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Forest W. Arnold, DO, MSc: Hello. My name is Dr Forest Arnold. Welcome to season 2 of the Medscape InDiscussion podcast series on respiratory syncytial virus (RSV) in adults. Today we've asked Dr Brittanie West to join us again to talk about the impact that RSV is having on rural communities, specifically looking at where she practices, in Bridgeport, West Virginia. In this episode, we will review the 2023-2024 RSV season regarding incidence, rural impact, vaccine use, and promising areas of research as we explore the management and outcomes of RSV infection in adults. First, let me introduce my guest, Dr Brittanie West. Dr West is a family medicine specialist practicing in Bridgeport, West Virginia. Welcome to the Medscape InDiscussion podcast.
Brittanie N. West, DO: Thank you for having me.
Arnold: Dr West, we last spoke 9 months ago in episode 6 of season 1. I know I've been busy since then, recruiting people interested in infectious diseases fellowships and faculty because the demand of our specialty has increased so much since COVID-19, and RSV only adds to that demand. How have you been?
West: We've been well. We just matched our resident slots for family medicine this year as well. We take six residents here. I'm at the United Hospital Center in Bridgeport, and I agree with you that we definitely need more committed candidates, definitely in the primary care realm as well due to our rampant infectious disease issues like COVID-19, flu, RSV.
Arnold: We had another winter season since we talked, and it wasn't so bad. Or was it on your end?
West: When I look at data from a rural health standpoint, I really care about the morbidity and mortality outcomes of respiratory viruses. It really stinks if you get a "cold," like our patients say that they do. But what I care about is who ends up in the ED, who ends up in the hospital, and who ends up succumbing to the virus.
In RSV, we know that happens with little babies and in our elderly, more immunocompromised adults. I also like to know each season what the split or skew between all the viral pathogens is. In some seasons, if you come in with a runny nose, I can say this is probably flu, if flu is rampant in my community.
This year that wasn't really true. It was a "you get a quad test, you get a quad test, everybody gets a quad test" sort of approach to testing. We'll talk about why that is. This year's season in comparison to the 2022-2023 season was a bit different in how the viral positives were dominating nationally.
If you look at the CDC positive tests for viral respiratory illness, this year's peak occurred around New Year's. Our RSV positivity throughout the season was about 10%. Flu is about 18% and COVID-19 is about 13%. If you contrast this with last year, our peak last year was around Thanksgiving. It was about a full month earlier than this year.
Flu was more prevalent last year, with about 26% positivity; COVID-19 was about 8% and RSV was about 8%. So, obviously, if you move backward in time, COVID-19 is going to dominate for multiple years. Flu and RSV were not as prevalent, and the peaks occurred all over the place. What I really care about in family medicine and rural medicine is not what is dominating, but how sick are people getting and how full will my ED and my hospital be.
Arnold: How did that compare to the RSV that you saw last year?
West: This year, the easy answer as to who presented to the ED for the level of care was people who had co-infection — people who had RSV and flu, or RSV and COVID-19. Those patients tend to be more immunosuppressed or sometimes just unlucky and got hit with both. The co-infection peak this year was similar to last year. The rate of people presenting to the ED with co-infection was about 10%.
When you looked at single flu infection or COVID-19, flu was 6%, COVID-19 was 3%, and RSV was about 1%, which doesn't sound that bad, right? But then we asked ourselves, who gets admitted from the ED, who needs to be there and needs to come in for stabilization. To answer that, the CDC has a really cool tool called RSV-NET which looks at the hospitalization rate for viral illnesses.
Nationally, we hit our hospitalization peak around New Year's. Last year, again, the peak was at Thanksgiving. The overall trend over the past five seasons was altered due to the COVID-19 pandemic. The season was more on par this year compared to years like 2015 to 2018. It is a better comparison when talking about when the peak occurred. If you look at pre-COVID years, the season 2018 to 2019, our peak hospitalization rate was only about 2 per 100,000 in January.
The overall hospitalization in that pre-COVID period was half of what we're seeing now, which was about 25.2 per 100,000. We're looking at 50 to 60 per 100,000 hospitalization rate in the past couple of seasons. Pre-COVID-years rates were half of that. Keep in mind that's before we had RSV vaccinations, and before all the things we have now to prevent illness in people. We're still seeing a big jump in numbers.
The final question becomes, who succumbs to these viral illnesses? That's one of the more important things for us to pay attention to. If you get hospitalized and you don't get to go home from the hospital, that becomes a really big deal. This is where we see the big difference, and I think this is where the public's perception of RSV gets confused. We see so many more kids get hospitalized with RSV, but adults are dying from RSV.
Our peak overall death rate from RSV this year was the first week of January, with the highest overall death rate in the greater-than-65 age group. That was about 5.5% to 6%. In the 2022 season, it was 7.8%. In our younger age group, the death rate from RSV was somewhere between 3% and 4%. We consider anyone under 64 to be in the younger age group. Deaths attributed to COVID-19 in those greater than 65 also peaked in January this year, at about 4%. The COVID-19 death rate in the 18-to-64 age group was about 1% to 2%. Nationally, the percentage of total deaths due to COVID-19, flu, and RSV was about 1.5% for those over 65.
Arnold: In your area, were patients receiving the vaccine?
West: Vaccine uptake for us has been low and there are lots of factors to consider. When you look at any vaccine, and studies on vaccine hesitancy overall, about 20% of patients are going to be early uptakers of a vaccine or recommendations. Then you have 20% of the population, no matter how much you try to explain why it's important, who are unlikely to choose to take that vaccine. So, you have that 60% of people in the middle to play with. The CDC has a reporting platform called RSVVaxView where they report state by state and by jurisdiction. I think you can even break it out into area code. It will tell you how many people have accepted the RSV vaccine.
As of a couple weeks ago, which would have been April 13, 2024, about 23% of adults 60 or older nationally had gotten our RSV vaccine and about 10% said they plan to get it in the future. Nationally, we would hope to end up around that 33%, taking into account those who plan to get vaccinated. We still have a way to go for our potential pool of people that we predict would be willing to get vaccinated.
There is a skew about where the vaccines are being administered. As of the end of March of this year, about 10 million doses were given in retail pharmacies and only about 340,000 were given in physicians' offices. A lot of that has to do with Medicare and how vaccines are billed under Medicare. That's why a lot of people have to get vaccines at a retail pharmacy. When we break out into the group of pregnant women who are eligible for a vaccine, as of the end of January, the vaccination rate wasn't much better. It was about 17.8%. But when you look at those moms with an infant less than 8 months old, meaning they had a baby in these past 8 months through RSV season, 42% had given their child nirsevimab (Beyfortus) and about 23% of the moms said, " I'm willing to do this and I plan on doing it. I'll talk it over with my physician at the next visit." So, you can see that our general perception of who's most impacted by RSV really shows in the vaccination rates.
I'll talk about my state specifically. West Virginia is always low in the numbers for a lot of vaccines. About 10% of our adult population has been vaccinated. One of the only states to lag West Virginia is Mississippi, at 5.6%. And then the state where you live, Kentucky, is around 11.6%. We are neck and neck in Appalachia. I think the best thing we can do to fix this is, first, to fix the public view of RSV as a pediatric disease.
This goes for physicians as well. The more we can educate each other, the better. I know our electronic medical record system will launch an alert for the RSV vaccination for elderly adults or people who qualify. That has been really helpful. We can have that discussion when the alert happens. One thing that we have started doing in our practice is giving patients handheld prescriptions. If they have to go to the pharmacy because of their insurance, we will print a script for the RSV vaccine and hand it to them. That kind of holds a place in their brain that says, "Hey, I need to get this vaccine." I think it confers to them that I think this is important enough that I'm printing this out for you.
At the end of the day, the numbers and those mortality risks seem low; 1%-6% of patients dying due to an illness seems low. And it all seems like a number on paper — until it's your patient, or your neighbor, or your family member, or your child, or your grandchild that's been affected by the complications and morbidity of that disease. It's all just a number until I have to intubate an otherwise healthy patient who may not make it off that ventilator, or I have to stand at the bedside and have end-of-life discussions with a family that thought, I didn't think they'd get that sick from this. We think, It's just RSV or It's just flu or It's just COVID. I think our job is to educate that the risk is low but to increase that appraisal of risk for people to think it's high enough for them to get the vaccine.
Arnold: The lower numbers we saw this past RSV season must not be attributed to a high vaccination rate because not that many people got vaccinated. And we know that RSV seasons trend up and trend down over time, but in the long run, it would certainly be better for adults to get vaccinated to prevent that big next RSV year, whenever that is. As we move on, are you aware of any key research findings from the past year related to RSV infection in adults?
West: We have a lot of interesting things on the horizon. When my patients come in with a runny nose and a cough, and they're not feeling great and ask why I quad-test them, I try to explain that for flu and for COVID, I have antivirals I can give them. Currently we don't have any that are FDA approved for RSV.
There are some under development and there is one that I think will come to market. ReViral has been working on multiple different antivirals for RSV in adults and for kids. The one that I think will probably come to market and looks like it's going to head that way in trials is originally known as RV521.
This antiviral will be administered as an oral capsule. Patients tend to tolerate that well. It works on the same protein candidate as the vaccines. It's working on that RSV fusion protein to prevent injury. It's been granted fast-track designation by the FDA. In 2021 ReViral announced that they completed part A of their phase 2 REVIRAL 1 study, which was in infections in hospitalized infants. They're looking into trials to expand that. I would expect that in the next couple of years we're going to see that come to market. We do have an antiviral both for children and for adults. A lot of the work has been led by DeVincenzo et al; they've tested a lot of different substances. I'm not going to delve into it here, but if you look at their research, they've tested three, four, five compounds.
This one tends to have the lowest side-effect profile. One of the others that they tested tended to result in a lot of neutropenia and side effects like transaminitis. This has the cleanest side-effect profile. The most common side effects on patients' lists were nausea and vomiting. These are things we attribute to antivirals and antibiotics anyway, and no one stopped taking the antiviral. The interesting thing about all these studies is that they were all a viral-challenge study. Basically, the researching group voluntarily infected volunteers with a particular strain of RSV that's been well studied. Once they became seropositive and started testing positive on the RSV testing, the researchers would start giving them the antiviral.
The problem with that is that in real practice, you and I both know that the incubation period for RSV is long. It's like 3 to 8 days. They based all these testing protocols off of flu. Well, the flu incubation period is so much shorter. In real practice, I don't know what the outcome will be. This was a virus-challenge study. It's not using it in real-world situations where someone's been developing a large amount of virus over the past 3 to 8 days and now they've hit the peak and are symptomatic. Most of the patients in the study didn't become symptomatic. That would be interesting to see come to market and see if any of the other antivirals do. The other interesting agents under study are on the more preventive side.
Another reason I think vaccine uptake is low, particularly with pregnant females I see in practice, is because I am recommending to them that they get Tdap, COVID, flu, and RSV vaccines. That's a lot of vaccines, all around the same time. This is at the 28-to-32–week mark of pregnancy. I know that a couple of other companies are looking at mRNA combo vaccines that will combine RSV, flu, and COVID all into one vaccine, plus or minus the cytomegalovirus vaccine — I think that was the other one. I would hope that some companies start doing the same so that we can justify two jabs or one jab a season for our 65-and-up patients vs "Now you need COVID, flu, and RSV, and boosters."
Arnold: Great. You've mentioned discussing issues with your local university, but with those other family practice physicians around you, do you have collaboration with them?
West: The biggest thing for me, because I teach in a residency, is the thought that the better that I train them, the better they're able to take care of people in the community. My residents will inherit a panel of 2000 to 3000 patients. They rotate with other family docs in the community. When they're learning new standards of care — like RSV vaccines being available and that they're recommended for this age group, and this is available for infants and is recommended for this sort of indication — they're able to spread that information to people in the community.
We do a lecture series as well. We discuss all of those things. But I think about how when you come from an academic background, like we do, if I don't train them to the level of being up to date now and keep up to date in the next 5 to 10 years, then I've really failed in my job as an educator. The best thing that I can teach them to do is to look at guidelines and stay up to date.
I had a discussion with my residents recently about how hard it is to stay up to date on everything that comes out in primary care. There are some recent studies that show that the average US adult will spend about 156 hours a year looking for healthcare-related information online.
How much time do you think you and I spend on looking things up, as an average practitioner? Maybe not in academics like we are, but what do you think the average report was?
Arnold: What value did you get?
West: Doximity did a study where they asked a bunch of practicing physicians, "How much time per day in your work day do you spend looking up new information?" And the average was somewhere between 15 minutes and 30 minutes. If you go with 30 minutes, then the average amount is like 120 hours a year. We're spending less time than our patients are in looking things up. There have also been new studies where they've looked at a primary care doctor's day. In my day, if I were to stick to all the preventive measures and do all my charting in the same day and provide all the care that I need to give and do my inbox management, there is a study out of Mass General and Brigham and Women's that it would take 27 hours a day for us to do that. If we do team-based care, it brings it down to about 10 — somewhere in that range.
For practitioners in the community who are trying to decide whether to recommend this vaccine to patients, you really are looking at that patient and assessing their risk, right? So, if I have somebody who has COPD and type 2 diabetes, my push on that vaccine is going to be harder than for my healthier adults. I think patients look at that too. They think, What's going to give me the most bang for my buck? As a practitioner, I have to counsel about these things — in West Virginia in particular; we are a very impoverished state and there are many factors in the decision to get vaccinated. We're the fifth lowest median household income per capita at around $51,000 a year, and we have one of the highest rates of poverty; it's around 15%. We also have one of the lower education levels.
When my patients are coming to me and they have an RSV infection, they're waiting until they're really sick, for lots of reasons. They can't make it to the physician due to access — for instance, they can't drive to the office. They can't afford to miss work. If I tell them they have to quarantine — you have to quarantine for RSV, COVID, or flu — they can't afford to; they're already working two jobs to make ends meet, and they already don't have enough to make that happen. They travel further distances to get healthcare. There are studies by the American Hospital Association that shows that if you're in a rural community, your commute time to your physician's office is about double.
I will say that for my personal patient census, and I talked about this in the last episode, my patients travel sometimes an hour and a half to come see me. If they think they just have a cold, they may or may not make the drive to see me. Then you look at how many patients we have who are uninsured. Our national rate of uninsured people is 8%. In West Virginia, 36% of our population is low income and 28% of our population are Medicaid patients.
For this uninsured population, they may or may not be able to get the RSV vaccination covered. They may not get RSV testing covered. A lot of things go into persuading a patient, and a population, to invest in their health. From a primary care standpoint, especially with our patients, we are able to advocate for them because we know them. We invest in their communities. We're on their community boards with them. We are volunteering at the churches with them. We are coaching the kids' Little League teams. We've invested in the community and we develop these long relationships with our patients. They see the same doctor for 5 years, 10 years, 15 years, 20 years. It's because of that relationship that they trust my recommendations. Even if it's something they don't agree with, maybe they are a little vaccine hesitant, I might say, "Hey, you know, you have COPD and you have this other immunosuppressive condition; you're on medicine for your psoriasis. You should really consider getting the RSV vaccine."
Even if they don't say yes that day, they know that we're making that recommendation out of caring for them. I think that's where rural medicine vs suburban and more urban medicine differs. We're really invested in our communities, and those patients care that we're invested in them. The recommendation seems really authentic to them.
Arnold: Today we've talked to Dr Brittanie West about several key aspects of RSV in adults. The first RSV wave was lower this past year than the previous year. Overall, there was not a predominant viral infection; it was a mixture of flu, COVID, and RSV. Co-infections did still occur. In general, more children get infected with RSV but more adults die from RSV. That's an exaggerated statement, but it makes a point that RSV is not just a children's disease. The vaccination rates continue to be low, but with a new vaccine, we hope that they pick up. Trials are underway for anti-RSV treatments in adults. We want to encourage healthcare providers to stay informed about the latest development in the field.
Thank you for tuning in. Please take a moment to download the Medscape app to listen and subscribe to this podcast series on RSV in adults. This is Dr Forest Arnold for the Medscape InDiscussion podcast.
Listen to additional seasons of this podcast.
Resources
Respiratory Syncytial Virus Infection
RSV in Rural Communities: Lessons From Appalachia
CDC RSV Surveillance and Research
American Hospital Association Rural Report
rural-report-2019.pdf (aha.org)
Physician Learning Preferences
physician-learning-report-2022.pdf (doximity.com)
Do You Spend More Time Searching for Medical Information Than the Average American?
One Assay to Test Them All: Multiplex Assays for Expansion of Respiratory Virus Surveillance
Respiratory Syncytial Virus Hospitalization Surveillance Network (RSV-NET)
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Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.
Cite this: When RSV Hits Home: Community Care in Rural West Virginia - Medscape - Jun 04, 2024.
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