Respiratory Viruses & RSV

McCulloch is now offering a similar treatment to mine, if you want to pay for it.

Respiratory Viruses & RSV

Branche: I'm a respiratory virologist and an infectious disease doctor. I find it so critical and important to be able to tell my patients what I think they have or what a diagnostic test shows. Obviously I'm a fan of using diagnostic tools whenever you can, but I recognize that in practice, some of these tests are expensive. They're not always widely available. Clinicians really have to think what's going to shift the needle in terms of how they care for their patients. I think that early and timely diagnosis of influenza and SARS-CoV-2 will help you make important treatment decisions. I think early and timely diagnosis of RSV will help you to know how to support your patients and will prevent you from doing things that aren't needed, like getting echocardiograms, getting urine tests, giving antibiotics, giving things that won't help your patient and potentially could actually hurt them. I think our early diagnosis, specifically of RSV, will help with transmission in important settings like hospitals, nursing homes, in adults who go to daycares. Even within a home, knowing that you have an RSV-infected person, because RSV is so easy to transmit, will help you protect others around that infected person.

Arnold: How does the epidemiology of RSV in adults differ from that in children?

Branche: Like most respiratory viruses, RSV does tend to cause more severe illness in extremes of age. The most infections we see in a year, nationwide or worldwide, are in children 2 years or under. It's a major cause of hospitalization in young children. However, the most deaths that we see in the United States are in older adults. That's why, even though you might not see millions of cases in adults in the United States, in the ones you do see, there's a significant risk for mortality that we don't have in young children right now — thankfully. The other thing that's different about these two groups in terms of their illnesses is that they can present differently. Often, young babies and toddlers that get infected with RSV will have bronchiolitis, which is sort of a childhood version of bronchitis — really severe airway obstruction. They could develop pneumonia. They tend to get acutely ill very quickly. Within a few days, they'll present to your office or the hospital because they're quite sick. Many of them will have fever, and so it's easy to see the impact of RSV early on with children. In adults it tends to be a little more insidious. They might have a cold for 3 or 4 days, and then as it progresses and gets down to the lower respiratory tract into the lungs and the lower airways, that's when they'll have wheezing and shortness of breath. If they have underlying chronic medical conditions affecting the heart or the lungs, they'll have exacerbations of those conditions. By time they come to see you, they're probably 5-7 days into their illness. At that point, it's not necessarily how quickly they can clear the virus; it's more about what damage has this viral infection done to their airways and their lungs? What has it exacerbated? How do you manage all those other things?

Arnold: RSV in both of those populations, children and adults, peaks in the winter. But do the peaks exactly overlap?

Branche: I think it starts in children first, typically. You'll start to see babies being hospitalized or seeing their doctors probably about 2-3 weeks before you start to see adult infections. The peak for babies will tend to be a few weeks earlier than adults, but there is pretty good overlap. For whatever reason, babies and children, and school-age children particularly, are just sort of the reservoirs for RSV and what starts an epidemic within the community.

Arnold: Adults should take the increase in RSV in children as a heads-up that, hey, they really need to be cautious about the weeks ahead because they'll be more at risk. What risk factors are we concerned about that might lead to the worst RSV, that results in a hospitalization for adults?

Branche: We've been studying this here, and others around the country and around the world have been studying it too. There are some very specific risk factors that predispose people to more severe RSV disease. They're not unique to RSV. You'll see some of the similar risk factors with influenza and COVID as well. The most well-defined risk factor in adult populations is age. For every decade of life over 60, you basically double the incidence of RSV as you move from sixties to seventies and seventies to eighties. Adults in their mid-seventies and eighties are probably the best-defined and potentially the highest-risk groups.

For adults in their fifties and sixties, risk is more based on the presence of certain underlying medical conditions; specifically, chronic cardiac and chronic pulmonary conditions confer some of the higher risks. Chronic pulmonary conditions like COPD and asthma have been associated with increased risk for hospitalization, needing oxygen, and ending up in the ICU. Risks that I think are less well appreciated, but may be even more important, are the cardiac risks. RSV has been associated with increased risk of having an acute myocardial infarction; after you have an RSV infection, in those first 3 days there's maybe as high as three times the risk of having a heart attack in somebody with heart disease. It's also associated with up to a 20 times increased risk for hospitalization if you have heart failure and you get RSV. That's an incredible risk factor. There are other things that we're still working to understand and define, like diabetes — but mostly poorly controlled diabetes — chronic kidney disease, folks on dialysis, and those sorts of things.

Arnold: When we consider epidemiology specifically, people are more familiar with the communicability of a pathogen as expressed as R naught (R0). Would you remind us about what R0 means and where RSV falls on that scale?

Branche: R0 is a mathematical model that helps you to understand how transmissible a virus is from person to person within a community. To put that in perspective, measles is probably the most transmissible virus that's ever affected human populations, and I think that had an R0 of something like 10-12, which means that for every person that gets a measles infection, they would then go on to transmit it to 10-12 people. Seasonal influenza has an R0 of somewhere around 1.5, so between 1 and 2. Every person infected with flu will go on to potentially infect one or two other individuals, if they expose them to their infection. SARS-CoV-2 (COVID) has an R0 of somewhere between 2 and 3. So that's more than flu but not as infectious as RSV, whose R0 is 3. Every person infected with RSV will go on to infect three other individuals. That's probably because RSV can infect you in a way that many other respiratory viruses can't, including influenza and to some extent SARS-CoV-2. With RSV, you don't get infected just by having somebody sneeze or cough in the air and inhaling those respiratory droplets. With RSV, it's actually in the snotty nose from the kid that you're holding or whose nose you're wiping. It's on the surface that the tissue landed on, and it stays on that surface for a number of hours. That's something that influenza can't do. It can't live on surfaces for an extended period of time, whereas RSV is more hardy and it can. So there's the possibility of transmission by just coming into contact with contaminated surfaces, which is what probably increases that R0 a little bit.

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McCulloch is now offering a similar treatment to mine, if you want to pay for it.