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Professionals talk about RSV
Medical Doctor and epidemiologist
For medical doctor and epidemiologist Koos Korsten (31), RSV (Respiratory Syncytial Virus) has played an important role throughout the past 10 years of his career. He has been working under supervision of Professor Louis Bont at the department of Paediatric Infectious Diseases at Wilhelmina Children’s Hospital since he was in his second year as a medical student. He also did his research internship at this department. After finishing his medical studies, Koos continued as a PhD student in the research group of Professor Bont. During this period, he conducted two clinical studies of the RESCEU project: one on RSV in children and another on RSV in older adults. This April, he will obtain his doctorate for the latter.
The reason for a RSV study in the elderly
‘It is known that people go through multiple RSV infections in life. Severe RSV infection usually affects small children. The reason for this is that young children’s airways are still small, making them more prone for airway obstruction. However, reinfection can also cause complications later in life, when the immune system becomes more vulnerable, for example. Many complications of RSV infection in older adults are similar to those of Influenza. The infection can cause pneumonia, which can even be fatal in some cases. As the elderly are rarely being tested for RSV, little is known about the potential impact of RSV infection in this age group, especially among general practitioners. The aim of this study was to learn more about the burden of RSV disease in this part of the population.’
‘In this study we studied the effects of RSV infection in adults aged 60 years and older who are still living at home. We investigated how often respiratory symptoms were caused by RSV and how ill these patients became. And if these patients with RSV became ill, how many of them had to be hospitalized? In total, 1040 people from three countries (Belgium, The Netherlands and the UK) were included in this study. About two-thirds of this group became ill with respiratory symptoms. In about 60 people of this group the respiratory symptoms were caused by an infection with RSV. About one-third of these 60 people went to see their General Practitioner, but none of these patients developed pneumonia and nobody had to be admitted to the hospital. The majority of RSV infections in the elderly, with the exception of these patients who required secondary care, therefore appears to be mild. In other studies, however, it was found that elderly people with heart failure, COPD or immune deficiencies, as well as people living in nursing homes have a higher risk of developing a severe RSV infection.’
Relation to RSV in children
‘Another aim of the study was to investigate which age group should be vaccinated first when a vaccine becomes available. We also looked at how many of the respiratory infections in older adults were caused by children. Based on this, we estimate that roughly 10% of all respiratory infections in the elderly can be explained by their contacts with children under the age of 5. So, one could argue that when the burden of RSV among children is being reduced by a vaccine, elderly people would also benefit from it and be indirectly protected against the virus.’
Steps for the future
‘A vaccine against severe RSV infection is on the way. Once children are protected against RSV, it will be good to reassess the disease burden of RSV-infections in older adults to see the effects on this age group.’
Prof. Federico Martinón-Torres
Professor Federico Martinón-Torres is currently head of Pediatrics and Director of Translational Pediatrics and Infectious Diseases at the Hospital Clínico Universitario de Santiago in Spain, Academic of the Royal Academy of Medicine and Surgery of Galicia, and Associate professor in Pediatrics. What initially raised his interest in RSV infections, was the fact that these were so common among children, while the treatment options were very scarce. He obtained his PhD on the use of heliox in infants with bronchiolitis and got involved in many more research topics on RSV. Nowadays he is involved in studies concerning all aspects of RSV: from studies on diagnosis and treatment, to pathophysiology and prognosis.
The child will have to do the fighting
‘Unfortunately, currently we can only offer children supportive care when they suffer from RSV infection. There is no cure, which means the child will have to do the fighting against the infection. A lot of young children get RSV and can overcome this infection on their own, but for those children who are at risk for a severe infection, it is crucial that we offer enough supportive care and work on the development of therapeutics and preventive options. We are working very hard on this, but vaccine development in RSV is difficult. The good news is however, that as RSV is such a common disease, from a political perspective treatment and vaccine development is very important. Therefore, there is more investment in RSV research, which speeds up the process.
I think there is still much room in improvement of the awareness on RSV among parents. Some parents have heard about bronchiolitis, but considering RSV, there are many parents who have never heard of it. Apart from the parents who have experiences with their child having a severe RSV infection, there are few people fully aware of the impact of RSV.
It is important to realize that any child can suffer from a severe RSV infection. In previous studies we have identified categories of patients that are extra vulnerable for a severe infection (for instance premature babies, or children who also suffer from a pulmonary or cardiac disease), but more than 90% of severe RSV infections occur in healthy infants. It is very difficult to predict how the child will respond to an RSV infection. In previous studies we have identified some genetic variations which are common in infants who are prone to RSV, but we can’t use this information during clinical bedside examination of a child.
Unfortunately, during my career as a pediatrician I have also lost children due to RSV. They were mostly children with other problems, such as children with cardiac malformations or children who were born extremely preterm. In well-developed countries we can offer a lot of supportive care, but these options are very limited in low-income countries. Although the mortality of RSV is not as high in well-developed countries as in these countries, a severe RSV infection remains a traumatic period for children and parents to go through.
Although there is no cure or vaccine, we can prevent the spread of RSV and protect children against this virus. Therefore, it is crucial that together we raise more awareness on RSV. We all are concerned about SARS-CoV-2, but as a paediatrician I am much more concerned about RSV and its potential impact on young children.’
Prof. Dr. Louis Bont
Paediatrician, infectiologist immunologist at UMC Utrecht
“Unfortunately, few parents know about RSV. RSV infections cause a heavy burden on children and their parents. Every winter, paediatric wards and intensive care units are filled with babies infected with the virus. However, RSV does not only affect young children, the elderly are also more susceptible to severe RSV disease, especially if they suffer from heart or lung disease. RSV patients have trouble breathing because the virus damages
the airways, but also because of the immune response against the virus.
RSV is very unfair, because most children dying from RSV infection live in developing countries due to lack of intensive care facilities. There is no vaccine or medicine to treat RSV yet, but WHO and pharmaceutical industry are
working hard at it. Currently, there are two important developments in preventing serious RSV disease in children:
1. a maternal vaccine. Pregnant women are vaccinated to generate antibodies against the virus which are subsequently transmitted to the baby through the umbilical cord and breast milk. This vaccine is similar to the maternal vaccine against Whooping cough (Pertussis). It protects the child from severe RSV infection during the first months of life.
2. a new antibody. This antibody is given by injection to new-borns and – like the maternal vaccine – protects them from severe RSV infection for several months.
We expect these new preventive immunisation methods to be available within the next 5 years. In the meantime it is important to raise public awareness about RSV. This will improve care for infected children and accelerate vaccine development.
Epidemiologist respiratory infections at RIVM (Dutch National Institute for Public Health and the Environment)
At RIVM I work at the Centre for Infectious Diseases, Epidemiology and Surveillance. We analyse and monitor the occurrence and trends in infectious diseases in the Netherlands. The focus of my work is on respiratory infections. One of the things we do is register the number of people in the Netherlands with flu or flu like symptoms on a weekly basis. The symptoms of RSV infections are quite similar to those of the flu and lab tests are necessary to distinguish the RSV cases. Because the severity of infection varies a lot, we collect RSV incidence data at hospitals as well as GP practices.
Unfortunately, there is no vaccine against RSV yet. However, there are quite a few vaccines in development. If one of them makes it to the market, it is important to know who needs it most. In order to prepare for potential vaccine introduction we need to learn more about the risks groups of severe RSV. That is why we are actively involved in the RESCEU study on the RSV burden of disease in Europe. Once the vaccine is introduction we need also need to monitor the effects of the vaccine. Again, we will do this together with various healthcare partners like GP practices and hospitals.
To improve RSV surveillance in general we cooperate with international public health institutions, mainly in Europe but also in other parts of the world. We need each other to gain better understanding of RSV, to share knowledge and expertise and to follow global developments in the field of RSV.
My personal experience with RSV
I do not work with RSV patients directly, but from the experiences of others I know about the impact severe RSV disease can have on patients and their families. I am therefore happy that through my work I can make a contribution to generate more knowledge and understanding about RSV.
Clinical Officer at KEMRI-Wellcome Trust Kilifi in Kenya.
RSV in Kenya
I have been working as a clinical officer for 20 years, and have been involved in the RSV project at the KEMRI-Wellcome Trust Research Programme in Kilifi, Kenya, since it started in 2002. Across Kenya we mainly see high numbers of children admitted to the hospital diagnosed with pneumonia or bronchiolitis caused by an RSV infection during two seasonal outbreaks that occur at times that differ from the East to the West of the country. On the coast of Kenya, where our hospital is located, the RSV season starts during the second rainy season and usually peaks in January and February, when it is hot and dry. Elsewhere further west it occurs during the first rainy season around March to July. Many people are not aware of RSV infections and the impact of this disease; it is the biggest cause of hospital admissions with pneumonia in children under 5 years of age worldwide. When a child is diagnosed with an RSV infection parents get some information from the general practitioner or pediatrician, but in public health facilities they are often too busy to properly educate parents on this condition, due to the high workload.
Treatment with limited resources
Our hospital in Kilifi has a high dependency unit, which is not the same as an intensive care unit (ICU), with access to ventilator machines. In Kenya there are only around 10 public hospitals with an ICU. There are also private and mission hospitals which offer ventilator machines, but most parents can’t afford to go to these facilities. In Kilifi, when a child with pneumonia or bronchiolitis is in urgent need for oxygen support they are managed at the high dependency unit where we can offer high oxygen flow by use of a ventilation mask. When this is not enough, we could transfer the child to a hospital with an ICU at one hour drive away, but we prefer to continue treatment of the child at our hospital and optimize the treatment of comorbidities. Before transfer is possible we first have to stabilize the child and inquire if there is an available ICU bed. During stabilization often children either improve and continue management at our hospital, or get more ill and pass away.
Not only are our treatment options limited, but also the preventive measures. In Europe children at high risk (i.e. premature babies) for RSV bronchiolitis can get Palivizumab to prevent an RSV infection, but it is very expensive. Because many parents can’t afford it this is not being offered at our hospital.
Awareness and education
By use of community engagement activities the KEMRI Wellcome Trust Research Programme tries to create more awareness on RSV among the public. There is a weekly radio program (Jukwaa la Utafiti) in the local radio station where health issues and health research are discussed, and people can call in and ask questions. We also try to engage with the community via a network of community representatives, elected by the community, who create a bridge between the community and the research that is being done at the KEMRI Wellcome Trust.
There is much room for improvement in the education of the general public on RSV. As doctors often lack time to provide information during sick visits, it would be useful to give this information during the Maternal and Child Health clinic visits and at the health centers and dispensaries, which provide outpatient services for simple ailments such as a common cold.
Steve Cunningham, professor of pediatric respiratory medicine at the University of Edinburgh
RSV raised my interest as I saw the big impact of RSV on patients, parents and the health service during my ward rounds as a paediatrician. I chaired the national guideline on bronchiolitis for Scotland (SIGN 91), which were published in 2006, and I subsequently chaired the National Institute for Health and Care Excellence (NICE) guideline on bronchiolitis in 2015. I’ve also been involved in more clinical research topics on RSV, such as the optimal oxygen saturation for patients, the development of new treatments and vaccines, and studies on the mechanistic side of RSV.
Phase I trials
Early phase and Phase 1 clinical trials especially raise my interest. The Children’s Clinical Research Facility embedded within the Royal Hospital for Sick Children in Edinburgh is the only children’s hospital in the UK with a paediatric Phase I accreditation. A phase I trial is the first stage of research, for RSV potential treatments are tested in infants with RSV, after being tested first in young healthy adults. Of course we have to work carefully, utilsing the knowledge of many people from the drug company and our staff to understand from the laboratory work and testing in adults what might be the risks and benefits of the new medicine, and what kind of adverse effects we might expect. From this we can provide parents with extensive information on all the knowledge we have gained thus far from the drug. It always has a big impact on me when parents are willing to let their child participate in these trials; it is incredibly altruistic.
Vaccine and Antiviral development
There are two big challenges in vaccine and antiviral development for RSV: we have to recruit sufficient patients at speed, and we have to correctly evaluate the effects, which is difficult as RSV is a variable disease that can lead to symptoms varying from a very mild cold to severe breathing difficulties. We can expect a vaccine and an antiviral to become available in the next 3-5 years, and hopefully it will be more than one. Of course we hope to develop a vaccine that is perfectly safe, so we can give it to all children as part of a routine schedule.
I think the coronavirus will definitely have an impact on the development of new treatments and vaccines for RSV. A lot of resources we need for our research are unavailable because of COVID-19, also social distancing impairs the monitoring process and follow up which is needed to safely provide these experimental therapies. It is difficult to say how big the impact will be, but as we expect COVID-19 to be a long-term issue, we will have to adjust to it. Luckily we have technology to help us out, for example by enabling us to acquire informed consent by use of photographs, and to do follow-up digitally where possible.
The awareness among the public about RSV is variable. Many people know about bronchiolitis, but are unaware of RSV. However, the coronavirus pandemic might change this. I expect people will be more aware of the large impact of viruses, including RSV.
My take home message for parents is: If you are worried about your child, don’t hesitate to reassure yourself early by contacting your health service or going to see a doctor.