This webinar was recorded on Wednesday, January 18th 2023
RSV is a respiratory virus that is causing a surge in hospitalizations for young – and old. How can we prevent infection and treat it once someone is infected? Join us for this timely webinar
- Dr. Vick Tejwani
This transcript is automatically generated. While this transcript is believed to be accurate, errors sometimes occur. It remains your responsibility to evaluate the accuracy and completeness of the information in this transcript. This transcript is not intended to substitute for professional medical advice.
Speaker 2 00:03
Thank you everyone for joining us. Just hang on a few minutes and we’ll be starting in about the webinar in about 4 minutes. Thank you everyone for joining the webinar. We will start in about 2 minutes.
Speaker 1 01:32
Speaker 2 03:11
Hello and thank you for joining us today and thank you for bearing with us as we were troubleshooting a few technical issues. We have a few housekeeping items before we start today’s program. I’m Andrea Jensen, I’m the education specialist for allergy and asthma network. A few housekeeping items. All participants will be on mute. For the webinar, we will be recording today’s webinar. It will be posted on our website within a few days so you can listen to it again or you can share it with one of your colleagues. You can go to our website at allergyasthmanetwork.org scroll all the way down to the bottom of the page and find our recorded webinars and upcoming webinars. This webinar will be one hour and that will include time for questions. We’re still having a few technical difficulties, so if you wanted to ask questions you can send them via email to chris brown. That’s brown at allergy asthma network. Dot org we’ll see if that will be a little bit of a work around for us. We’ll get to as many questions as we can to conclude today’s webinar. We do not offer CU’s for this particular webinar, however we do offer a certificate of attendance. You may have noticed that we are using a different platform this year, hence a few of the technical difficulties as we switch platforms. Instead of being able to download the certificate during the webinar. You will receive an email after the webinar with resources about RSVP and also a link to be able to download your certificate. So let’s get started with today’s webinar winter can be a challenging time when we are spending most of our days indoors along with several viruses in the rooms with us. This makes it easy to spread the viruses to others. The last few years have been focused on COVID, but the flu and RSV are still circulating. This has been a bad season for RSV and it has affected all ages. Did you know the RSV can affect babies, older children, and even adults? Today we’ll learn more about RSV, who it affects, and what we can do to prevent it. Doctor Tejwani, do you want to go ahead and forward the next slide? wonderful. So before we continue, and I’ll read his introduction, allergy and asthma network is a grassroot organization that was started over 35 years ago by a mom who knew that other mothers like her needed resources and support. Our mission is to end the needless death and suffering due to allergies, asthma and related conditions through outreach, education, advocacy and research. Today it’s my pleasure to introduce our speaker, Doctor Vic Tejwani. Doctor Tejwani is an assistant professor at the Cleveland Clinic Lerner College of Medicine. He joined Cleveland Clinic Lerner College of Medicine as a physician and investigator in the asthma and COPD centers after completion of a pulmonary and Critical Care fellowship at Johns Hopkins University. Doctor Tejwani is an active scientific investigator in asthma and COPD, and also attends in the medical Intensive care unit, including care of critically ill COVID-19 patients since March of 2020 He is passionate about patient education and translating nuanced evidence and data into actionable recommendations. He has enjoyed partnering with allergy and asthma network on numerous patient centered and academic endeavors. Thank you for being with us here today, Doctor Tejwani. We look forward to you sharing your unique perspective to treating those with respiratory infections.
Speaker 1 07:07
So much Andrea for the kind introduction and to you and allergy and asthma network for organizing this I think is certainly a timely topic on the top of everyone’s mind and if not impacting everyone in some way or another. So I’m really honored to be here spending the time talking to all about it. By way of disclosure, as I have no relevant disclosures in terms of conflict of interest, I do have one disclosure that will just impact some of the experiential knowledge I’m able to share, which is that my time in pulmonary clinic and in the intensive care units is spent caring for adults. So those over 18 and as Andrew mentioned in the background, RSV affects adults but also has a significant pediatric burden as well. I’ve certainly reviewed the literature. Discussed it with a number of my colleagues as well, but just in terms of my own practical experience, I’ll be able to offer a little less on the pediatric side. I think as Andrew mentioned the webinar will be recorded and posted for those that may not be able to attend today or want to listen back to hear anything that was missed. I believe Andrea went over this as well, but just to reiterate the mission of the average enhancement network, which is certainly something i’m proud to be partnering with and furthering. So our main objectives today really are to go over what the respiratory sensual virus is, who it affects, which is quite a wide array, the signs and symptoms, how it’s treated, the mode of transmission. And by reviewing the mode of transmission, I think we could go over the best methods to prevent it. Throughout this I’ll try to contrast it a little bit or in some ways compare it in similarity to COVID-19 which I think we’ve all. You know, whether by our own volition or not, received a little bit of a crash course on over the last two to three years so. And I’m not sure if we’re doing this. I think if we’re doing this, I’ll move past this just to go over. Introducing what is the respiratory saying? Social virus. So RSV is a virus, it’s essentially a seasonal virus. It’s one of the common viruses that occurs every year in the winter and. This year through a number of combinations that I’ll talk about we’re having what’s been referred to in the lay media and i think now among the scientific community as well as the triple demic which is essentially a confluence of three respiratory viral illnesses occurring at one time. And this was quite profound starting in the October, November months and this is a combination of RSV, influenza and COVID and i think the reason this has occurred this year because of course COVID has been with us for two to three years is this is. Probably since COVID started in March 2020 the 1st and winter where really they’re very limited precautions beyond the usual and i think there’s a number of features contributing to that as well. So we’re continuing to see COVID numbers, although less than usual years. But it turns out a lot of those precautions that we were undertaking as a society for COVID ended up preventing RSV and influenza as well and in particular the pediatric population this season. Is experiencing a higher burden of RSV and there are some other background related to pediatric hospitalizations and some other kind of things that have occurred societally in terms of worker supply and even supply chains that I think have aggravated all of these things. So none of this is really occurring in a vacuum. It’s all occurring in this backdrop of everything that’s been evolving over the last two to three years culminating in really this very high burden of these three viruses at one time. And this is, again, received certainly appropriate attention. And in the news and in the medical literature, there’s quite a bit that our hospitals are being overwhelmed by this. And briefly on the pediatric side, there are really 2 main contributors to this. One is the higher caseload. And the higher caseload is likely because most children, as we’ll talk about later, typically would have experienced this before one year of age, but children that have been that young or been one or two. Have not actually gotten that exposure. So it’s kind of like everyone you know from one two and three is getting it all at once as. Social distancing measures are laxing. The other thing that occurred is unlike COVID, which is predominantly a disease, although it can affect children, it’s predominantly a disease of older individuals. There was a lot of efforts at expanding out adult care units, adult intensive care units, medic, adult medical intensive care units, and particularly early in March and 2020 and onward, there was. Much less volume in terms of pediatric illnesses because of those social isolation measures or social distancing measures that were taking place. And that led to a little bit of a reallocation of the workforce and hospital units in the United States. So a combination of a higher quote unquote demand, if you will, because of a higher infectious burden and then also a higher, excuse me, a lower supply of the ability to care for those individuals has kind of led to this unfortunate perfect storm of the hospitals being overwhelmed. So again i think it’s good to help helpful to anchor this to COVID just because it’s something we’ve all become familiar with. So RSV is short for respiratory sensational virus. In terms of the usual symptoms in most people it essentially feels like the common cold like a rhinovirus or influenza. Fortunately and this is fairly similar to COVID, most symptoms and most people are mild and generally people will recover a week or two unlike COVID we’re fortunately not seeing as much of the long haul type of symptoms or long. Over type of symptoms that are observed with that virus as that tends not to really be a feature of RSV. It’s a it’s you kind of get it, you feel terrible and hopefully don’t get too sick, but you do recover. Overwhelmingly without any residual symptoms. Again, unlike COVID, RSV can actually be serious for children, and then similar to COVID, it can be serious for individuals that are older and that have some type of immune compromised status. In infants it can cause bronchiolitis. So the Airways, they essentially go out, go down, they bracket branch out into bronchi and then the very small part of the airway where gas exchange or oxygen actually comes into our body and carbon dioxide leaves, it’s called a bronchial and that can get inflamed and then it can also just cause a full blown pneumonia and infants. And in adults and those that are immunocompromised, it can lead to pneumonia or those that are older, it can lead to pneumonia. But the other thing I can do which we see a lot of on the adult side of care is that for individuals with pre-existing chronic heart or lung conditions, typically congestive heart failure, COPD or asthma, it can actually cause those underlying diseases to flare up and then this severe enough to actually necessitate a hospitalization. So we’ve touched upon this a little bit, but in terms of who it affects, it’s predominantly the extremes of age group along with those that are immunocompromised. This is data that is compiled on the CDC website, but from a number of resources that are listed at the bottom. So in terms of per year, we’re looking at 2000000 outpatient visits per year, approximately 60.000. Thousand this is referring to children, so starting from the left to right. In children less than five, we’re looking at 60 to 80.000 thousand children that are hospitalized per year and then in adults, just given much more individuals in this age group, we’re looking at 60 to a hundred twenty thousand individuals that are hospitalized. Fortunately, despite, you know, still causing some mortality, though, the death rates are fairly low. So at 100 to 300 deaths of children under 5 and 6000 to 1000 adults over 65 per year. The one thing I do want to emphasize from this though, and you’ll notice the years of the citations at the bottom, is all of this data is from prior to this current kind of epidemic of the virus that we’re experiencing. So this is really a historical data and we have some of the data of this in real time, but we really won’t know until later on what the total effect is from this winter season to be able to compare it to historical benchmarks. But it certainly seems that we’re on track to be higher than anything and you excuse me, recent history. So typical to the seasonal flu or any respiratory viruses, there is a seasonal onset to this. It’s usually mid-september to mid November. It was a little bit earlier than usual this year and the peak as well was a little bit earlier. It seemed to be we seem to be coming down from some of the peaks in November and December. This is again what’s shown here a typical year and a part of this just has to do and we’ll talk about ventilation later is that people are just inside more during these years. And the transmission of these things is much higher or during this part of the year, excuse me. So it’s quite, it’s certainly a very widespread virus and just given the weather variations that also varies by region. So we’re starting to plateau and actually now come down here in the winter regions in the Midwest and the Mid-Atlantic In terms of those most likely to be hospitalized, it’s younger children and as we kind of talked about and we’ll show some data for this that they’re much more easy visits and hospitalizations overall and then we’ll talk about older children really referring to the two to four. Age range where we’re seeing the much higher rates compared to years prior. And so this is just to give a sense of hospitalization rates of RSV. So you’ll see in this kind of green line going up that peaks out at 5. That’s from this year, so that’s 2022 to 2023 And you could see it’s much higher than anything in years prior in terms of the peak, what we’re looking at is the hospitalization rate per 100,000 thousand people. So I think certainly on track to have a much higher burden than we have in years past. And interestingly, and I suppose not surprisingly, you’ll see that the 2021 numbers and 2022 numbers are actually fairly low. And that’s in part given the social distancing measures that were undertaken for COVID. You can see then the Gray line. Which indicates 2018 to 2019 So this was of course before kind of better days where none of us knew would COVID-19 was that the rates of this year are still higher than that. So it’s not all just a backlog of COVID. I mean, there’s certainly some seemingly something else going on beyond that might be underpinning this. And then this is what I was referencing earlier. So this is a patient visit by age group and. Unequivocally, those that are 0 to one years of age still remain at the highest risk and have the highest emergency department visits over this period much higher than yours passed again. But what you’re where you’re really seeing the difference is in this blue dotted line which is the two to four years age group. And again these are kids that in years past I essentially think of these as we’re basically getting three years, two to three years of RSV exposure and RSV contraction one season. It’s kind of that backlog of kids that would have been. Spread out every winter that are now all getting it at once. In terms of the signs and symptoms of RSV. So fortunately in most people they’re just kind of your typical sick symptoms. So runny nose, decreased appetite, feeling terrible, a fever, sneezing, coughing and then you really you individuals can get wheezing and particularly in those with pre-existing asthma and RSV and individuals for example that maybe have not had asthma in years and ever in their life but have a family history or some type of. Predisposition not only can flare, it can actually cause that disease to manifest. So if you have individuals with pre-existing asthma, can certainly flare it up. But the other thing it can do is actually essentially precipitate disease onset for those that have some type of genetic or otherwise environmental predisposition to the disease. So it affects babies. It usually will just they’ll feel pretty sluggish, lethargic kind of the general signs and symptoms that you expect to see in a sick infant. But and I’ll just contrast this from COVID again, which remarkably causes very mild and little disease in children. This actually can cause a very severe lung infection or pneumonia or bronchiolitis and is in fact the leading cause of this pneumonia in infants or excuse me and children under one. And the leading cause of hospitalization. So this some of this again is related to. Prior seasons, a lot of the epidemiologic data we’re talking about doesn’t really account for what’s we’re in the midst of right now. But prior to this, most infants were infected in their first year of life, and essentially everyone would have had it by age 2. Most, although there are. Children with pre-existing risk factors like immunocompromised status or heart and lung are more likely to be hospitalized in aggregate just because there are so many more children that are healthy. Those that ultimately are in the hospital still are more likely to be healthy. But the three or four big risk factors are prematurity, heart disease, lung disease and immunocompromised status. And then ultimately 2 to 3 % of sick infants will need to be hospitalized. And again, historically we’re talking about kind of one age group getting this per season, but this year we’re seeing this thing, we’re two to three phases of age groups are getting in all at once. And this is just to reiterate some of the historical data. We’re certainly on track to be higher than this. But even before this kind of epidemic, we’re seeing that there was this number that we presented earlier about 2000000 outpatient visits per year, 60 to 80.000 thousand hospitalizations per year. And all those small numbers, still very unfortunate number of 100 to 300 deaths per year of young children that have kind of yet to really embark on their lives unfortunately. And this is the risk factors for more severe disease are prematurity and there are some cutoff statuary give preventative medication which we’ll talk about being very young less than six months, chronic lung or congenital heart diseases, immunocompromised and neuromuscular disorders because they just don’t have the ability to kind of expectorate and get out some of the secretions that start to occur with an infection such as a bronchiolitis. And I draw your attention to this because I think those that have cared for children or have children certainly are familiar with these symptoms. But I just draw your attention to this, given that these are individuals that certainly cannot communicate themselves regarding how they’re feeling. So beyond your usual sick symptoms, if a infant is irritable, if there’s decreased activity, decreased appetite, not as many wet diapers as you would anticipate, these are all signs with the wet diapers. More sign of dehydration, but signs. That’s something else might be going on. And then apnea or if they stop breathing that’s certainly a emergent condition with an immediate 9-1-1 call. And as we’ve touched upon in once they’re getting to that stage that risk of progressing to more severe disease is a little bit higher. So probably seeking at least urgent care at that point either same day or the next day would be important. And so when I talk we talk about preventing disease, I think it’s important to understand the distinction of transmission. So if you all kind of think back to March or April of 2020 there was a lot regarding not touching your face or you know not there are many news anchors talking about rubbing their eyes. I I’ll speak for myself, we were anytime we received any type of package we were kind of. Wiping it down vigorously. Not really understanding. You know how COVID was transmitted, but it’s since become apparent that COVID is transmitted more by respiratory droplets. So this is somebody coughs or sneezes or breathes even, and the droplets of the virus kind of linger in the air for a period of time. Rsv and the flu are generally transmitted a little bit more through or more through contact transmission. So what that means, this is kind of the things we used to think about before COVID. So I sneeze on my hand, I don’t wipe my hand. I open a door knob. Now our SB lives on that doorknob. You then use the same doorknob, you rub your eye, you you’ve got the RSV. So that’s good and bad. I mean it’s not necessarily better or worse, it’s just a different method of transmission and requires different. Methods of precaution. So typically what you’re going to use for that is much more hand sanitizing. Certainly if you go out and you touch a doorknob or something in public, this would be 1 where you don’t want to touch your face until you wash your hands or sanitize. Fortunately, most hand sanitizers will kill this virus. And then in terms of the mass for RSV, it it’s helpful in the sense that if somebody sneezes or coughs or breathes and they have the virus and you’re in their direct vicinity, it. Going to help prevent it from landing essentially in your nasal epithelium or your mouth. It’s a little different from COVID where you might breathe into a room, leave the room, and then I could come into an empty room and the droplets from COVID might still be in the air, whereas this requires a little bit more of what we call direct contact. So the ways to prevent it essentially are extrapolated from the way it’s transmitted. So washing your hands, not touching your face. If you’re sneezing or coughing, cover it so that it’s you’re not spreading the virus out or potentially a virus out. This is where cleaning and disinfecting services becomes quite critical. And this is the similar prior to the end the flu or influenza. And then do your best to avoid close contact with sick people and stay home when you’re sick. Which i’ve i think like many over the last two to three years, just tried to take away. Some silver lining for which has been you know I think kind of globally incredibly stressful event with a lot of terrible news but I think maybe some Silver Linings. I think most places of employment now have a little bit more of a culture of doing this which maybe was not the case in 2018 or 19. So hopefully if you’re not feeling well it’s just better not to be an environment where you can transmit that to other individuals and similarly for better words I think. Many daycares and schools have kind of taken similar approaches to children. So in terms of how RSV affects adults beyond just the usual 6 symptoms, it can flare underlying chronic illnesses, asthma, COPD not listed on this slide, and then congestive heart failure. And it can cause a true pneumonia as well. More commonly it will flare those with underlying heart or lung disease though. And just again to reiterate some of the statistics to reiterate, again this is prior to the season, we’re talking about approximately 60 to a hundred twenty thousand hospitalizations per year for those over 65 and 6000 to 10.000 thousand deaths for those over sixty five per year. So it’s multiplied over a number of years and the risk factors are kind of similar, you know to those that we saw for the infants which is rather than much younger age or less than six months, now we’re talking about much older age or those over 65 Having a heart or lung disease, so this is a risk factor in the sense that it can cause a flare of your underlying heart lung disease, but you also are at risk just for more severe RSV. And then lastly, being immunocompromised. This generally refers to, there’s kind of varying definitions of this, but generally those with an existing cancer, blood cancer, those on chemotherapy, there are a few immunodeficiencies that can lead to this. So this like this is something if you’re kind of wondering, am I in this immunocompromised status, I would definitely discuss that with your doctor because there are some particular definitions around what that means for this virus and then in addition to the typical 6 symptoms this can progress to. Pneumonia and then as we’ve touched upon, can worsen or flare underlying heart or lung disease. And this is just to reiterate the ways of preventing it or are really based around the way it’s transmitted. So contact precaution. So again for COVID we’re typically using droplet precautions. For RSV and influenza, it’s contact precautions more so they they’re cases and suggestions that both, all three of them can do all of them. But we’re really talking about the how much, how the bulk of the virus is transmitted. And this is kind of a picture without a fomite, is just referring to any kind of inaminate object, whether it’s a doorknob in my example or a table in this example, that it just somebody touches and then has this virus on it and then other people touch. So in phones this is a certainly a very important one as well. So the I think fortunately there are a lot of at home COVID tests which has been great and now there is there is a developed test called Pixel by LabCorp which is a PCR test that can be mailed to you. It does seem from a quick review I don’t have any personal experience with this either for myself or my patients, but it does seem like insurance would cover if certain criteria are met. And similar to the COVID test, you swab your nose and then the results take. Few days the caution, the caveat or kind of disclaimer on these home tests and this is true for COVID and this as well as if they’re positive they’re very helpful. I think if you have a home test and you’re positive whether it’s for COVID flu RSV you can be pretty confident that that’s the case. A negative test is not as meaningful due to the IT could be that the swab didn’t quite get where it should be. It could be that the viral load was not as high as it is necessary. So I think if you’re negative, you probably don’t have it, but it’s still possible you do. And actually for my patients where they’re very concerned about COVID, I’m typically having them do two or three home tests. It’s not related to this test that’s on the screen, but just a COVID test because once you get up to that number, you’re usually and you’re still negative. If you have symptoms, you’re still, you’re barely confident that it’s not COVID. But it is nice that this happens particularly or that this is available. Excuse me. For this triple test, particularly given that sometimes it can be challenging to go to an urgent care, and certainly an emergency department for a test can be many emergency departments across the nation are struggling with long waits, so that’s a bit much for a test. And the other thing is if you don’t have it, you don’t want to go and kind of put yourself in an environment where you might get exposed to it. So i think it’s nice that these are available at home, but I do want emphasize that these are for minimal symptoms. If you have a lot of symptoms, you should seek medical care and then too that if a negative test is not even, it’s not 100 %, I mean there’s quite a bit of margin for error there on the negative test. And then in terms of hospitalizations, So what kind of drives them, our respiratory symptoms or symptoms which can drive respiratory symptoms as well and then pneumonia, whether that’s bronchiolitis in infants or just a true pneumonia. And then the other one which really applies to both age groups is because of all these symptoms, it can be quite hard to maintain oral intake. And this is where the wet diaper comment that I was talking about earlier comes into place. That some individuals just need to come in for intravenous fluids. They literally just cannot, whether it’s babies or older adults, literally just cannot get in enough hydration orally. And this is. I think not. It’s frightening, particularly if it’s I it’s frightening if it’s owner adult, but it’s particularly, I think, frightening if it’s, you know, your 8 month old or 14 month old. But dehydration, fortunately, you know it’s it’ll be frightening. But it’s a, it’s a easily reversible thing. Intravenous fluids, they get hydrated and should recover. And I do emphasize with many of these things, it’s just better to do it earlier because as things progress, whether it’s breathing, whether it’s dehydration, the more advanced they are. There’s generally more effort and it’s more challenging to reverse it as things get more progressed, so. Sometimes it’s challenging because in a practical sense you’re at home or whatever kind of wondering how do we take, you know, our child or you kind of know what it’s going to entail. But hopefully you can get in touch with your doctor’s office to get some guidance and then if not, hopefully an urgent care or something is available until he’s get a second set of eyes on him or her. So transmission of RSV, like we talked about, the infected person coughs or sneezes in here. This is the virus, unlike them just kind of lingering in the air, it’s the virus droplets when they cough or sneeze actually get into your eyes, nose or mouth. And this is where masks do help because they help on both directions. They help that it would prevent that the infected individual from transmitting as much of the virus and then they would help protect you from getting that virus to land in your nose or mouth. It would not help in your eyes unless you have there are certain masks with face Shields or you’re otherwise wearing a face shield. It can be passed directly by certainly. Whether you’re it’s your grandchild or your own child by kissing and then as we’ve talked about, touching a doorknob or any type of fomite and then touching your own face. So this is really where I think some of them. You know, the habits that we all might have been ocated back in spring or summer 2020 actually can be quite helpful kind of the sanitization, hand sanitizing, washing hands, it’s really quite critical for the RSV and flu. And then prevention really just tracks back into the way it’s transmitted. So if you’re coughing, cover your mouth or technically if you don’t want to get it on your hand because let’s say you cough into your own hand and then you, it’s still on your hand. Now if you touch something as you could just cough or sneeze into your elbow inside your elbow, wash your hands frequently. Fortunately, hand sanitizer is effective for this. And then particularly if someone sick and even just otherwise, any type of contact. Might lead to transmission of this disease in cups utensils because it’s essentially landing on that and then you’re using it. And then in addition to washing your own hands after use, if they’re high touch areas in the house or at work, if it’s like a shared workstation for example, those might be places where you just want to clean those high touch areas. A shared computer with the shared keyboard keypads would be another thing. So any of those things, this is, this is where those kind of wipe downs that. Had been being done historically. Well, we’ll certainly be helpful and this. The topic for today is RSV and they will help prevent RSV, but this will also help prevent influenza. And then the other type of prevention is to stay, stay home or sick when we’re talking and then. Although you know, particularly in your House for example or in a larger work environment, it’s you’re not being able to wipe down every surface. So fortunately ventilation does help. So this is, this is particles. So this is for an example of somebody with some form of infection comes in and this is looking at respiratory droplets and the kind of dot shown or how many droplets there are, particles there are and if you have all your windows closed etcetera, then there’s really no. Particle reduction, reduction, they’re essentially all still there. But if you then do that, and this is kind of just a nice schematic to show this is if somebody’s there for four hours and you have the windows open, you get a 93 % reduction in the particles of somebody. If you keep that open and you continue to ventilate, that would be great. So this a part of this is going to be a little bit more effective at preventing COVID than RSV. It will still have some effect, but it’s just to emphasize and that. This kind of underscores why we see the rates and the incidence of these viruses go up in the winter time because you’re just not as able to. That’s not as desirable to ventilate your home when it’s 10 degrees Fahrenheit or you know, there was that cyclone, the snow bomb at the end of December. So that’s not a time where you’re going to be keeping your window open. So that that’s the challenge with this. So I think in the absence of this. If you’re able to at least wipe some surfaces down that are high, use and then if there is a day where depending on where you live it breaks over 32 or it breaks over 40 or 50 or whatever your threshold is, even just doing it for some short period of time might be helpful, just to ventilate a little bit. And this is really a downloadable graphic which might be nice to share with your own patients or anyone that has questions for you with just how to prevent this. Depending on who it is, you could go over each one or just talk through the different mode of transmission. And i think once folks understand the mode of transmission, you’re really able to kind of extrapolate from that mode of transmission how to avoid doing that. And then in terms of medical therapies for prevention, so there’s really only one approved treatment for prevention of RSV, so it’s called palivizumab. It’s only improved for individuals that are pre infants that are born, excuse me, premature, which is accounts as less than 24 months. Excuse me, they’re premature and less than 24 months, I apologize. So if they’re born premature and in the first two years of life and if they have heart or if they have heart and lung disease, so essentially what the mab, anything that ends with the mab is a monoclonal antibody. So it’s essentially in which actually is also received a lot of attention in the setting of COVID. So this is essentially an antibody against the RSV virus and it’s been shown in these individuals to prevent the rate of that they’ll need hospitalization. So these it’s essentially in high risk infants. That this has been approved so young premature and or young and heart or lung disease, there’s three other things that are in study and there’s kind of a summary of the greatest or best potential scientific discoveries or findings of 2022 and two of these made the list. So one is a nurse web. So this is under study for late preterm infants and then actually term infants as well. So this is kind of to see if that. This is also to prevent. So I think we’re pretty far away from this being widely administered because one, you need that proof of concept that it actually is effective. So there was an encouraging phase two trial. But the other thing in that just the reality of this situation is that these monoclonal antibodies are fairly expensive to. One kind of discover and create and then two once they’re synthesized they’re fairly expensive to continue to manufacture. So the idea of having enough produce to give to every infant that’s born, i think it’s I we’re very far from that city to be mass produced ultimately and it might not make sense just given the risk in term infants it’s not so high. This i think is probably a little bit more. Encouraging of a long term possibility which is that you basically give a protein to pregnant women and antibodies trans, they cross through the placenta. So the idea is that basically you give the pregnant woman the vaccination, she makes her antibodies and then those antibodies transmit through the placenta into the fetus and those that fetus is then born with those antibodies. So that’s those. Say it would last for a few weeks and months in the fetus or in the infant at that point after birth. And then lastly there is an adult RSV vaccine that’s been studied in those in 18 to 50. So all of the three therapies are preventative methods I should say on the right are all have phase two trials completed that are fairly encouraging. So a phase two trial is not, it’s not typically open excuse me it’s not typically placebo, it’s not typically double-blind it’s not typically a randomized control trial it although some can be. So the next step for these would be a larger phase three. Randomized controlled trial to see if some of these encouraging signals that we saw in the smaller and less sophisticated amount of data continue to bear true as it gets studied in a more rigorous way. That’s for prevention. So treatment once you have it. I kind of put this in the heading a little bit tongue in cheek, but that it kind of is generally the reality of it, which is you know, the same thing that your parents might tell you to do, your grandparents might tell you to do. You know, drink some soup, get some sleep, take some Tylenol. That’s honestly for the overwhelming majority of people that is the treatment. So you want to use anti inflammatories, which acetaminophen, which would be appropriate. You do want to ensure that the fever does not get too high. Acetaminophen again would help with that, as with non steroidal’s And you want to ensure that individuals, children, adults are staying hydrated. And then for infants in particular, you want to be sure you’re monitoring their hydration status by the number of wet diapers. There are two available treatments. To my knowledge, they’re not typically used in children, but ribal ribavirin and intravenous immunoglobulin. So these are. Ribavirin is an antiviral medication. And then intravenous immunoglobulin which also can be used in code is just basically administering a nonspecific antibody. So unlike those mab MB medications we saw earlier which are targeted monoclonal antibodies against RSV, intravenous immunoglobulin is just giving somebody immunoglobulin just antibodies kind of more globally. And these are our most helpful in those that are immunocompromised because they just don’t aren’t able to mount the response that those with an intact immune system would be mounting. So they kind of help along with this. So these are really and typically hospitalized immunocompromised patients. So these are individuals that are very sick and have some type of underlying immuno immune deficiency. And that’s why I just emphasize for the overwhelming majority of people, it’s just making sure you don’t get a fever or have too bad of a fever, excuse me, making sure you’re getting rest and making sure you’re staying hydrated. And then monitoring for progression of disease. That might suggest you need to either take your child to urgent care or maybe a parent or yourself depending on the situation. And really there’s no role because it is a viral infection. For antibiotics. There are a small number of people that will develop pneumonia after this. They might need antibiotics and then if it causes a flare of COPD, generally azithromycin or doxycycline would be a part of the care for a flare of COPD. So you might use it for that perspective. But if it’s kind of pure, RSV and antibiotic will not offer any benefit. So beyond just kind of the general sickness that occurs in a child, runny nose, irritability, the emergency symptoms for infants where you want to. Take them to for urgent cares, trouble breathing, fast breathing so children do at baseline breathe much faster than adults. So if you’re used to treating adults as I am and you’re concerned about a child, you’ll have to look and the respiratory rate actually changes by age as well. But certainly if it’s if it’s your child or a child or they care or someone is the caretaker for you to kind of be able to notice a difference and the ribs pulling in with each breath. And this is similar to kind of neck or rib muscles going in for adults. Just shows that they’re working very hard to breathe and that’s not really sustainable. So as you start to see that, that’s a sign that they also emergency care needs to be seeked sought. Bluish or purple colorate discoloration is a sign that there’s low oxygen levels or cyanosis. Pale skin, chest pain. Again, chest pain could be assigned pneumonia. Pale skin could be a sign of either low oxygen or dehydration. If it’s an infant that walks and they’re no longer walking because of that’s kind of a sign that they’re having very bad muscle pain dehydration. Irritable and withdrawn to the point where they’re not interacting. That would be assigned to seek medical care. That could be because of the virus. It could also be because the virus and dehydration has affected their electrolytes that there’s a number of things that could mean seizures and then temperatures above one O 4 and a part of this and the reason of any fever in infants under three months is in that window. There’s a risk for a lot of other infections and unfortunately it could be RSV and something else. So under three months it’s important to seek care and then over that age you’re looking at that one O 4 cutoff. And then this last one that. Someone starting to improve and then they get worse. That essentially suggests what I was talking about earlier, which is that now there is this new bacterial infection. So RSV does not really have a waxing and waning course as some illnesses do. Once you start to improve from RSV, you should continue to improve from RSV. So the basically the recurrence of whether it’s a fever, cough or whatever symptoms it might be, suggest that they were recurring or improving or recovering from the RSV and now something new has developed. On top of that. As a kind of disclaimer, this is not a complete list i think so if there’s something you’re concerned about and I would just encourage this globally as a getting able to update your pediatrician, your child’s pediatrician or an urgent care that these are the resources that are there and they’re to be used. And then if certainly if there’s something on that prior list or the prior slide, they should see care urgently or you should see currently. Emergency symptoms for adults, again very similar. So trouble breathing, shortness of breath, and the adult, unlike the child will be able to articulate. An infant would be able to articulate it, but you’re also looking for those withdrawal of rib muscles, those withdrawal of neck muscles, bluish or purple discoloration for the same reason as prior, which is low oxygen levels, seizures, weaker on steadier, severe muscle pain, not urinating. Again, it’s kind of dehydration and I should say. Their adults can articulate this, but some of these are occurring unfortunately in older adults that may have other cognitive issues and might actually need to be monitored for them and unable themselves to articulate it. If they’re typically not dizzy or confused that would be a sign that ours view might be affecting electrolytes and should be checked and then consistent pain in the chest or abdomen. This could be a sign of pneumonia or that the RSV is causing a flare of an underlying harder lung condition and then chronic medical conditions getting worse I would say. From a practical perspective, this is really the most common reason for admission from RSV. So if it’s somebody you know has CHF, COPD or asthma, that’s definitely there’s a high likelihood that disease is going to flare up because of the RSV. And then as we discussed previously, if they’re feeling better on a trajectory of improvement and then start to get worse again. Kind of similar disclaimer as prior. And then prevention and this is really across all three of them. So for right now ours for RSV there is no vaccine pellets. Vizima B is available for those that are premature and or have congenital heart and lung issues as a preventative and we’ve discussed the higher hospitalization rates in previous years and. I burned the heading here, contact and droplet precaution, because really we want to prevent all three of them. To be honest, they’re all even if you don’t get hospitalized, they’re all fairly miserable experiences, whether it’s for you or your patients. So I think trying to prevent it is really preferable. The flu vaccine, the flu, excuse me, in terms of prevention, it’s transmitted via context. So similar to RSV, everyone in healthcare, myself included, gets vaccinated against the flu. It’s kind of a requirement in most hospitalizations or employers. The way that is done at a high level is that we look at the serotypes or strains that cause the most disease in South America or other seasonal variations and kind of try to prevent against those three most common ones. So it’s definitely not 100 % but it will you know reduce the most likely strains you’re exposed to. And then COVID i think the vaccination there would be a whole nother topic or talk but i think many are familiar with them and there was a. But seasonal bump again fortunately not as bad as last year, but still a seasonal bump and there seem to be coming a little bit back down for all of these and hopefully that trend will continue. There is also a possible vaccine RSV vaccine and those that are older and this is focused on this population unlike that 18 to 50 years age group that I showed on this slide prior because these individuals are much higher risk. This is their ongoing phase three trials. They’re preliminary data seems to be fairly encouraging, but we don’t have not seen the data or the kind of peer reviewed publication made widely available yet. So I just put a little asterisk on this, but this is what we could see this upcoming year. Of the vaccination available for those that are older than 60 and therefore at higher risk. There are resources available both in the as I talked about on the critic you know acutely ill setting and then just to understand these a little bit more from allergy and asthma network. And this is just a nice kind of infographic on the virus that allergy and asthma network has available and might be nice. So kind of a nice printed handout for some of your patients or to refer them to which I do in my own clinic. So with that i’ll thank you all for your attention and I would be glad to take any questions that might have arose during all of this.
Speaker 2 51:16
Doctor Tejwani, thank you so much. I learned so much today. And one thing that really stood out to me is having that second set of eyes. And if there’s a time when you think I wonder if I should and then if the next question is should I go to the emergency room usually follow up on that. It sounds like it’s what you’re saying so.
Speaker 1 51:38
And I’ll exactly and thank you. I’ll I mean just sharing a kind of personal anecdotes. We went through this with our 11 month old in October and we had the same conversations I talked about the respiratory rate. We tried to measure his respiratory rate which you know I’m laughing because an adult doctor measuring an infant respiratory rates not as not as straightforward as you might imagine but that’s what we did. We ended up just and I’ll say it’s better to go at five PM or six PM then at two AM you know and that’s the other thing and then you just kind of rust easy so yes, i it’s all i completely empathize with my patients. It’s a bit of a pain at times, but unfortunately the right decision.
Speaker 2 52:22
Yes, wonderful, wonderful information. So a couple of our questions here. We have what age or diagnosis for the recommendation for Synagis vaccine?
Speaker 1 52:33
For which vaccine, I’m sorry?
Speaker 2 52:35
For the synergist is what they have in here.
Speaker 1 52:38
Referring to the age over 61 syanagis I know that there was one that they had for preemies at one time. Not really. And what I might be seeing here. Yeah, you know what I’m talking about.
Speaker 1 52:57
Yeah, I see. Yeah, I’m sorry. So this is this is referring to the brand iPod is this is the brand name of the pelvis map. So I guess it’s technically not a vaccination, it’s a monoclonal antibody. So it’s it won’t confer long standing protection, it would just be kind of a administered antibiotics. So my understanding is they’re using 2420 8 weeks as they cut off, but it seems to be varied and I saw that the American Academy Pediatrics did not change the cutoff, but they did recommend if historically it’s been 5 doses. But extending that course, if it’s been a longer course, i think it’s usually in the 24 to 28 week range. I suspect that again not practicing neonatal medicine but that it’s a very case by case decision. But i think that’s kind of the general guidelines from what’s been identified OK.
Speaker 2 53:50
Thank you. And another question we have is how long is the transmission for RSV?
Speaker 1 53:56
So this is if you’re, if you’re sick yeah as far as I’ve seen, it’s really if you’re symptomatic and this is another kind of advantage we have combating RSV rather than COVID where there are many asymptomatic carriers, it kind of lingers for a longer of time, a longer period of time. So RSV and the flu generally, if you’re symptomatic, you’re transmitting and once you’re no longer symptomatic, you’re not coughing out those viral droplets. So we tend to be less symptomatic or less transmissible. Excuse me.
Speaker 2 54:26
Ok, wonderful. Thank you for answering that. Another question we have is how long does RSV typically last in an adult? And then this might go back. The second part of their question might go back to some of the things that you mentioned as far as the treatment for cough and sore throat, what grandma used to do.
Speaker 1 54:45
Yeah, yeah no so I think for how long it lasts in adults in the absence of immunocompromised status and the absence of heart or lung disease, it would be really less than a week for most folks. So most folks are kind of looking at three to five days. If there’s any of those other things, it can vary and it can get much longer.
Speaker 2 55:07
Thank you. Another question is can you explain more about the test for RSV COVID and influenza? How would one get this? How much does this cost?
Speaker 1 55:18
So I’ll explain that with the disclaimer that I have no first-hand experience with it, but basically there’s, it’s called, I won’t go back to the slide, but it’s called pixel, it’s by LabCorp and from what I saw they say if you have insurance or certain insurances that cover it, they will express mail it to you overnight. And then you mail it back and they you get the results within three to five days. So I think if you just search pixel and the company that makes it as LabCorp, I know you know I’m not endorsing it by any means, but it’s just beyond availability of communicating it’s availability that it seemed to be a fairly straightforward process. The only thing I would just emphasize is what I did in the talk which is if it’s positive, I think that’s helpful and you’ve kind of say you know diagnosed this a little more efficiently. But if you’re if you have worse symptoms or if it’s negative, if you have symptoms you should seek emergency care. If you have worse symptoms, you should probably still think of yourself certainly as sick with some type of viral infection which is why you tested yourself to begin with and kind of isolate accordingly.
Speaker 2 56:28
Ok. Another question is what are the lingering effects of RSV for adults? And someone said they have had it for three weeks.
Speaker 1 56:35
Three weeks yeah well, I’m sorry to hear that. That’s a bit lengthy, which I’m already here. Fortunately not much so. And if there’s underlying heart or lung disease, whether it’s CHF, asthma, COPD, it can make those diseases linger. If somebody has a proclivity toward asthma, it can kind of basically met cause asthma to manifest. But, and this is, this is a welcome reprieve from COVID where there’s long COVID, there’s all these types of kind of seemingly immune mediated symptoms that are occurring. Rsv really does not have that unless you get very sick. If you get very sick or you’re an intensive care unit and you’re hospitalized, there’s consequences of that from just weakness and generally and deconditioning. But in the absence of underlying heart or lung disease or it causing new heart or lung disease, it should not. Need anything very protracted so three weeks is a little long which I’m sorry to hear and hope it starts to turn the corner soon and it should.
Speaker 2 57:36
Thank you. Some people, myself included, seem to have bad luck when it comes to respiratory conditions. Another question we have is there any special concern for groups such as military colleges, churches and in person meetings?
Speaker 1 57:51
Yeah, that’s a great question. I think again, that’s a part of why we’re seeing what we’re seeing this year. So I would say there is no. And there’s no like special consideration per se, other than that all those individuals, because of the way it’s transmitted will be at higher risk in dorm rooms, are going to be at higher dormitories, are going at higher risk in churches and other religious get togethers where there is a congregation, often parts of different religious celebrations involve, you know, touching one particular thing as a part of the ceremony. So I think all for all of those things, there’s going to be increased risk and certainly the same with military and barracks. So i think from a. Individual perspective. When you’re in those spaces or if you’re counseling somebody in that space, you just kind of talk to them about the way it’s transmitted and say, OK, so you know, go through masses, you would normally just try not to, you know, touch your face during mass the best you can and then ensure you wash your hands right after. So that that’s kind of the just practical takeaway there’s nothing. Beyond that, specifically for it, other than that, they’re a little higher risk of exposure.
Speaker 2 59:04
Ok. Thank you. And that’s one of those things that people don’t realize how often they touch their face and their eyes and their nose. And I used to do little trainings for kids in elementary schools. And I’d have this lotion that we put on and it was glow in the dark. So we’d put that on and we give them a few minutes and then we’d use this black light. And then you could see everywhere that they had touched and their faces are covered and their noses. And I think it’s just habit. And people don’t realize how often that they touch their face and then that’s transmitting viruses. So one of those things that’s really hard to control. Another question on here and let’s see, this one’s actually about COVID. So how soon after the bivalent COVID vaccine should an older adult plan on getting another booster?
Speaker 1 59:47
At this point, we’re. Kind of. Well maybe not at this point sub understatement so we’re it’s a little bit of building the plane as we’re going but most of the. Immune these are immune based measurements seem to suggest that the boosters would or have robust protection for about six months umm. And that’s nothing specific to the bivalent vaccine because we don’t actually have that level of duration or excuse me, that duration of evidence or data on the bivalent vaccine yet since it’s just been recently administered. But most of the prior boosters seem to suggest that they would last about six months with a good level of data. It’s not like you go, excuse me, a good level of protection. It’s not like getting month seven. You just drop off to where you were before you got the vaccine. But there are the booster, but there does seem to be a little. Drop down at that point. So i think if you’re high risk or otherwise you know in settings where it’s still could be contracted and particularly if you haven’t gotten it yet because i think it’s fairly apparent that infection does offer some degree of immunity. I think it is better with the vaccine unequivocally as well. But if you’re high risk and haven’t gotten it, I, oh, excuse me, haven’t gotten the infection I think six months would be reasonable.
Speaker 2 01:01:13
Ok. Thank you. And we have time for one last questions, which is do you think most people who had thought that they had a common cold in prior years really had RSV?
Speaker 1 01:01:24
That’s a good question. So i think it’s possible. I wouldn’t say most people. So generally, even before COVID, during the winter seasons when we had folks admitted or presenting to urgent cares or the hospital, they would get tested for RSV. Well, let me refer to the hospital. They would get tested for RSV. If you go to an urgent care kind of like a walk in, they usually just do a flu influenza test and not RSVP. So if they were influenza negative, then definitely could have been RSV more common and in years prior would likely just be the rhinovirus depending on the severity, which is kind of like a usual upper respiratory tract infection. There’s the metapneumovirus, M E T A P N E U M O virus and then coronavirus like pre. Pre COVID-19 coronavirus which we’ve seen a couple of a few of this is like the usual coronavirus that occurred as well. So I would say most people in years past have had one of these but i don’t know I don’t think it was mostly RSV I think it was they just had one of these things and the reason we don’t go through that much trouble to test for them is because outside of influenza where if you catch somebody in the first 48 hours you can give them Tamiflu. There’s really nothing special or specific you whether it’s RSV or rhinovirus or the old, you know, coronavirus classic if you will, or meta neumo virus. It doesn’t really you. It’s all that kind of supportive care. Unless they’re very sick. That’s why we test in the hospital, because then it does change things.
Speaker 2 01:03:05
Understand thank you for that. So thank you, Doctor. Tejwani, if you can just forward one more slide. That will go forward. Oh one. More and one more, sorry about that. So our next webinar we will actually have it will be next Friday, January seventeenth if you january twenty seventh, if you’d like to register on our website. And I just wanted to repeat this, we mentioned this at the beginning, but I know we have people coming and going on the webinar. So you undoubtedly notice that we have a different platform this year and had a few technical difficulties at the beginning. So thank you all for bearing with us. So previously you could download. Certificate during the webinar. However with this platform what we’re doing is you will receive an email after the webinar, you will have a lot of resources about RSVP and you will also have a link to be able to download your certificate. So thank you again for joining us and we hope that you all have a great rest of your evening.
Speaker 2 01:04:09
Thank you all.