all three of you sound like you all endorse it and you feel pretty confident that this is the right thing for your patients who qualify for the immunization. Is that pretty accurate?
Lisa Davidson:
Yep.
Jaspal Singh:
And there's a special population recently with the pregnancy. I don't know if you want to talk about that, Dr. Ahmed.
Amina Ahmed:
Yeah, so it's something I'm so excited about. I mean, this could be a game changer between the vaccine for pregnant women, which will protect babies. And you're giving the vaccine to protect the baby and the monoclonal antibody, which is more long-acting that's now going to be available in [inaudible 00:12:03], or before this. I mean, it could honestly be a game-changer. And for those people that are not told, like me, and have not seen the dramatic effect of vaccines as in Hemophilus, like boom, a drop in number of cases, same thing for pneumococcal disease, not as much as for hemophilus, but still dramatic disease. I'm hoping that this will bear out to also result in a huge decrease in RSV hospitalizations because that's something that's bread and butter for pediatrics, but it just really fills our hospitals every winter.
So, the vaccine for pregnant women is recommended for between 32 to 36 weeks. It was given a little bit more widely or broadly in the actual trial, but the idea is to give the woman enough time to build the antibody and then transfer the antibody to the baby, which mothers do for all antibodies for babies. And then that antibody will basically be in that baby's system protecting them from RSV. We know that you need more than antibodies obviously, but that at least will be a major contributor to protecting those babies.
And then in addition to that, is the new monoclonal antibody, which we've had a monoclonal antibody for years. We've had synagis, and palivizumab, which is really given only to babies who are at high risk for getting RSV, like the congenital heart disease, the chronic lung disease that we talked about before. But this product is for really all babies under eight months of age through their first RSV season to protect them. So, if a baby either benefits from maternal vaccination or from this monoclonal, they'll be protected through that first RSV season and once they're over six months of age, their disease is not going to be as severe, so it may be a significant game changer.
Jaspal Singh:
That's great information. Does anybody else have anything to add on that? All right, well this is exciting actually. It sounds like a season of hope a little bit. It is nice to have ... the RSV, you feel helpless. I don't know. I mean, in the ICU especially, you just feel like someone who has RSV, you diagnose it upper pathogen panel and you're just kind of like some rapid assay and you're just like, "Okay, well now, just supportive care." Put them on the ventilator if they need mechanical ventilation, and you just wait. But now you're feeling like, okay, hopefully, we'll see less of these really sick people coming through and at least in the adult world. And obviously, for the pediatric role, it could be, like you said, Amina, a game changer. So, that's great.
Katie Passaretti:
And especially after last year for pediatric hospitals last year. RSV just blew it up. So, having this hope after that trauma of last year, I think is super exciting, even to an adult provider, much less a pediatric one.
Jaspal Singh:
That's a great point. I mean, I'm just thinking about capacity. You mentioned capacity issues. I mean obviously, the workforce being the in hospital, the workforce being challenged beyond belief. This is a way to potentially alleviate some of that strain on patients' families, but also the system itself. That's great. That's great. Thanks so much for giving us and our audience a lot of updates here. It felt like a pretty high yield 20 minutes' worth of information.
So, thanks so much on behalf of Consultant 360 on this portion of the webcast, and thank you so much. Again, I'm your host, Jaspal Singh. On behalf of Consultant360, I want to thank our guests, Drs. Passaretti, Ahmed, and Davidson for their infectious disease update.