Pediatric Infectious Disease Medical Director at Peyton Manning Children’s Hospital, Christopher Belcher, MD talks about new treatments and vaccines for RSV.
Interview conducted by Ivanhoe Broadcast News in 2023.
The typical RSV season is approaching. First of all, just tell us what RSV is and who it impacts the most.
Belcher: So RSV stands for Respiratory Syncytial Virus. It’s one of the many respiratory viruses that affects humans and a few other animals, and it’s a traditional thing. It’s been identified in specimens back from the ’50s and beyond. It’s been with us for a long time. And traditionally, we’ve thought of it as a disease of infants. About 80% of kids will catch it in their first year of life, and by the end of the second year of life, almost everybody has caught it and in the last decade or so. We’ve also realized that on the other end of the age spectrum, people as they get older also get affected by the same respiratory virus.
What’s the percentage of people that have it?
Belcher: So RSV can show up in many different ways. And in some people there’s no symptoms. If you’re an older person, you’ve had it before and you’re healthy, you may have no symptoms at all. A lot of people will experience a cold, runny nose, stuffy nose. That’s probably the majority of older children and adults. A small number though. It goes down into the respiratory tract and it ends up causing things like bronchiolitis, which is a little different than bronchitis or pneumonia. Sometimes even a croup like illness. The younger you are or the weaker your immune system or on the other side, the older you are, the more likely you are to have those complications. And the numbers vary, but it’s really the minority where it goes down into the lungs overall.
So for parents who have babies or young children, and their child is sick – maybe they’re suspecting it’s RSV – at what point do they say, “Okay, this is not normal. They need extra help. We need to go to the hospital or doctor”?
Belcher: Yeah. So for RSV, like many respiratory viruses, it’s signs that something’s wrong. That it’s moving down into the lower attract or the child’s having difficulty breathing or swallowing or feeding. So some of those signs could be things like high fever, it could be breathing fast or breathing hard. It could be what we call retractions, where you see the chest sucking in either above the breast bone, under the ribs, or even within the ribs. Those are signs of respiratory distress. Not being able to feed because you’re breathing so hard is one of them. And then the development of higher fevers can indicate there’s a new problem.
Then, when they come into the hospital, what’s a general treatment, or how do you treat babies and young kids that have RSV once they’re here?
Belcher: Yeah. So young children and babies with RSV, one of the things is they produce a ton of mucus. So clearing out the respiratory tract and that can be as easy at home as doing things like the little bulb suction or something to clear the nose out. We often do use suction in the hospital to clean out the nose and mouth. As kids get worse, they may need more and more support. So giving them oxygen to help because they’re having difficulty getting it into their lungs. And then increasing levels of support to help them breathe. Because a lot of times they’re fighting against all the secretions and all the inflammation.
Can you tell us a little bit about the “turtle shell” and how it works?
Belcher: So the turtle shell type devices really hearken back to the days of an iron lung. So instead of pushing air into your lungs, it actually draws the chest upwards with negative pressure. It creates a vacuum around the chest. And it pulls the chest, and then that brings air into the lungs. So it’s one way to do it. That then doesn’t require a breathing to be put down the throat, and you don’t need to push the air in, which potentially can cause more damage.
So last year seemed to be a particularly bad year for RSV. Why was that? And do you have any indication of what this upcoming flu and cold and RSV season is looking like?
Belcher: Yeah, for sure last year was a bad year. It was atypical in lots of ways. So not only was there a lot more cases than we would expect in a typical year, but it hit very early and very hard, leading to children’s hospitals filling up and all sorts of problems. We think a lot of this was an immunologic gap. So during times of COVID and lockdown, we really had a year or two where young children did not get exposed to these viruses. Children get RSV usually in the first year of life, 80% all by age two and if they sneak out past that now you don’t just have the two year gap, but now you have kids up to four or so who’ve never had it and are going to catch it all at once. So it spreads like wildfire. Really it is just like the dry brush on the hillside waiting for a spark. So it was a very bad year.
But there’s a little bit of good news – there’s a vaccine out for older people, for pregnant women, for babies. Are they available now? If not, when will they be available and what’s the different purposes for each age group and the benefits for each age group?
Belcher: Yeah, so it’s very exciting that for the first time in more than 20 years we have something new to do specifically about RSV. So the bigger developments in the spring were the development of adult vaccines for those older adults because RSV can really be a problem in nursing homes and care facilities. So those are approved for people 60 and over. And it’s what we call shared decision making where the provider and that patient can sit down and talk about some of the risk factors. Do they have heart disease? Do they have lung disease? Do they have uncontrolled diabetes? All of these risk factors including advancing age and make a decision if they should get the shot at this time. It’s only a one time shot for them. We will see if boosters are needed in the future. So that’s a very active way to promote immunity, just like we do with flu vaccines and COVID vaccines. One of those got approved by the FDA in this last month for use in pregnant women. And the idea there is that mom makes the antibodies and they’re crossing the placenta into the baby to give the baby protection through the RSV season. So the baby gets an indirect effect of the vaccine without being vaccinated themselves. And so that is now a recommendation the CDC made last week at this time. And we’re going to go ahead and try to get some pregnant women done. And that’s a discussion again between them and their providers. It’ll happen between 32 and 36 weeks gestation, and it takes about two weeks for the antibodies to start crossing into baby at a protective level. So if somebody gets the vaccine at 32 weeks and the baby delivers the next week, they’re going to be considered inadequately immunized. The third big development was infant passive immunization. So the idea there is when you have a baby, otherwise well baby, and you want to prevent RSV in them, within about a week of birth, you want to give them the vaccine. And this is not an active vaccine, these are pre-made antibodies. Just like mom transferring antibodies into the baby, this is an injection of antibodies that will hang around the baby for at least the five months that the season is expected to last. So babies who are less than eight months old, not having their eight month birthday yet, at the beginning of the season, which is around October 1st, will be eligible to get this vaccine, if their mother did not have the vaccine herself. You don’t need to do both of them. Availability. Yes, those vaccines are out there. They’ve been used in people 60 and over since they were approved in May. And that’s filtering its way out into the community for places for vaccination and people’s comfort with it. The maternal vaccine just got approved very recently. So talk to your providers about availability because it may or may not be in that office yet. And again, there’s some time and comfort in just working through the system. The infant antibody to prevent disease in the infants is coming out and available, but it’s still being warped out. How are they going to deliver it? In the hospitals or outpatient? Do kids need to be called back? There’s a lot of moving parts this season. So I think this will be our first season. There’s going to be good times and bad times, but really by next year things will be worked out.
And if these stay as one dose and they don’t discover they may be needing a booster, do you think this will become a yearly shot, like the flu shot?
Belcher: So it’s possible that in the older individuals that there would be a need for boosting, whether it’s every year or beyond that, but we’ll just have to see. That data is out there. That’s one of the unfortunate things is you can’t speed up the studies to know how many years they last. You can only follow the patients during that time. As far as the infants, most all of the infants need protection in that first year of life because that’s not only where the majority of RSV disease happens, but it’s also where most of the severe disease happens in hospitalizations. For some children who remain at high risk, kids with heart disease, lung disease, and a few other problems, they may get a second injection of the antibody in that second year of life to protect them for the second season, but that’s a small number of them.
One thing I think we learned through COVID is that there’s a lot of hesitancy with new vaccines. So for hesitant parents, do you have a message for them or any encouragement there?
Belcher: Yeah. So the vaccines really, they go through safety and efficacy studies. They’re looked at in several thousands of patients to make sure they’re safe. The reactions we saw were typical of other injections or vaccines. Lots of sore stuff, lots of red stuff at the injection site, maybe some fevers. But really, these things were very well tolerated, and they looked for specific other problems that would be of concern and didn’t find anything unusual out of there. Vaccine reactions can happen. Vaccines get monitored for them when they’re out in the public and may reveal new problems. So those get looked for. If you remember, there’s a few COVID vaccines that aren’t around anymore because they had some problems. So we can detect even very rare things and change it. I think this season there’s enough of a start that if you’re very uncomfortable with it, that’s fine. I think there’s going to be enough of a shortage that you’re not taking vaccine away from anyone. There’s going to be enough for people who need it. We all want your kids to be safe. RSV can be a very bad, very severe disease. And it’s not- if tour kid is going to catch RSV, your child will catch RSV. It’s a question of how severe it’s going to be.
So for parents, they have a new baby, this is their first year, their first RSV season, what message do you have for them? What do they need to look for?
Belcher: If you have a new baby at home, and especially those who have some risks born prematurely, heart disease, lung disease, you want to keep that baby as isolated as much as you can, for as long as you can. We’re getting into the winter respiratory virus season and those viruses can cause illness for your baby, they can cause fevers that lead them into the ER, and they may cause more severe things like RSV causing bronchiolitis or respiratory failure. Really prevention, the best way is to keep your child around- away from other children and other people in large groups. It’s just hard in the first few months of life, it creates a lot of problems. After that, vaccinating the people around them can help prevent transmission of influenza and whooping cough and other diseases to your baby, including COVID. So it’s good to do this cocoon strategy of vaccinating around them. And because RSV is so common, do talk to your provider about the eligibility for either the RSV vaccine for mom prenatally, or for the RSV antibody injection for the baby.
Then, the mother that we spoke to earlier, her daughter had it last year – she was a really bad case. She says you need to be a strong advocate for your child. As far as – even when they’re family, say, “Wash your hands” or “Don’t kiss my baby”, what are your thoughts on that as a doctor?
Belcher: Oh, absolutely. I will often take the fall on that and tell parents like, you can tell them their infectious disease, Dr. said. They cannot have visitors. Make me the bad guy, I don’t mind that. I really want to prevent things and that isolation of the first few months of life is very good for babies and families, and it does allow some bonding time too. So I think it’s a good thing around and I’m glad to take the fall on that.
I love that. Do you have any final messages or anything you really want people to know?
Belcher: I’m hoping we have a milder season. We won’t know how it is until it is. Things have been very unpredictable since the times of COVID. But it really did create quite a pressure on Children’s Hospital to care for people, not just RSV. So some of this is preventable. And your older children, the ones who are around them, get them vaccinated for influenza, get them vaccinated for COVID. Make sure they’ve had their other vaccines, because if your child’s not sick, nobody likes them in the hospital, and it does make it hard for us to care for everyone. So we just want all the kids to be okay and vaccination is one way to do that.
END OF INTERVIEW
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