Trish Perl, MD, and Donald Murphey, MD, both have chilling memories of seeing their own infant children hospitalized with respiratory syncytial virus (RSV).
Even for healthy children with no preexisting conditions, RSV can create serious problems.
“She was not a high-risk baby; she was full term, she was fine. It was frightening. It was really frightening,” said Dr. Perl, chair of TMA’s Committee on Infectious Diseases. She is also a professor in the internal medicine department at UT Southwestern Medical Center and a member of its Division of Infectious Diseases and Geographic Medicine.
Unfortunately, RSV commonly takes hold in babies with older siblings, such as his own baby years ago, says Dr. Murphey, pediatric infectious disease specialist and past chair of TMA’s Council on Science and Public Health.
“It’s a common story,” he said. “First one does fine, and then the second one’s born, and then the first brings RSV from the daycare. My second kid was hospitalized for a few days and had a little wheezing afterwards. We’re hoping to prevent that.”
Now, with the Food and Drug Administration’s (FDA’s) recent approval of new ways to protect babies and seniors from RSV, physicians hope families won’t face the same fears.
The breakthrough prevention options are particularly encouraging because they could lighten the load on a burdened health care system, especially during a respiratory illness season that now delivers the triple threat of RSV, COVID-19, and flu, Dr. Murphey says.
“You can say, ‘It’s 2023, have we made progress on science and vaccines?’ And the answer is, yeah, we have. And we’re seeing some of it.”
Recognizing the reality of patients’ vaccine fatigue that physicians face today, Drs. Perl and Murphey share their own tips for overcoming that hurdle. The new treatments present an opportunity for physicians to talk to their patients about the overall importance of staying up to date on vaccinations, they say.
With hospitals crowded in winter, helping patients understand how to reduce that resource strain goes a long way, Dr. Murphey says.
“If your kid has appendicitis or if your parent has a stroke, you want to be able to go to the [emergency department], get admitted, and get taken care of right away. You don’t want to be waiting for a bed. We shouldn’t overwhelm our health care [system] when we don’t need to.”
New RSV preventions
FDA recently approved three new RSV treatments:
- In May, Abrysvo was approved for the prevention of RSV lower respiratory tract disease in individuals 60 years of age and older.
- In July, Beyfortus (nirsevimab) was approved for the prevention of RSV lower respiratory tract disease in neonates and infants born during or entering their first RSV season, and in children up to 24 months of age who remain vulnerable to severe RSV disease through their second RSV season. Though nirsevimab is administered similarly to vaccines via injection, it’s not a vaccine but a monoclonal antibody treatment.
- In August, Abrysvo was approved for use in pregnant patients to prevent RSV lower respiratory tract disease in infants from birth through 6 months of age. The Centers for Disease Control and Prevention (CDC) recommends pregnant women get the vaccine in weeks 32 through 36 of pregnancy, during September through January.
Physicians who see adults over the age of 60 or pregnant patients should already be able to stock and administer Abrysvo, making this the first winter where a vaccine can prevent RSV. The first successful RSV vaccine came after decades of research and builds on technology similar to that used in the COVID-19 vaccine, Dr. Murphey says.
While the vaccine is approved only for specific groups of adults, nirsevimab also could come into play this season, a much-needed line of defense for infants.
“RSV is, in the United States, the most important contribution to hospitalizations of young infants in the respiratory viral season,” Dr. Perl said.
Prior to nirsevimab, Synagis (palivizumab), another antibody treatment, had already been in use, but only in high-risk babies, and it must be given once a month throughout the winter and early spring.
“Nirsevimab is one dose, and it lasts for five or six months,” Dr. Murphey said. “And if you look at who gets RSV, who gets hospitalized, who gets in the ICU, who gets on a ventilator, there’s enough normal kids that have bad RSV that if you can give nirsevimab to kids who are likely to end up with bad disease and prevent it, it makes sense [to do so].”
Dr. Perl is similarly optimistic about the application for all babies, as opposed to the predominantly high-risk population.
“In the past, we’ve had these monoclonal antibodies, but they were so expensive that they were really just utilized in super high-risk kids,” she said. “But that doesn’t obviate the impact on children who are otherwise lower risk. This is really something that can widen and broaden that net that we’re casting.”
For pregnant women eligible to receive Abrysvo, Dr. Murphey thinks the vaccine could become a preferred option.
“If you look down the road with RSV prevention, I am hoping we shift from giving monoclonal antibodies to immunizing moms,” he said. “It’s easier, safer, and less expensive.”
He points to the example of pertussis: When CDC’s Advisory Committee on Immunization Practices began recommending immunizing pregnant mothers against the infection, cases of severe infant illness and associated mortality decreased dramatically.
“We have immunized pregnant women for flu and for pertussis, and now we should also add RSV, because it’s usually these kids in the first six months of life that have the most problems,” he said.
All these avenues of RSV prevention will reduce the burden of disease, but the rollout of nirsevimab into physician practices may be slow, Dr. Murphey warns. At time of writing, he had yet to see the product stocked.
Physician payment for nirsevimab, which costs about $500 per dose, is also up in the air, which may be compounding stock issues.
“Everybody’s aware that it needs to happen quickly, and I think there’s a lot of work [happening],” he said. “But there’s always a delay rolling out new products. I think this year, in this season, it’s not going to be available for every kid, but a year from now, it should be all there.”
Talk to your patients
After years of encouraging patients to get vaccinated, get boosted, some even boosted again, and then get an updated vaccine, it may feel like a hard sell to promote seasonal vaccines.
A simple change in approach may do the trick, Drs. Murphey and Perl say.
For instance, CDC currently recommends patients get both the flu vaccine and most recent updated COVID-19 vaccine at the same time, which gives physicians the chance to emphasize convenience and better protection if patients are unable to schedule vaccinations separately.
Dr. Murphey also recommends taking the personal angle, by reminding patients, “We encourage our family members to get vaccinated. We get vaccinated ourselves. And we’ve just been through a really difficult time, and we may be back in a difficult situation this winter where hospitals are full,” he said.
Dr. Perl suggests emphasizing the broad impact of vaccinations.
“Respiratory disease is a huge contributor to hospital health care utilization,” she said. “We should really be telling [patients] that ‘[vaccines are] how we keep you safe. This is how we keep you out of the hospital.’ We should be doing this because this is how we make sure they have the beds they need to facilitate needed surgeries, or other reasons people need to be in the hospital,” especially for those with limited access to care.
“If you look at the impact of vaccination, you’re preventing cardiovascular admissions, you’re preventing stroke. That’s what people don’t understand: These infections can actually increase the risk of having a noninfectious event occur.”
Dr. Perl adds physicians may need to change their own processes.
“In adult practitioners, we have not treated vaccines as part of routine care in the way that pediatricians have,” she said. “We haven’t [said], ‘This is as important as getting your blood pressure checked. This is as important as making sure you’re on a statin.’ That educational part of it has really been limited.”