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5. TRANSCRIPT: RSV: The OTHER Respiratory Virus
Part 1:
Dr. Jill Sellers:
Welcome to the On Medical Grounds podcast. I’m Jill Sellers, your host. On Medical Grounds is a casual, friendly place where you can find an authentic, audible blend of timely scientific and medical knowledge. We talk with experts about their experiences and knowledge, the utilization of new therapies and challenges within the world of healthcare. Select podcasts offer continuing medical education credits for those of you needing an additional why you should listen. We provide perks to all posted podcasts by linking content so you can drink in more if you so choose.

Lately, it seems that everything health related is revolving around COVID-19, yet another respiratory virus that is commonly overlooked has raised concerns in the medical community. Respiratory syncytial virus or RSV is on the rise across the United States and surging in some locations in the South, filling up pediatric hospital wards and posing a serious risk to the children and older adults that contract it. This is the first of two episodes that will focus on RSV, the threat, the tools available to diagnose it and developments on the horizon to protect against it.

Our two guests today will focus on the pediatric side of RSV. Our first guest is Dr. Joseph Domachowske who is professor of pediatrics and professor of microbiology and immunology with tenure at the State University of New York Upstate Medical University in Syracuse. He also serves as the director of the global maternal child and pediatric health program at the Center for Global Health and Translational Science at SUNY Upstate Medical University and has an international appointment as the director of the research center of the SUNY Upstate Medical University Teófilo Dávila Hospital in Machela, Ecuador. His specialties and research interests are pediatrics and pediatric infectious diseases. Dr. Domachowske completed his medical degree and residency at the SUNY Health Science center in Syracuse, New York and completed a fellowship at the National Institutes of Health Laboratory Host Defenses in Bethesda, Maryland. I will link to a more complete bio of Dr. Domachowske in the show notes. Welcome to the On Medical Grounds podcast, Dr. Domachowske.

Dr. Joseph Domachowske:
Thanks very much. It’s great to have the invitation to be here.

Dr. Jill Sellers:
Without going into a lot of detail and for full disclosure, the topic of RSV is important to me because my second daughter was diagnosed with it at five weeks old. The week prior to the RSV diagnosis was exhausting, worrisome because she was congested, she had a cough and was tachypneic and I had to hold her upright against me at night so she could sleep. And all the while I kept calling the doctor and they’d say, “Give it another 24 hours, give it another 24 hours.” Looking back, the most frustrating part of that time was what it took for her to be diagnosed. It was almost a full week. And then finally, when we got her in and they diagnosed her with RSV and hospitalized her, relief came and we had great care at the Walter Reed Army Medical Center, but I can’t help but think, it seemed to be an afterthought in our case, RSV. And looking back, I think it was primarily an afterthought because she was a full-term baby. My question is, how serious is RSV? And does it often go undetected or overlooked when trying to make a diagnosis?

Dr. Joseph Domachowske:
Yeah. RSV or respiratory syncytial virus infection is so common in young infants, so commonplace and the signs and symptoms overlap with so many other different respiratory viral infections that could be easily overlooked or ascribed to something else. But the situation that you’re describing, especially as you got into it, really is very characteristic for RSV infection and so many of our infants are infected every year.

Dr. Jill Sellers:
Well, how does the presentation of RSV differ in a pediatric patient versus an older patient?

Dr. Joseph Domachowske:
Well, unlike many infections that we’re familiar with, once you have a serious RSV infection, you don’t necessarily have protection against another RSV infection later on in life, even a year later. Children often will get RSV infection year after year for several years in a row. Each subsequent infection is generally milder than the initial one and then there can be a period of time where there may not be infections from year to year. Older children, young adults and elderly adults also get infected, particularly if they’re around other younger kids. When they get infected, they tend to only get mild cold type symptoms but as we age, we are susceptible to more serious consequences from RSV infection as well.

Dr. Jill Sellers:
What are some of the common methods of testing for and diagnosing RSV? And does that differ based on the age of the patient?

Dr. Joseph Domachowske:
Sure. The best test for diagnosing RSV infection for any age now is doing so using PCR. And PCR is familiar to us now because it’s such a common test used for a COVID-19 infection diagnosis. This is a DNA based amplification type test. There are many different platforms that are used and it is the most sensitive and the most specific test available but not the only type of test available.

Dr. Jill Sellers:
Would you describe RSV testing easy? Or has it become easier?

Dr. Joseph Domachowske:
RSV diagnostic testing has really become much more easy than it used to be. I remember going up and down the wards in the middle of RSV season, the cold and flu season, and doing nasal wash samples on hospitalized infants with what we call bronchiolitis. And washing them means laying them on their side and squirting five to 10 CCs, so that’s one to two teaspoons of saline into the superior nostril and suctioning from the inferior nostril. It’s very unpleasant procedure for both the person doing it and obviously for the baby, but it was necessary at the time because the diagnostic testing was not quite as sensitive. We used antigen tests back then and it was more difficult to get a positive result with those types of tests.

Dr. Jill Sellers:
Do the testing methods differ depending on the age of the patient? Would you do these nasal washes with older patients too? Or just the infant?

Dr. Joseph Domachowske:
Yeah. The only reason I would consider nasal washing in these days would be for research purposes to culture the virus at a high level of sensitivity. The PCR type tests that we use for really all age groups now is so highly sensitive we don’t have to do washes anymore. We can do a simple nasal swab or a nasopharyngeal swab, which is commonly used for the diagnosis of many types of illnesses cause respiratory trouble, including COVID-19 of course. And we don’t have to use the deep nasopharyngeal swabs either anymore. We know that the nasal swabs more in the front part of the nose are highly effective, especially for use in infants.

Dr. Jill Sellers:
That was going to be my next question is which of these methods was more accurate and reliable? You just answered that.

Dr. Joseph Domachowske:
Yeah, I think the nasopharyngeal swab is going to give us better accuracy and reliability just because the manner in which the sample is obtained, the quality of the sample is going to be better guaranteed.

Dr. Jill Sellers:
I’m curious, there’s been a lot of CDC guidelines being discussed recently with COVID, but what are the current CDC guidelines and health department reporting requirements regarding acute respiratory illnesses such as RSV?

Dr. Joseph Domachowske:
Well, in general, there aren’t any unless we’re talking about other types of respiratory infections, like whooping cough, pertussis, which is a vaccine preventable infection. But for RSV and its nasty relatives, we don’t have clear written out CDC guidelines or even local health department guidelines. The committee on infectious disease from the American Academy of Pediatrics put together a nice guidance statement several years ago, which basically speaks toward the benefits of doing RSV testing in some circumstances and the lack of utility in doing so under other circumstances.

Dr. Jill Sellers:
How has the emergence of COVID-19 changed the diagnosis and treatment of RSV?

Dr. Joseph Domachowske:
Yeah, such a great, intuitive, insightful question. From March of 2000 until very recently we saw very little hospitalized RSV at all in infants and in our community in Upstate New York, we typically see approximately 200 hospitalizations every RSV season and last season we saw two.

Dr. Joseph Domachowske:
The community response to COVID-19 with distancing and masking and really staying at home, isolating, frequent hand washing, all of those things were highly effective at preventing the transmission of both RSV and influenza, quite frankly, because of the efforts that we were putting forth to try to reduce the rates of COVID-19 infection.

Dr. Jill Sellers:
That brings up a good point with my particular case with my daughter and her RSV because we had brought her home from the hospital, she had not gone anywhere, so we must have brought it in somehow to her. And I think that’s another reason why it took them so long to think it was RSV and then finally take her through the testing for it because she hadn’t been anywhere and we were being very cautious. But so I guess that that can happen. Discuss some of the precautions taken to contain RSV once a patient has been diagnosed.

Dr. Joseph Domachowske:
Well in the hospital, we use contact precautions for RSV, which surprises many people, because most of the time, if we’re going to prevent RSV transmission or sorry, respiratory viral transmission, you would think a mask is required but RSV is transmitted much more effectively across fomites, doorknobs, and hands that recently had touched secretions or maybe holding the baby, trying to take care of the baby and getting their hands contaminated and then cross contaminating perhaps another individual or touching your nose or your eyes. That’s really how RSV is transmitted. The specific guidance in the hospital is called contact precautions but in a household, that’s extremely difficult to do. What we advise folks is really good hand washing. And if you have an older child that’s been diagnosed with RSV or has an RSV-like illness and you also have a younger infant in the house, is to be really careful about the types of interactions those two are having while the older child is symptomatic.

Dr. Jill Sellers:
Okay. Yeah. I’d like to talk a bit about the RSV vaccine that’s under development. Have you participated in the clinical trials? Or do you have any recommendations on whether or not you would have your patients get that once it’s available?

Dr. Joseph Domachowske:
Yeah. There are several efforts that are ongoing for RSV vaccine development and I’ve been involved in those types of clinical trials for infants, young children and even for women during pregnancy, on and off for the last 20 plus years. The most recent developments have changed everything based on two scientific discoveries that were made only about six years ago, that they’ve allowed enormous progress, an explosion really of progress in the prevention of RSV infection, both in infants and children and potentially even in elderly folks. I think that the RSV vaccine that you’re referring to, the one that’s furthest along in progress today, is sort of a different mechanism that we’re using to try to prevent RSV disease for young infants. And that’s using a very high affinity, long half-life, monoclonal antibody. Clinical trials are still ongoing with this but they’ve shown very promising results with phase two, three results published last summer in the New England Journal of Medicine and more results coming very soon.

Dr. Jill Sellers:
Will the availability of an RSV vaccine change how the diseases viewed and treated?

Dr. Joseph Domachowske:
I’m convinced that these new discoveries that were made that allowed this explosion of progress will change the entire landscape of RSV, especially for infants and young children. As I mentioned earlier, we have 200 or so infants hospitalized in our small city or small children’s hospital in Upstate New York every year and I’m looking really forward to watching that go away to the types of levels that we saw during the COVID period when we were masking and distancing so much. And I think that this new investigational product has the potential to do so.

Dr. Jill Sellers:
It sounds to me like you would recommend without question that your pediatric patients get vaccinated for RSV.

Dr. Joseph Domachowske:
Once the RSV vaccine becomes available, once the FDA gives its nod for safety and efficacy with approval, yeah, absolutely. There’s no question in my mind, especially for those children entering their first RSV season, so those under a year of age. That’s the group that I think we need to be targeting first. Although there are several other high risk groups that we’ll need to pay attention to as well. Older children beyond infancy, maybe in their second, third year of life that have underlying chronic lung disease are patients with cystic fibrosis, those with chronic lung disease of prematurity, underlying congenital heart disease, those types of things.

Dr. Jill Sellers:
Yeah. Any final thoughts on what our audience should know and be aware of regarding RSV?

Dr. Joseph Domachowske:
I think it’s always impressed me that influenza is very well known across the general population inside and outside of medicine everywhere and I’m not sure why it gets that much attention, although, the morbidity and the mortality can certainly affect us at any age. And we do have vaccines and antiviral treatments available to either prevent or to treat it. But if we take the young infants, children in their first year of life, RSV is six times more likely to lead to hospitalization compared to influenza. Why is it that so few people really know what this respiratory syncytial virus is? We have to get the out and increase awareness for how dramatic this virus can be and how pervasive it is every year. We have between one and two percent of our entire birth cohort hospitalized with this infection every year. Any other infection that did something like that would get loads of attention or we have long had a vaccine to prevent it. RSV is that one that sort of lingers. And I think that we really need to increase awareness and make folks understand why it’s so important to try to prevent this infection.

Dr. Jill Sellers:
And that is one of the reasons why we are here today. Thank you, Dr. Domachowske for your time and educating us on RSV.

Dr. Joseph Domachowske:
It’s my pleasure. It’s my favorite thing to talk about.

Dr. Jill Sellers:
As Dr. Domachowske mentioned earlier, RSV is very common in children. The majority of cases are mild and resolve on their own without treatment, yet in some cases, RSV can be very serious. According to the National Institutes of Health, more than three and a half million children worldwide are hospitalized annually with RSV. For our next guest, the seriousness of a pediatric RSV case is hitting very close to home and heart. Tyler Zongker's four-year-old daughter, Maddie is currently hospitalized with RSV. Tyler, thank you for being here to share your family’s story. Having been through an RSV case with my daughter, I know there’s a lot on your mind and a burden on your heart right now.

Tyler Zongker:
Jill, first I’d like to just thank you for letting me join you today to share my story and my family’s story. Yeah, there’s been a lot on my mind and my heart. Anytime that you have a kid that’s in the hospital, it’s always a very difficult situation. You feel helpless. When they’re hurting and crying you sit there, all you wish you could do is take the pain away but all you can really do for them is just sit there, hug them, comfort them and be there for them.

Dr. Jill Sellers:
Let’s tell the audience a bit about your daughter and her health status up to the point of hospitalization with RSV.

Tyler Zongker:
Well, with my daughter’s health status really, I’ve got to go back to the time she was born. Maddie was born premature at just 25 weeks gestation. Her original due date was on May 30th of that year. She happened to surprise us on Valentine’s Day, weighing in at just a pound four ounces. We were in the NICU with her, which is the neonatal intensive care unit for 146 days before we were able to bring her home. The first month in the NICU, she was on a ventilator helping her breathe. Her lungs were not developed enough to support herself. We had some of our biggest ups and downs in the NICU. One of the sayings and reminders we always got from the wonderful doctors, nurses, respiratory therapists and good reminders we got from them to my wife was just remember, there’s always two steps forward and one step back. Meaning as we see her progressing and getting stronger, expect some setbacks. And there were lots of setbacks.

At times it just felt like we had setback after setback. It was very difficult watching our daughter struggle day in and day out in the NICU, feeling helpless because we felt like there’s nothing we could do for her. The staff in the NICU, they’re some of the most amazing people you’ll ever meet. They’re compassionate, caring. They’re always there for us. They’re our emotional support. The best day was when we got to bring her home from the NICU for us. We really miss the NICU staff, we’d develop those personal relationships with them but after being in the NICU for 146 days, it was just, it was joyful to be home with her.

Dr. Jill Sellers:
Yeah. I can only imagine. And because she was premature, does Maddie have any underlying respiratory conditions or chronic lung diseases or other congenital heart problems or anything like that?

Tyler Zongker:
Yeah. Maddie actually has chronic lung disease, specifically what they call bronchopulmonary dysplasia, for short they call it BPD. Through bringing her home and having BPD, this really results in multiple hospitalizations over the course of a two year period. Common colds would basically cause her to go in respiratory distress, would require oxygen and it led to her having to be hospitalized. One of the things the NICU physicians and staff nurses always told us during the time in the NICU, is that really it’ll take her up to about age two to really get to the point where she can support herself and make it through things like a common cold. And that really, that held true.

Dr. Jill Sellers:
You’ve been through a lot with Maddie up to this point. And so you were probably a hypervigilant parent already, but as Dr. Domachowske mentioned earlier, the symptoms of RSV are similar to many other respiratory illnesses and you’d already been through all of this with her. When did you and your wife know that Maddie was suffering from an acute respiratory illness and that it was more than just a sniffle?

Tyler Zongker:
Well, just like you said, it started off as a sniffle, which then led to a cough. Then she developed a little bit of fever so we decided to hold her out of daycare. Throughout the day, her cough just became more frequent. There were more episodes that are lasting longer. From our time when she was younger, we did have a nebulizer in the home. She did start to develop a little wheezing so we went ahead and started doing nebulizer treatments albuterol for her. That evening, I checked her O2 sat and she was sitting around 90% on oxygen, on room air. We sat there and kind of monitored. She was breathing quickly. When ahead and did another albuterol treatment on her, went to bed.

That evening we actually let her sleep in our bed, which is not something we do hardly at all. Just that way we could keep a closer eye on her. Throughout the evening, I just noticed she was breathing harder, breathing heavier. Went ahead and put O2 sat on her, a pulse ox on her, check her O2 sat again and she was hovering around the mid-eighties and I kind of sat there and watched her for a few minutes and noticed that it wasn’t improving and even trying to arouse her and get her to cough a little bit. At that point I knew we were destined to be back in the hospital again.

Dr. Jill Sellers:
We should note to our audience that you are a physician assistant and that’s why you don’t talk like just a regular father. And so your background in medicine probably gave you a headstart in ruling things out and also an understanding of the potential severity of what you could be facing with RSV. I’m curious, how long did it take to get the RSV diagnosis? And were there other respiratory illnesses that they ruled out prior to the RSV diagnosis?

Tyler Zongker:
Yeah, so we knew that in her daycare, they had some cases of RSV in some other classrooms, that we hadn’t heard of any in her classroom at the time. Really initially from the beginning, we kind of suspected that was RSV was the probable culprit. At first we took her into urgent care, with COVID going on now, the ERs, you always hear all the stories about how they’re overran, they’re busy. Well, that is true and that’s one of the reasons I decided to take her to urgent care first, where we could get her evaluated quickly because I knew she needed oxygen to help support her.

Going to urgent care, I knew right away that they were going to ship us right to the ER, which is what happened. But we had her on the oxygen. We had her ready to go to the ER. The nurses from urgent care were able to give a really good description of her history and what was going on to the ER staff. Were able to get us a room very quickly, just because she was in respiratory distress. She was very tachypneic, her respirations were in the fifties to sixties. She was just struggling to breathe overall. The RSV diagnosis came pretty quickly. They got her swabbed really quickly. They did rule out COVID, they also swabbed her for COVID. As far as I know, they just did a nasal swab to confirm the RSV diagnosis. I’m unsure whether they used a PCR or an antigen test to officially confirm the diagnosis of RSV.

Dr. Jill Sellers:
Now, when we had spoken prior to this, you had also swabbed her using a home test COVID kit. Is that correct?

Tyler Zongker:
Yeah, that is correct. Actually, my wife had gone to CVS that day and bought one of the Abbott at-home kits. I did swab her for COVID earlier in that day and that rapid test did come back negative.

Dr. Jill Sellers:
Which gave you probably some relief in ruling that out and then it was nice to have that confirmed, I’m sure, in the emergency department at the hospital. Tell me about what Maddie has been going through as a patient and what you and your wife have been going through as you watch her fight through this.

Tyler Zongker:
One of the most difficult things about being in the hospital, especially with a four year old is trying to get them to understand why they have to be there. It’s confusing to them why they just can’t go home and be at home in their own bed. Having to go through and explain why they have to start an IV on her because she doesn’t feel well, so she’s not eating and drinking. Trying to keep the oxygen tubing on her so that way she’s breathing easier. For my wife and I, really just the physical and mental exhaustion of being up there, not being in our own home. We’re very lucky that we have a great support system with family, friends, coworkers. They all reach out and check on us. They’re a good emotional support system for us. It’s just, again, it’s just it’s very difficult. It’s mentally exhausting being up there day in and day out.

Dr. Jill Sellers:
And I think that until you’ve been through that, you can’t even describe how physically and mentally exhausting that is. What kind of treatment is Maddie receiving to help her body fight this illness?

Tyler Zongker:
For the most part, she is on oxygen. They’re doing albuterol nebulizer treatments to try to open up her airways. She’s getting the IV fluid support because she’s not drinking. At the current time they’re doing oral steroids. Just this morning, they’re thinking that she may have developed some pneumonia secondary to the RSV diagnosis. I believe this evening they’re going to actually be starting her on some IV antibiotics. They think she may be developing a bacterial pneumonia secondary to the RSV.

Dr. Jill Sellers:
I am very sorry to hear that. That’s a complication. And the other complication in this case is COVID. You’re in an area of the country that is experiencing a surge in hospitalizations due to the Delta variant. Do you feel like the surge in COVID cases is impacting the care your daughter’s receiving?

Tyler Zongker:
Yeah, so first I’d like to just say that the nurses, physicians, respiratory therapist, pretty much everybody that we’ve encountered this hospital stay, they’ve been nothing short of amazing. That being said, COVID has complicated how healthcare is delivered, especially in the hospitals. Talking to the nurses, the respiratory therapists, everybody up there, they have staffing issues. They are overworked. They are being pushed to the brink, the limits. You’ve got nurses that every evening we talk to them, they’re not sure if they’re going to be staying another four, eight hours extra because there’s nobody coming in behind them. You can just tell by talking to them that they’re burned out. And you can see it in their eyes. They’re exhausted. They’re worn out and they don’t know when an end is coming to all this.

Dr. Jill Sellers:
Your background in medicine certainly helped you to identify quickly that something wasn’t right with Maddie. What would you tell other parents to look for in regard to RSV?

Tyler Zongker:
With kids, especially one thing that, especially when they get these respiratory illnesses, they initially they compensate very well. They do very well. And so I would always suggest watching them very closely. They can go from being fine one minute to really struggling the next. They developed the fever, the cough and it just progressively gets worse. Look for the belly breathing, look for them using those extra muscles to try to help support them breathing. You can look at their belly. If their belly is going in or out, they’re breathing very fast pace. Sometimes they’ll get what we call nasal flaring so at their nose just look if they’re really drawing hard and you see the edges of their nose are going in and out. That just means they’re using a lot of those accessory muscles to breathe. Just make sure you don’t ignore these symptoms. You want to make sure you seek care, whether it’s your pediatrician’s office if they’re open, if they’re not, it’s an evening time, go seek medical care as quickly as you can. Go to urgent care, go to the ER, try to get them evaluated as quickly as possible.

Dr. Jill Sellers:
Good advice. Any final thoughts for the other health professionals that are listening and who may be dealing with RSV patients during this pandemic?

Tyler Zongker:
Yeah, just keep your heads up. This pandemic in general has just been a huge strain on members of the medical community, especially with the current outbreak of COVID and especially in the community that I live. And then now you start throwing in an increase in RSV cases, which is very unusual for the summertime. This is typically a wintertime illness, and then you throw in all these other communicable diseases, it makes it just so much worse. And I just feel, let them all know that, I know you guys are stretched and I know you’re burnt out. Keep taking care of your personal mental health, stay on top of that and just know that you are making a difference in people’s lives just like my family right now.

Dr. Jill Sellers:
Thank you Tyler, for being here and sharing your story. We wish Maddie a full and speedy recovery and rest for you and your wife.

Tyler Zongker:
Thanks Jill, for having me here today and thank you for the well wishes for myself, my daughter and my family.

Dr. Jill Sellers:
And thank you for listening. In our next episode on RSV, we’ll focus on how RSV impacts older adults, the available diagnostic tools and developments on the horizon to protect against the virus. I will be interviewing Dr. Angela Branch, an infectious disease specialist from the University of Rochester Medical Center in New York and Dr. Jonathan Temte, professor of family medicine and community health and associate dean for public health and community engagement at the University of Wisconsin School of Medicine and Public Health. If you like what you hear on the On Medical Grounds podcast, please subscribe, rate and review us. And don’t forget to visit OnMedicalGrounds.com for show notes and bonus content.
Part 2:

Dr. Jill Sellers:
Welcome to the On Medical Grounds podcast. I’m Dr. Jill Sellers, your host. On Medical Grounds is a casual, friendly place where you can find an authentic, audible blend of timely scientific and medical knowledge. We talk with experts about their experiences and knowledge, the utilization of new therapies and challenges within the world of healthcare. Select podcasts offer continuing medical education credits for those of you needing an additional why you should listen. We provide perks to all posted podcasts by linking content so you can drink in more if you so choose.

Welcome to part two of the On Medical Grounds podcast on respiratory syncytial virus, otherwise known as RSV. Many of you may be aware by now that RSV is on the rise around the globe during a season in which we normally do not see it. This is a winter virus, not a summer virus. This discussion will focus on the available diagnostic tools, developments on the horizon to protect against the virus and how RSV impacts older adults.

Our first guest today is Dr. Jonathan Temte, who is associate Dean for public health and community engagement at the University of Wisconsin School of Medicine and Public Health, where he also serves as professor of family medicine and community health. Dr. Temte was the first family practice physician to serve on and chair the U.S. Advisory Committee on immunization practices. He currently chairs the Wisconsin Council on Immunization Practices, is a member of the CDC’s Board of Scientific Counselors, and is the AAFP representative on the CDC’s Advisory Committee on Immunization Practices COVID-19 Vaccine work group. Dr. Temte is the principal investigator in multiple studies and has been very involved with the COVID-19 response at local state and national levels. I will link to a more complete bio of Dr. Temte in the show notes. Welcome to the On Medical Grounds podcast, Dr. Temte.

Dr. Jonathan Temte:
Well, thank you very much for the invitation. It’s a great pleasure to be here today.

Dr. Jill Sellers:
I am looking forward to this discussion and I’m going to jump right in with some of my questions. So how serious is RSV and does it often go undetected or overlooked when trying to make a diagnosis?

Dr. Jonathan Temte:
The easy answer to that second question is yes, we oftentimes don’t even consider this as a possibility. We usually think of RSV as a significant disease of infants and young children, but it is also a very significant pathogen for older adults and those with underlying pulmonary conditions. It contributes to thousands of pediatric hospital admissions every year, and now is increasingly recognized as a driver of hospitalizations and death in elders and in people with underlying COPD and asthma. And I have to mention that outbreaks of RSV in long-term care facilities are common and result in increased morbidity and mortality. My research and surveillance team conduct studies in primary care settings, in long-term care facilities and in schools. And I’ve been struck by how common RSV is across the entire age spectrum. Now, in terms of our detection, we do very little testing on average in primary care, in long-term care and in other settings. And our testing is usually dependent on the age, situation in place. And I would say that most commonly, we do testing for ill infants at the time of hospital admission. It’s occasionally done for hospitalized patients, particularly as part of a respiratory panel, but testing for RSV is rarely done in the ambulatory setting.

Dr. Jill Sellers:
Interesting. How does the presentation of RSV differ in a pediatric patient versus a middle-aged patient versus an older adult patient?

Dr. Jonathan Temte:
I’ll have to confess that early on in our surveillance program, I was struck by a woman in her thirties who presented primarily with a sore throat and it turned out to be RSV. And that has led me down the line of really paying attention to what we see. We typically think of RSV in infants as rhinorrhea with cough. And oftentimes, I describe this to my residents as being the green 11 sign where you have thick copious, nasal discharge coming out of both nostrils. But oftentimes with other people, we’ll find a milder illness in older children, healthy adults, and then exacerbations of asthma and COPD in older adults. So it runs the whole spectrum of a respiratory virus with a multitude of symptoms.

Dr. Jill Sellers:
So what are some of the common methods of testing for and diagnosing RSV? Are they the same in all those populations or do they vary depending on the patient?

Dr. Jonathan Temte:
They very dependent on the patient, the age and the setting. But the common tests out there are reverse transcriptase polymerase chain reaction, rapid molecular testing, direct fluorescent antibody testing, and rapid antigen testing. In the past, we used to use culture, but this is a technique that is rarely used anymore. But again, I think the important concept of our two, three across here is testing is often dependent on the location. And so for example, with an infant admitted to hospital, we largely rely on polymerase chain reaction testing. And on outpatient settings where they’re used, we can use the rapid molecular and the rapid antigen testing.

Dr. Jill Sellers:
And are those relatively easy, the rapid tests, are those relatively easy to use?

Dr. Jonathan Temte:
In general, they are very easy to use. They tend to be CLIA-waived tests and they tend to be fairly straightforward tests to conduct. But the important thing is first, acquiring a respiratory specimen. And this is actually pretty easy. We use nasal swabs, nasal pharyngeal swabs, or nasal aspirates. And in general, these are samples that are easy and very safe to collect.

Dr. Jill Sellers:
When we talk about these tests and these methods of testing, which of them are more accurate and reliable? I know that you’ve said it depends on the patient and the setting. Are there certain tests that are used in certain settings that are more accurate and reliable than others?

Dr. Jonathan Temte:
Absolutely. So the clear winner for accuracy is the PCR-based tests. These have the highest sensitivity and specificity. However, and this is an important consideration, these tests are not easily available in outpatient settings, and they require time for specimen transfer, for testing and reporting. And so it really depends on the situation. Do I need the answer quickly, or can I wait for a few hours? And typically, with a hospital admission, we have time on our hand because our treatments are supportive, we don’t have any definitive treatment for respiratory syncytial virus, and that patient isn’t going anywhere. On the other hand, in a primary care setting, once that patient episode is done, and I have a result coming in, it requires me to locate the patient, communicate with a patient, get the information across. And if something comes back to me, three or four hours later, it really represents a pain that I have to deal with. And so we really like the rapid tests in settings where they can be used rapidly. And I’m going to just divert a little bit here. We did a study looking at rapid influenza testing in long-term care facilities. And even though the rapid flu test has a lower sensitivity than the PCR, the rapidity of resulting allowed facilities to respond much more quickly to outbreak situations. And so I think it’s really, really important to carry across, it depends on the location, depends on the need for timing and it depends on who you’re looking at.

Dr. Jill Sellers:
But there’s no difference in the accuracy and reliability of the rapid test versus the longer term when you have more time test, correct?

Dr. Jonathan Temte:
The PCR tests clearly have a higher sensitivity and specificity, and we’re willing to trade some of that away with a more rapid test in clinical settings. And so in general, the rapid tests have a lower sensitivity, and oftentimes a lower specificity. But the specificities are usually very, very high.

Dr. Jill Sellers:
Okay. Understood. What are the current CDC guidelines and health department reporting requirements regarding RSV?

Dr. Jonathan Temte:
Well in general, there is no mandatory reporting of RSV and the exception may be an outbreak in a long-term care facility or a hospital. But unlike a number of our other respiratory pathogens, such as SARS-CoV-2, measles, diptheria, pertussis, chickenpox, RSV is not reportable. And so it fits into that same class as influenza. Influenza’s only reportable if there’s a laboratory confirmed pediatric death. So we don’t have good ways of tracking RSV because of that lack of reporting.

Dr. Jill Sellers:
How has the emergence of COVID-19 changed the diagnosis and treatment of RSV, or has it?

Dr. Jonathan Temte:
Well first and foremost, there are no specific treatments for RSV. Basically, our approach in the inpatient setting is supportive and this has not changed over decades. In the outpatient setting, the most important thing with RSV is the recognition and the anticipatory guidance and education of patients. So the COVID-19 pandemic hasn’t changed anything along that line. However, one of the amazing things with this pandemic has been the fact that our public health interventions, our masking, distancing, hand-washing and so on has had a profound effect on RSV. RSV largely has disappeared because of these public health interventions. And this has been really educational to me and to other clinicians because we see the incredible effect that we can have with these non-pharmacologic measures out there. On the flip side, what we’re seeing as we relax these measures is a resurgence of RSV. And I have to mention, I just got an email this morning from a colleague in Australia with a pre-print attached, showing that in Australia, as the public health measures were relaxed, they experienced a great resurgence of RSV. So this is something that we have to keep in mind as we’re, hopefully in the next months, coming out of this pandemic. The other thing out there that’s really important for our guests is the fact that as we’re coming out of this pandemic and we’re seeing resurgence of other respiratory pathogens, this is going to be incredibly, incredibly confusing for clinicians and it’s going to be a source of worry for patients. And I say this simply because as we’re seeing the presence of the Delta variant and increased transmissibility of COVID, and if this is happening at the same time that we see other respiratory pathogens come back with a vengeance, people are going to be confused as to what they have. And this is going to be really confusing for public health guidance. There’s going to be a lot of testing required, and it’s going to be a chaotic time, for several weeks to months.

Dr. Jill Sellers:
So if you had to look into that crystal ball for the future, based on what we know right now with COVID-19 and RSV, if the COVID-19 test was negative, what would be the next respiratory illness that would be tested for, or what we’re going to look to in the future? What do you think would be the next progression?

Dr. Jonathan Temte:
I think our biggest worry right now is that for a significant influenza outbreak. And I mention that simply because influenza, we do have vaccines that are effective and we do have therapeutics that are effective if started early. So there are some of the rapid tests that are dual tests for SARS and influenza. But I think we have to consider the whole gamut out there. And this really brings to bear the importance of having intact surveillance systems that can help let us know what’s in circulation. For example, we’re running a surveillance program on our university campus right now, and I can tell you that the people who are ill right now are ill with rhinovirus and with parainfluenza. But unless you have the facility and the capability to test widely, you don’t have that situational awareness.

Dr. Jill Sellers:
That makes sense. So let’s discuss some of the precautions taken to contain RSV once a patient has been diagnosed. We discussed it a little bit earlier with the resurgence of COVID-19 and how we haven’t seen much RSV because of some things. But let’s talk a little bit about those precautions taken to contain RSV.

Dr. Jonathan Temte:
I think it’s important to understand that RSV is a virus that is shed for a longer period than things like influenza. And typically, we use eight or nine days as the shedding period. But when we start at very young, so the infants or people who are immunocompromised, we can see shedding going on for three to four weeks after initial infection. And this is really important because RSV can persist on surfaces and stay viable for hours to days. And so this is definitely a virus that can be easily spread by contact. Somebody coughs or sneezes on a surface, hours later somebody else comes along, wipes their hand and touches their nose or their eye, that can lead to transmission. And so in both hospital and ambulatory settings, it’s really important if RSV is recognized to have that full contact precaution. This is the bane to my life when I’m doing inpatient attending, because it requires gowning, gloving, masking and eye protection. And then also, surface decontamination because we can easily spread this in a nosocomial fashion. So I think it’s really important to just understand the dynamics of transmission here.

Dr. Jill Sellers:
It all goes back to let’s wash our hands and take care of our personal hygiene, right?

Dr. Jonathan Temte:
That is so very, very important. And this is why we see this incredible benefit of our public health measures during the pandemic. And we’ve seen not only affects on RSV and influenza, but virtually all the other respiratory viruses.

Dr. Jill Sellers:
How has the use of the device ID NOWTM impacted the diagnosis, treatment and follow-up in RSV patients?

Dr. Jonathan Temte:
The ID NOWTM RSV test is one of the options for rapid RSV detection. And this is a molecular test. We see results within 15 minutes, and this has a higher sensitivity than the rapid antigen test. So in my mind, the ideal settings for this type of test would be in an outpatient setting or in a long-term care facility where having the result early can have incredible impact. In an outpatient setting, it provides me the ability to give results to worried parents quickly. In a long-term care setting, I think more importantly, it allows those public health measures, the patient isolation, the contact precautions, and so on that are really essential to prevent this from spreading widely through a facility.

Dr. Jill Sellers:
We’ve talked a lot about RSV the disease, how it’s transmitted, how it’s diagnosed. It would be nice if we didn’t even have to worry about it. So I know there are clinical trials ongoing with vaccines for RSV. And so I’m curious, once FDA approved, is the RSV vaccine one you would recommend to patients and which patient populations should get it without question and why?

Dr. Jonathan Temte:
This really depends on what the FDA licensure is for and what information the companies take forward for that licensure. But if I use my crystal ball, I can see certain targets out there that are going to be important. So currently we have no licensed vaccine, although there are several in the pipeline. And when I look into the future, I think the targets out there are elders, people over the age of 65, adults with pre-existing medical conditions such as COPD or asthma, and trying to provide protection for infants. And for infants, it’s a challenge because oftentimes vaccines are not terribly immunogenic in infants. So I think there’s been a lot of work looking at the role of providing vaccine to pregnant women so infants are born with maternal antibody in circulation. So it really depends on which vaccines are out there and what the licensure is for. But, should a candidate become licensed and receive ACIP recommendation? I think it’s going to be really, really important for individual and public health. And once it comes through ACIP, they have such a nice evidence-based recommendation process. Anything that they make a recommendation for, I would echo that strong recommendation for the indicated recipients. And then I think the important thing, and that’s I think one of the reasons why podcasts like this are very important, this is going to require a great deal of education of clinicians and of patients, of mothers and others out there about the underlying nature of RSV disease and it’s significance.

Dr. Jill Sellers:
Agreed. Education will be key for sure. Do you believe that the availability of an RSV vaccine will change how the disease is viewed?

Dr. Jonathan Temte:
I really think so. And again, I have to go back and look at colleagues in primary care across this country. And we all have a good sense of RSV, but our impressions are limited. We tend to think of RSV as that nasty virus that causes hospitalizations in infants. And I think we have to develop a broader perspective and see how this is an important disease across the age spectrum. And in particular, how it really not only affects the infants, but those older individuals with significant morbidity and mortality.

Dr. Jill Sellers:
Agreed. We talked a little bit about COVID-19 and how it has changed some things with RSV detection and incidence, I guess. So in general, I can’t let you go on this podcast without asking a general question, has the COVID-19 pandemic changed views towards testing and surveillance of infectious diseases?

Dr. Jonathan Temte:
Yeah. I have to go back to the comments I made before, and this has been an incredibly profound test case for what we do in public health. And the combined forces of school closure, physical distancing, masking, hand-washing has just had such an incredible reduction in respiratory viruses, including RSV. And I dare say this has been very, very effective when used properly for COVID-19. So I think that is the context of this whole pandemic. But the other thing, when we talk about laboratory testing, is the importance of ongoing surveillance as a tool for all of us, for situational awareness, for both medical and public health personnel. If we can understand what pathogens are in circulation at which time and who they’re affecting, we can make much better decisions in terms of prevention, testing, response, and treatment.

Dr. Jill Sellers:
And that’s what we’re here for to make these better decisions, right? To have a better, healthier public.

Dr. Jonathan Temte:
Exactly.

Dr. Jill Sellers:
Our time is coming to a close. Do you have any final thoughts on what our audience should know and be aware of, regarding RSV?

Dr. Jonathan Temte:
Well, as I mentioned before, there have been very few changes in approach to RSV over decades. But the good news is our approach to RSV is likely to evolve rapidly in the next several years. As we see new vaccines, new approaches to vaccines and novel therapeutics. And we’re really looking forward to the advent of safe and effective vaccines and other effective preventive and therapeutic options for individuals who are at high risk for morbidity and mortality. So I think I would say stay tuned, keep that antenna up, looking for the newer developments in RSV and keep in mind that this is an important pathogen out there that we have to be aware of, especially as we start relaxing those measures for COVID-19.

Dr. Jill Sellers:
Thank you, Dr. Temte, this has been excellent. We appreciate you being our guest for the On Medical Grounds podcast. We especially appreciate your time educating us on RSV and all the work you are doing to move public health forward. Thank you so much.

Dr. Jonathan Temte:
Thank you so much for the opportunity today. It’s been a pleasure speaking with you.

Dr. Jill Sellers:
Our second guest today is Dr. Angela Branche, an assistant professor at the University of Rochester School of Medicine and an infectious disease specialist from the University of Rochester Medical Center in New York. Dr. Branche received her bachelor of arts degree from the University of Pennsylvania and her doctor of medicine degree from the American University of the Caribbean. She completed her residency in internal medicine at NYU Lutheran in Brooklyn, New York, and an infectious disease fellowship at the University of Rochester. Dr. Branche is board certified in internal medicine and infectious diseases. Her current clinical practice is comprised of patients with general infectious diseases and HIV. I will link to a more complete bio for Dr. Branche in the show notes. Welcome to the On Medical Grounds podcast, Dr. Branche.

Dr. Angela Branche:
Thank you.

Dr. Jill Sellers:
My primary clinical practice was with the geriatric population. Therefore, I have a keen interest in RSV in the elderly and the potential of it being overlooked when trying to make a diagnosis. So allow me just to jump in with my questions, how serious is a respiratory syncytial virus in the elderly, and does it often go undetected or overlooked when trying to make a diagnosis?

Dr. Angela Branche:
Those are great questions. So RSV was actually initially described as the cause of nursing home outbreaks and respiratory diseases. It was first discovered in the fifties as something that caused illnesses in chimpanzees, actually. And then it became clear that it was something that was causing a lot of illness in children, especially young children under the age of two. Really severe bronchiolitis, lots of bronchitis and respiratory disease, and even potentially a trigger for things like asthma. And so for decades, after its discovery, it was thought to be primarily a disease of childhood. In the late eighties and early nineties, some investigators, and in fact, some of them here at the University of Rochester who are good colleagues, started to describe outbreaks in daycares and nursing home facilities of older adults that congregated in these settings. And since then, that’s led to national and international interests that RSV could in fact be a significant disease in adulthood and who were the populations most affected. And now numerous studies around the world have demonstrated that it is in fact something that we’ve become periodically infected with throughout life. You do develop some immunity, but that immunity is partial. And it’s really not enough to prevent you from getting reinfected. But for most of your adulthood, it’ll just be a cold. Until you become somewhat older and you have some underlying medical conditions and you’re a little bit more frail. And that’s when having a cold is not just the cold. That’s what having a cold can be bronchitis, it can cause exacerbations of heart failure and COPD. It can lead to pneumonia, it can lead to incapacity and weakness and worsening of frailty. And older adults very often we’ll end up hospitalized with RSV infections. I don’t think people are aware that RSV in older adults, the attack rates can actually exceed influenza in some seasons, and it can cause similar numbers of hospitalizations. And even in some seasons, RSV’s the number one virus that’s associated with hospitalizations in older adults. It can also be equally complicated by pneumonia and respiratory failure and the need for mechanical ventilation, as what you might expect with flu. So if we’re vaccinating older adults and really making sure that they’re protected against influenza, we should also really be thinking about that with RSV. One of the reasons why it often goes undetected is that for a long time, people didn’t understand that RSV was such a big player. But even with better education and better knowledge, there’s not a lot of desire or push to test because we don’t have treatments. And so because there’s no treatment for RSV, there’s really little motivation to make a diagnosis because treatment is just supportive and people just expect, “Oh, it’s just another virus.” Not true. And so RSV testing isn’t always routinely performed and you really have to be thinking about RSV to test for it.

Dr. Jill Sellers:
So do you think most of the time, because it’s not routinely thought of, and then it’s not routinely tested for, it just goes overlooked?

Dr. Angela Branche:
I think there’s a significant underdiagnosis of RSV nationally and worldwide. We like to say that RSV has an identity problem because people just say, “You have a cold or you have another virus.” No, no, this person has RSV and it actually means something in this population. So make a diagnosis, make sure that they’re not spreading it around and be prepared to have to give a lot of supportive care. That might be what it takes in some vulnerable populations.

Dr. Jill Sellers:
So how does the presentation of RSV differ in an older adult patient than an infant?

Dr. Angela Branche:
Again, RSV in childhood is recognized as this really significant disease because a lot of babies end up in the hospital and they have really severe bronchiolitis. It’s just a really scary thing that happens in early, early childhood, usually in infancy. And so that’s all we hear about and really all that’s recognized. But in fact, more adults are hospitalized and die from RSV every year than children, more adults over the age of 60. In adults, you’ll often have a really prolonged illness. It might start as a cold and then seven, 10 days later, you’re not better. And then you really start to struggle to breathe and you end up in the hospital, and it turns out that now you have pneumonia. Or it’s triggered hospitalizations because your heart failure or your emphysema has now been exacerbated and you’re in the hospital for those. That’s how older adults present. It’s quite different than the dramatic bronchiolitis picture of children, but it’s in sometimes some cases more deadly. It’s very devastating because it does cause this tremendous loss of function in older adults.

Dr. Jill Sellers:
Let’s discuss some of the common methods of testing for and diagnosing RSV. So do the testing methods differ depending on the age of the patient, and which of these testing methods is more accurate and reliable?

Dr. Angela Branche:
Absolutely. So some of the earlier tests for RSV are the least sensitive. So 30 years ago in order to diagnose RSV, you actually had to be able to collect a respiratory sample like sputum and try to culture the virus. And you would only find it if the person really had RSV about a third time, which is just an incredibly insensitive test. And also virus viral cultures are just really hard to do. We don’t really have that expertise anymore because they’re obviously difficult. And then in the eighties and nineties, antigen based tests were developed, which are a really great point-of-care rapid test that you can do in your office. They’re quick, they’re easy, they have really good performance in young children. In fact, the sensitivities is about 90% in young children because they have a lot of virus. And so you’ll detect it. But we’ve shown that in older children and adults, for whom the amount of virus they might have in their nose is maybe a little bit lower and they’re shedding virus for a shorter duration of period, antigen based tests are actually sometimes in some cases less than 70% sensitive. So not a great test, which is sad because it’s so easy to do and so widely and readily available in most primary care practices. So how we diagnose RSV in adults is we have to use a PCR based test, so a molecular assay where you’re looking for the genetic material of the virus. And in fact, that’s become the gold standard because it’s 95% or better sensitive for all agents. It’s usually duplex for flu. So for most hospitals that do PCR testing for flu, that’s linked and duplex with a test for RSV. So you’re actually getting two for the price of one, but most people don’t even know that. And the results are often available within an hour.

Dr. Jill Sellers:
Has the emergence of COVID-19 changed the diagnosis and treatment of RSV? And if so, how?

Dr. Angela Branche:
Well there are no treatments for RSV. And part of the reason is because by the time we detect it, giving an antiviral is not going to make a difference. But I think the impact of COVID has taught us that it’s important to make viral diagnoses as early as possible because the earlier you can intervene in somebody that has a virus, whether it’s COVID or flu or RSV, the better your chances are of preventing that person to go on to have some more severe disease. And so if there was ever a chance to develop a successful antiviral in RSV, it’s really going to take a paradigm shift in people really and practitioners really working hard to make diagnoses of RSV so that you can get them treatment really early. But I think COVID in general has just raised awareness of how older adults are very vulnerable to viral infections. And so I think having that awareness will be a good starting point for the educational initiatives we’re going to have to put in place to help people understand the impact of RSV.

Dr. Jill Sellers:
Have you seen a decline in the cases of RSV during the COVID pandemic?

Dr. Angela Branche:
Yeah. It was really strange. Well, not really, it sort of makes a lot of sense. Everybody was masking up and so from the 2019 and 2020 and 2020 and 2021 winter seasons, which is when you usually see things like flu and RSV, they both pretty much disappeared. It was great. Such a lesson on what mitigation strategies can do when people actually wash their hands and wear masks and cover their coughs. But then we had this weird spike of RSV in the summer, which nobody would have predicted because dogma has always said these viruses really only circulate in the winter seasons when people are crowded indoors, cold weather is better for viruses. And so it has turned everything we know about seasonality of these viruses upside down.

Dr. Jill Sellers:
Yeah. I find it interesting. I think it is also possible that there probably were some RSV cases that maybe were masked as COVID or could that have happened? What do you think?

Dr. Angela Branche:
It depends on when they had those symptoms, where they went to be tested. It’s possible. In the State of New York, if you had a respiratory illness and you went to get tested, the State of New York was requiring most institutions to test, not just for COVID, but for RSV and influenza as well. So a lot of data was showing that there just wasn’t any RSV or flu around. But that’s not true for the whole country or even the whole world.

Dr. Jill Sellers:
You kind of hit on my next question, but I did want to go ahead and ask it. Can we discuss the precautions taken to contain RSV once a patient has been diagnosed?

Dr. Angela Branche:
It depends on what setting you’re talking about. If it’s in the outpatient setting, very often, RSV in a household or in a family group or in a social setting starts with kids. Kids are just a natural reservoir for viruses and they have lots of secretions and they love to spread those around. And so if you know your child is infected with RSV, the best thing to do is to keep them away from their older, more vulnerable relatives, because there’s just no way of cleaning them or keeping their secretions and wiping their noses well enough that you’re not going to be able to put other people at risk for contracting RSV. If you’re a mom or dad of a kid that had RSV and now you have it, then a lot of the typical precautions that we put in place for COVID should apply to you, wash your hands, cover your mouth when you cough. And if you’re in a hospital, because RSV is transmitted by both respiratory droplets and also to a larger extent than COVID, by contact with patients, with their secretions on wet surfaces, for patients who are in the hospital and have RSV, they have both droplets which means you wear a surgical mask as well as standard precautions, which means you glove, sometimes you wear gowns and then you wash your hands a lot.

Dr. Jill Sellers:
Once the RSV vaccine is approved, would you recommend it to patients? And is there a specific patient population that should get it? And will the availability of an RSV vaccine change how the disease is viewed and treated?

Dr. Angela Branche:
Yeah, I think for a number of decades now, as a medical community, we’ve been working to develop vaccines for RSV. It’s an important vaccine to have both for young children, because there’s still a lot of children around the world that die from RSV every year. And it’s also an important vaccine in adults over the age of 65, older adults who tend to have more severe disease, particularly those with underlying cardiopulmonary conditions. So I think that I would recommend the vaccine once approved in those populations. I think it will be something that we really have to do a lot of education about and I think it’s thinking about what can we do to prevent pneumonia, which we know is really devastating in all older adults. And this is one of the biggest causes of it in this population.

Dr. Jill Sellers:
In general, how has the COVID-19 pandemic changed views towards testing and surveillance of infectious diseases?

Dr. Angela Branche:
Well, I think people are really aware of their vulnerability. We’re all vulnerable to COVID, but I think it’s just made people more aware that there are viruses that can cause you to be very sick. It’s not just influenza. It’s not something that you can give antibiotics for. And the answer with many viruses is really about prevention. So I think the COVID pandemic has really put prevention of respiratory viral illnesses at the forefront of people’s minds in the medical community and in the general population. So I think in general, people will be thinking, “Well, how do we prevent these illnesses? How can I protect myself?” And I think that’ll maybe lead to some greater acceptance of an RSV vaccine.

Dr. Jill Sellers:
Thank you Dr. Branche for joining us on the On Medical Grounds podcast. We appreciate you educating our audience on RSV and the elderly and the importance of proper testing and diagnosis.

Dr. Angela Branche:
Okay. Thank you very much for having me.

Dr. Jill Sellers:
And thank you for listening to the On Medical Grounds podcast. We know your time is valuable. The resources that were referred to in this podcast can be found at onmedicalgrounds.com. In addition, please be sure to click the subscribe button to be alerted when we post new content.