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Tag: Respiratory Disease

  • Fall’s Vaccine Routine Didn’t Have to Be This Hard

    Fall’s Vaccine Routine Didn’t Have to Be This Hard

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    In an ideal version of this coming winter, the United States would fully revamp its approach to respiratory disease. Pre-pandemic, fall was just a time for flu shots, if that. Now, hundreds of millions of Americans have at their fingertips vaccines that can combat three cold-weather threats at once: flu, COVID, and, for a subset of us, respiratory syncytial virus. If everyone signed up to get the shots they qualified for, “it would be huge,” says Ofer Levy, the director of the Precision Vaccines Program at Boston Children’s Hospital. Hospital emergency rooms and intensive-care units wouldn’t fill; most cases of airway illness would truly, actually feel like “just” a common cold. “We would save tens of thousands of lives in the United States alone,” Levy told me.

    The logic of the plan is simple: Few public-health priorities are more pressing than getting three lifesaving vaccines to those who need them most, ahead of winter’s viral spikes. The logistics, however, are not as clear-cut. The best way to get vaccines into as many people as possible is to make getting shots “very, very easy,” says Chelsea Shover, an epidemiologist at UCLA. But that’s just not what we’ve set up this fall lineup of shots to do.

    Read: The flu-ification of COVID policy is almost complete

    Convenience isn’t the only issue keeping shots out of arms. But move past fear, distrust, or misinformation, solve for barriers such as insurance coverage, and getting a vaccine in the United States still means figuring out when shots are available and which you qualify for, finding and booking appointments, carving out the time to go. For adults, especially, who don’t routinely visit their doctor for wellness checkups, and whose workplaces don’t require vaccines to the extent that schools do, vaccination has become an onerous exercise in opt-ins.

    Bundling this year’s flu, COVID, and RSV vaccines into a single visit could, in theory, help ease the way to becoming a double or triple shotter. “Any time we can cut down on the number of visits for a patient to take care of them, we know that’s a big boost,” says Tochi Iroku-Malize, the president of the American Academy of Family Physicians. But the easiest iteration of that strategy, a three-in-one shot, similar to the MMR and DTaP vaccines of childhood, doesn’t yet exist (though some are in trials). Even the shorter-term solution—giving up to three injections at once—is hitting stumbling blocks. Pharmacies started receiving flu vaccines earlier this summer and are already giving them out to anyone over the age of six months. RSV vaccines, too, have hit shelves, and have been approved for people over the age of 60 and those 32 to 36 weeks pregnant; so far, however, they are being offered only to the first group. And although nearly all Americans are expected to be eligible for autumn’s updated COVID vaccines, those shots aren’t slated to make an appearance until mid-September or so, according to Kevin Griffis, a CDC spokesperson.

    Timing two or three shots together isn’t a perfect plan. Get them all too early, and some people’s protections against infection might fade before the season gets into full swing; get all of them too late, and a virus might beat the vaccine to the punch. Respiratory viruses don’t coordinate their seasons: Right now, for instance, COVID cases are on a sharp rise, but flu and RSV ones are not. Some data on the new RSV vaccines also suggests that co-administering them with other shots might trigger slightly worse side effects, or mildly curb the number of antibodies that the injections raise. Still, Levy argues that those theoretical downsides are outweighed by known benefits. “If someone is at clinic in the fall, they should get all the vaccines they’re eligible for,” he told me. Getting a slightly less effective, slightly more ornery shot a few months early is better than never getting a shot at all.

    All of that supposes that people understand that they are eligible for these shots. But already, family-medicine physicians such as Iroku-Malize, who practices in Long Island, have been fielding queries about the RSV vaccines from confused patients. Some new parents, for instance, have gotten the impression that the RSV vaccines are designed to be administered to infants, which isn’t quite right: Babies are the target of protection for the shots for pregnant people, but only because they temporarily inherit antibodies—not because they can get the injections themselves. Regulators also haven’t yet nailed down how often older adults might need the shot, though the current thinking is that the vaccine’s protection will last at least a couple of years. “It’s very hard to tell people, ‘I don’t know,’” says Jacinda Abdul-Mutakabbir, an infectious-disease pharmacist at UC San Diego.

    Other parts of the RSV-shot messaging are peppered with even more unknowns. The CDC has yet to release its final recommendation for pregnant people; for people over 60, the agency’s language has been “noncommittal,” says Rupali Limaye, a behavioral scientist at Johns Hopkins University. Unlike past guidelines that have straightforwardly recommended flu shots or most doses of the COVID-19 vaccine, RSV guidance says that eligible people may protect themselves against the virus—and are urged to first consult a health-care provider, which not all people have. The wishy-washiness is partly about safety: A few rare but serious medical events cropped up during the RSV vaccines’ clinical trials, including abnormal heartbeats and neurological complications. None of the experts I spoke with had qualms about recommending the shots anyway. Even so, some private health-insurance companies have seized on the CDC’s watered-down recommendation—and the fact that the agency hasn’t yet included RSV in its annual vaccine schedule for adults—as an excuse to not cover the shot, leaving some patients paying $300-plus out of pocket.

    For any of these shots, viral reputation matters too. Despite hospitalizing tens of thousands of Americans each year, especially at age extremes—numbers that, in some years, nearly rival those linked to flu—RSV is a lesser-known winter disease. People tend to take it less seriously, if it’s on their radar at all, Abdul-Mutakabbir told me. Which bodes poorly for future RSV-shot uptake. Annual flu shots have been recommended for 13 years for every American over the age of six months for 13 years. And still, just half the eligible population gets them in any given year. People tend to dismiss shots as subpar interventions against a disease that they don’t much fear, Limaye told me. With COVID, too, “people think it’s gotten mild,” she said. Only 28 percent of American adults are currently up to date on their COVID vaccine. And although older people have historically been more vigilant about nabbing shots, even vaccines against shingles—a notoriously painful disease—have reached just over a third of people who are 60-plus.

    Read: America’s flu-shot problem is also its COVID-shot problem

    To establish fall as an immunity-seeking season, shots would need to become an annual habit, ideally one easy to form. Mandates and financial incentives do prod people toward vaccines, but smaller nudges can persuade people to take initiative on their own. Some strategies may be as simple as semantic tweaks. Studies on HPV and flu vaccines suggest that telling patients they are “due” for a shot is better than offering it as an optional choice, says Gretchen Chapman, a behavioral scientist at Carnegie Mellon University. Other research suggests that carefully worded text-message reminders can evoke ownership—noting that a shot is “waiting for you,” or that the time has come to “claim your dose.” Noel Brewer, a behavioral scientist at the University of North Carolina at Chapel Hill, also thinks that vaccine deliverers could take inspiration from dentists who gently dog their patients with phone calls and postcards.

    Other interventions could be aimed at streamlining delivery. Government funding could make shots more available in rural regions, ensure access for those who lack insurance, and help local health departments offer shots in churches and hair salons, or even bring them door to door. More schools and workplaces, too, might try boosting uptake among students and employees. And although most shots are already given within the health-care system, there’s sludge to clear from that pipeline too. Better universal recordkeeping could help track people’s vaccination status through their lifetime. Kimberly Martin, a behavioral scientist at Yale, is researching ways to revamp medical training to help health-care providers earn their patients’ trust—especially among populations that remain marginalized by systemic racism. “The single biggest impact on vaccine uptake,” Brewer told me, “is a health-care provider recommendation.”

    An ideal vision of a fall in the future, then, would be turning vaccines into a default form of prevention—a more typical part of this country’s wellness workflow, says Saad Omer, the dean of the Peter O’Donnell Jr. School of Public Health, at UT Southwestern. After getting their vital signs checked, patients could have their vaccination status reviewed. “And then, if they’re eligible, you vaccinate them,” Omer told me. It’s a routine that pediatricians already have down pat. If adult health care follows suit, regular immunization is a habit we may never have to outgrow.

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    Katherine J. Wu

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  • Beyond Babies, RSV Infections Put Older People at Risk, Too

    Beyond Babies, RSV Infections Put Older People at Risk, Too

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    Dec. 5, 2022 – The respiratory syncytial virus (RSV) “season” this year is notable for a number of reasons, including the relatively early and large spike in cases that is challenging the capacity of children’s hospitals nationwide. 

    But the spotlight on pediatric cases is overshadowing how this virus also raises risk for people 65 and older. RSV in older Americans “remains under-recognized by both physicians and especially the public,” says Ann R. Falsey, MD, a professor at the University of Rochester School of Medicine in New York. 

    Even the family of the president of the National Foundation for Infectious Diseases has not been spared. 

    “Our family had what’s a pretty typical experience of RSV — where the little ones got it first,” says foundation president Patricia (Patsy) A. Stinchfield, a certified pediatric nurse practitioner. Her immediate family includes her and her husband, both in their 60s; their daughter and her husband, in their 30s; and two grandchildren, who are 3 years and 16 months old. 

    Stinchfield and her husband help with child care much of the week, “so we’re with the kids a lot,” she says. 

    It started when the 3-year-old went to preschool and came home with what seemed like a mild cold at first. Then a note came home that three kids in her classroom tested positive for RSV, “so it was very likely that is what she had, although she was never tested,” Stinchfield says. “The way the disease progressed was very much like RSV.” 

    The 3-year-old then passed the infection to the 16-month-old. They both had low-grade fevers, runny noses, and coughing, but not too much wheezing.

    Stinchfield, her daughter, and her husband each had mild symptoms for less than a week. “My whole career has been in pediatrics with kids coughing directly in my face, so I think I have some pretty good RSV antibodies,” she says.

    Her husband was not as fortunate. “My husband, who is the oldest at 66 years old, is just now, 4 weeks later, getting his cough settled down.”

    Illustrating how RSV can be more serious in older adults, “he had a lot of wheezy coughing, bad body aches, and he actually was in bed for the first few days. He really just had a hard time catching his breath,” she says.

    “That’s typical for RSV. After you’re done with the infectious period and you’re starting to feel a little bit better, you can have a lingering cough for 3 to 4 weeks,” Stinchfield says.

    Similar Symptoms

    Diagnosis in both the young and old can be challenging because RSV symptoms often overlap those of the flu, COVID-19, the common cold, and other illnesses. Clues that point to RSV include wheezing – a high-pitched breathing sound – and using stomach and other muscles to help with breathing. 

    The symptoms of RSV in younger and older people are often similar. “Many things are the same, especially the prominence of severe cough and airway disease,” says Richard G. Wunderink, MD, a professor of medicine at Northwestern University Feinberg School of Medicine in Chicago.

    But because children have smaller airways than adults, the inflammation caused by RSV can cause more trouble in younger patients, Wunderink says. Clearing increased mucus can be more difficult, for example. 

    That much mucus can plug the child’s airway and even cause a lung to collapse. This condition, known as atelectasis, “is a major reason for admission to pediatric ICUs,” Wunderink says

    In contrast, he says, “Adults have bigger airways, so we don’t see as much mucus plugging and atelectasis.” 

    RSV Risks in Older People

    More older people are getting RSV from exposure to grandchildren who have the virus, Wunderink says. 

    The risks in people 65 and older differ primarily because of weaker immune systems connected to aging and other health conditions. Wunderink pointed out in a 2017 study that said “as the number of elderly adults and those with chronic medical conditions increases, the burden of viral respiratory infections will increase.”

    People with heart and lung problems are at highest risk, Falsey says. An infection can worsen chronic obstructive pulmonary disease, emphysema, heart failure, or asthma, for example.

    Falsey co-authored a June 2022 review and analysis of 14 studies that found, depending on the health condition, people older than 65 who sought medical attention for RSV were up to 28 times more likely to be hospitalized, compared to someone the same age without a chronic medical condition. 

    Tracking the Symptoms

    It’s important to keep a close eye on someone with RSV of any age to make sure the symptoms don’t worsen, Falsey says. For example, if an older person with RSV is “very frail, elderly, or has serious underlying health issues, follow-up in a day or two is needed to make sure they don’t get into trouble and need medical care.”

    The weekly RSV rate by age group reported by the CDC shows RSV hospitalizations are more than 10 times more likely for children under 5 years, compared to adults 65 years and older. The rate for the week ending Nov. 19 was 36 hospitalizations per 100,000 people in the younger group, compared to 3 per 100,000 in the older group. 

    But even though it’s less common, RSV can be serious in some older people. The CDC also estimates 60,000 to 120,000 older Americans get hospitalized with RSV infections each year, and about 6,000 to 10,000 die from the infection. 

    “What we worry about with older people is that sometimes, that can turn into a secondary bacterial infection that settles in one part of your lung, causes you to have pneumonia, and that brings you to the hospital,” Stinchfield says. “That’s where we get some of these startling numbers” regarding hospitalizations and deaths in people 65 and older. 

    Stinchfield also shared a practical tip. “RSV is a virus that is very durable on surfaces, especially smooth surfaces like kitchen countertops, tables, and remotes – those high-touch surfaces.” If someone in your household has RSV, frequently cleaning with antiviral wipes could help reduce the spread, she says.

    Potential RSV Vaccines

    With no specific antiviral approved to treat RSV infection, many people will be prescribed supportive care. This means treating the symptoms and not the illness directly.

    “Until we [had] specific treatments or preventions, differentiating between the various types of viral respiratory tract infections wasn’t important,” Wunderink says. “Treatments for influenza and SARS-CoV-2 have changed that.”

    Multiple vaccines to prevent RSV infection are in development and are expected to be approved first for adults. 

    On a positive note, RSV is getting diagnosed more frequently, Falsey says, because the  tests doctors use to diagnose the flu and COVID-19 often detect RSV as well. 

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  • The Strongest Signal That Americans Should Worry About Flu This Winter

    The Strongest Signal That Americans Should Worry About Flu This Winter

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    Sometime in the spring of 2020, after centuries, perhaps millennia, of tumultuous coexistence with humans, influenza abruptly went dark. Around the globe, documented cases of the viral infection completely cratered as the world tried to counteract SARS-CoV-2. This time last year, American experts began to fret that the flu’s unprecedented sabbatical was too bizarre to last: Perhaps the group of viruses that cause the disease would be poised for an epic comeback, slamming us with “a little more punch” than usual, Richard Webby, an influenza expert at St. Jude Children’s Research Hospital, in Tennessee, told me at the time.

    But those fears did not not come to pass. Flu’s winter 2021 season in the Southern Hemisphere was once again eerily silent; in the north, cases sneaked up in December—only to peter out before a lackluster reprise in the spring.

    Now, as the weather once again chills in this hemisphere and the winter holidays loom, experts are nervously looking ahead. After skipping two seasons in the Southern Hemisphere, flu spent 2022 hopping across the planet’s lower half with more fervor than it’s had since the COVID crisis began. And of the three years of the pandemic that have played out so far, this one is previewing the strongest signs yet of a rough flu season ahead.

    It’s still very possible that the flu will fizzle into mildness for the third year in a row, making experts’ gloomier suspicions welcomingly wrong. Then again, this year is, virologically, nothing like the last. Australia recently wrapped an unusually early and “very significant” season with flu viruses, says Kanta Subbarao, the director of the WHO Collaborating Centre for Reference and Research on Influenza at the Doherty Institute. By sheer confirmed case counts, this season was one of the country’s worst in several years. In South Africa, “it’s been a very typical flu season” by pre-pandemic standards, which is still enough to be of note, according to Cheryl Cohen, a co-head of the country’s Centre for Respiratory Disease and Meningitis at the National Institute for Communicable Diseases. After a long, long hiatus, Subbarao told me, flu in the Southern Hemisphere “is certainly back.”

    Read: The pandemic broke the flu

    That does not bode terribly well for those of us up north. The same viruses that seed outbreaks in the south tend to be the ones that sprout epidemics here as the seasons do their annual flip. “I take the south as an indicator,” says Seema Lakdawala, a flu-transmission expert at Emory University. And should flu return here, too, with a vengeance, it will collide with a population that hasn’t seen its likes in years, and is already trying to marshal responses to several dangerous pathogens at once.

    The worst-case scenario won’t necessarily pan out. What goes on below the equator is never a perfect predictor for what will occur above it: Even during peacetime, “we’re pretty bad in terms of predicting what a flu season is going to look like,” Webby, of St. Jude, told me. COVID, and the world’s responses to it, have put experts’ few forecasting tools further on the fritz. But the south’s experiences can still be telling. In South Africa and Australia, for instance, many COVID-mitigation measures, such as universal masking recommendations and post-travel quarantines, lifted as winter arrived, allowing a glut of respiratory viruses to percolate through the population. The flu flood also began after two essentially flu-less years—which is a good thing at face value, but also represents many months of missed opportunities to refresh people’s anti-flu defenses, leaving them more vulnerable at the season’s start.

    Some of the same factors are working against those of us north of the equator, perhaps to an even greater degree. Here, too, the population is starting at a lower defensive baseline against flu—especially young children, many of whom have never tussled with the viruses. It’s “very, very likely” that kids may end up disproportionately hit, Webby said, as they appear to have been in Australia—though Subbarao notes that this trend may have been driven by more cautious behaviors among older populations, skewing illness younger.

    Interest in inoculations has also dropped during the pandemic: After more than a year of calls for booster after booster, “people have a lot of fatigue,” says Helen Chu, a physician and flu expert at the University of Washington, and that exhaustion may be driving already low interest in flu shots even further down. (During good years, flu-shot uptake in the U.S. peaks around 50 percent.) And the few protections against viruses that were still in place last winter have now almost entirely vanished. In particular, schools—a fixture of flu transmission—have loosened up enormously since last year. There’s also just “much more flu around,” all over the global map, Webby said. With international travel back in full swing, the viruses will get that many more chances to hopscotch across borders and ignite an outbreak. And should such an epidemic emerge, with its health infrastructure already under strain from simultaneous outbreaks of COVID, monkeypox, and polio, America may not handle another addition well. “Overall,” Chu told me, “we are not well prepared.”

    Read: The most important vaccine I’ll get this fall

    At the same time, though, countries around the world have taken such different approaches to COVID mitigation that the pandemic may have further uncoupled their flu-season fate. Australia’s experience with the flu, for instance, started, peaked, and ended early this year; the new arrival of more relaxed travel policies likely played a role in the outbreak’s beginning, before a mid-year BA.5 surge potentially hastened the sudden drop. It’s also very unclear whether the U.S. may be better or worse off because its last flu season was wimpy, weirdly shaped, and unusually late. South Africa saw an atypical summer bump in flu activity as well; those infections may have left behind a fresh dusting of immunity and blunted the severity of the following season, Cohen told me. But it’s always hard to tell. “I was quite strong in saying that I really believed that South Africa was going to have a severe season,” she said. “And it seems that I was wrong.” The long summer tail of the Northern Hemisphere’s most recent flu season could also exacerbate the intensity of the coming winter season, says John McCauley, the director of the Worldwide Influenza Centre at the Francis Crick Institute, in London. Kept going in their off-season, the viruses may have an easier vantage point from which to reemerge this winter.

    COVID’s crush has shifted flu dynamics on the whole as well. The pandemic “squeezed out” a lot of diversity from the influenza-virus population, Webby told me; some lineages may have even entirely blipped out. But others could also still be stewing and mutating, potentially in animals or unmonitored pockets of the world. That these strains—which harbor especially large pandemic potential—could emerge into the general population is “my bigger concern,” Lakdawala, of Emory, told me. And although the particular strains of flu that are circulating most avidly seem reasonably well matched to this year’s vaccines, the dominant strains that attack the north could yet shift, says Florian Krammer, a flu virologist at Mount Sinai’s Icahn School of Medicine. Viruses also tend to wobble and hop when they return from long vacations; it may take a season or two before the flu finds its usual rhythm.

    Another epic SARS-CoV-2 variant could also quash a would-be influenza peak. Flu cases rose at the end of 2021, and the dreaded “twindemic” loomed. But then, Omicron hit—and flu “basically disappeared for one and a half months,” Krammer told me, only tiptoeing back onto the scene after COVID cases dropped. Some experts suspect that the immune system may have played a role in this tag-team act: Although co-infections or sequential infections of SARS-CoV-2 and flu viruses are possible, the aggressive spread of a new coronavirus variant may have set people’s defenses on high alert, making it that much harder for another pathogen to gain a foothold.

    Read: Don’t worry, it’s not the flu

    No matter the odds we enter flu season with, human behavior can still alter winter’s course. One of the main reasons that flu viruses have been so absent the past few years is because mitigation measures have kept them at bay. “People understand transmission more than they ever did before,” Lakdawala told me. Subbarao thinks COVID wisdom is what helped keep Australian flu deaths down, despite the gargantuan swell in cases: Older people took note of the actions that thwarted the coronavirus and applied those same lessons to flu. Perhaps populations across the Northern Hemisphere will act in similar ways. “I would hope that we’ve actually learned how to deal with infectious disease more seriously,” McCauley told me.

    But Webby isn’t sure that he’s optimistic. “People have had enough hearing about viruses in general,” he told me. Flu, unfortunately, does not feel similarly about us.

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    Katherine J. Wu

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