Children’s hospitals in the Bay Area are already experiencing a surge in ER visits, so this timely update from infectious disease specialist Peter Chin-Hong, MD, is a must-watch. With a focus on RSV, he covers which patients are most at risk; tips on distinguishing RSV from colds and COVID; treatments to consider (or avoid); and the evidence on RSV prevention, including use of palivizumab and vaccines. Bonus: a look at flu and COVID vaccine studies that may bring new options in 2023.
I will introduce our speaker. I'm honored to introduce dr Peter Chin Hong. He is associate dean for regional campuses and professor of medicine for the division of infectious diseases at UCSF. He is currently involved in the clinical care of covid 19 patients. Dr Chin Hong has been a leader of institutional and community education regarding covid 19 and monkeypox, particularly among minority populations. He completed an undergrad and medical school at Brown University and then went on to train in internal medicine and complete an infectious disease fellowship here at UCSF. Dr Chin Hong was recently awarded the Carl Sagan Science Popularization Prize for 2022. Before we give the floor to Dr Chin Hong Dr steve Wilson, the VP of Chief Clinical Strategy Officer and for UCSF Benioff Children's hospitals has joined us to give us a brief overview of the current state of RsV at our Mission Bay and Oakland Children's hospitals. So I just thought it would be helpful for context and probably a good lead in for Peter's talk to update folks on where things stand, not just in our Children's hospitals but in Children's hospitals across the state and really across the country. So we're experiencing close to unprecedented RSV numbers certainly for this time of the year. Um and um and really quite significant strains on the healthcare system for um for Children in the state and the country. The starting with U. C. S. F. R. R. Two campuses in in Mission Bay and um in Oakland are at or near capacity. Our emergency departments are really straining under a very high volume. We had yesterday, an unprecedented number of quote unquote left without being seen basically, people who came to the emergency department and the weights were so long that they chose to to not stay. Um, and more importantly and significantly, we've been needing to cancel a lot of um planned admissions for some of our chronically ill patients, planned surgeries, um and turn patients away who we get calls from around the state for patients to come. This would be hard enough if it was just us. But stanford Valley Children's, the Children's hospitals in southern California Oregon and Nevada are experiencing very similar conditions and we have activated our, our emerges emergency command center structure or hicks structure up. Children's hospitals are doing the same. We are starting to work together with Children's hospitals to problem solve and work with community hospitals that have the capacity to take care of RSV patients to help them expand their expertise and explore what resources they might need to expand their capacity temporarily. I know in the east coast where this hit a little earlier, um, many hospitals that have both Children's and adult components have started to um make use of adult inpatient units to take care of um, of some of the older Children to make space for the babies with RsV within the Children's centers and we're starting to do the same thing in Mission Bay. We've expanded some of the um sort of larger pediatric patients in the adult iCU in Mission bay to make more space in Mission Bay. So um I basically would say that in the coming days and weeks we will probably be coming to you all as um as primary care pediatricians to basically explore options that might be alternatives to the emergency department. Since we anticipate this is going to get worse in our emergency departments are going to get somewhat overwhelmed with not with taking care of the sickest patients, but just with the volume of kids coming to the emergency department. So I don't have any any ask other than just awareness at this point. Um If you have relationships with community hospitals that have inpatient pediatric units, um please, you know, be aware that we'll be, we're going to be collaborating along with our colleagues at stanford with um with those community hospitals to see what we can do to expand capacity there. And I basically would ask everybody's patients if you find that things are going a little slower in EDS and patients get back to you and complain that they waited a long time. Just be aware of the context. I think that's pretty much what I had to say. If there's a question or two. I'm happy to answer otherwise I don't want to take any more time away from peter thanks steve and you never take away any time for me. Um Thanks for that. Very somber note. Um and I'll just share screen now and proceed and thanks Lauren for the kind introduction um as well. So what I'm gonna do is really focus on RSV but I'll also put it in context with the other rest story viruses circulating around which include of course COVID-19 as well as influenza. And I think we're all a little bit worried because RSV typically takes five months for 75% of the cases. So we were just in month one there about four more months left. Um so it really makes for somewhat of a bleak winter. So what I'm gonna do is just really go over a few basics about RsV and then really go through um epidemiology, some clinical and diagnostic pearls um treatment issues prevention and really bring everything together with these three viruses at the end. So just speaking about restaurant viruses in general and this will be a lot of review for for all of us. But I think it really is important to just set the stage. Um most of these RNA viruses and what that means is that they have very high mutation rates like covid 19 over time. And typically they tend to follow seasonal patterns in general. Although uh last year's RsV in the summer and this year's RsV starting off really end of september october is very very unusual and really speaks to and we can speak about reasons why this might be um with abnormal patterns due to Covid 19 in general. They peak in the winter period when there's cool temperatures and low humidity. And that's because many rest story viruses like Covid and influenza RsV have these envelopes and these envelopes are very, very sensitive to heat and humidity. So things when it's cold and when there's low humidity, they tend to really proliferate and of course there's human behavior as well driving much of of the transmission. Um, to rest story viruses that are all year round are rhinovirus and adenovirus. Um, they're non enveloped. So they tend to be a little bit less sensitive to environmental perturbations. Uh, the animal role is generally features prominently, particularly with influenza and the origins of Covid likely. Uh, and we really don't have a lot of good treatment options. Um, Including in RSV. Although I'll talk about um, you know, many of you might have heard about the new vaccine that's probably going to be available in 2023 season, but not for this season yet. And it looks really, really promising. So this is a typical restaurant virus season. Just to put it in graphical form and you can see that most of it is in the november december to february period of time when you have influenza RsV, we have Covid, you have human melanoma virus. Uh, and then add new and rhino kind of happen all year round and power influenza typically starts off, um, you know, the crew causing virus around March. Um, so really picking up on what steve was saying uh you know what's been happening at all hospitals really in the bay area and I was really hidden hitting the media and I really thought this could very um you know uh startling uh and this from Jackie group felon she says for health care staff working U. C. S. S. Pediatric units. The current rest story outbreaks among Children are basically their March 2020. So it's really uh an unprecedented level. So let's zoom in a little bit more on RSV now. So RSV, like I mentioned his envelopes is very sensitive to the environment. Um And typically they have these seasonal outbreaks although in warmer countries they tend to happen all year round. And the main way of transmission is of course through droplets. So unlike Covid which is more aerosol influenza, RSV are primarily card carrying restaurant viruses so they tend to travel be on these heavy droplets that fall within 3-6 ft. The big difference also in terms of transmission between COVID and RSV and flu is that surfaces are a lot more important with RSV surfaces are a lot more important with influenza. So I think we've kind of fallen off the washing your hands in the community aspect and cleaning toys and services but I think they really have to come back very prominently with RSV. And as all of you know that me it's the major restaurant track pathogen and kids the very young the very old and immune compromised individuals. Um So RSP is extremely, extremely contagious. It can survive for several hours on hands and full mites it replicates in the nasopharynx and then spreads the lower tract. Um And the major target of the infection is these epithelial cells in the upper and lower airways and these epithelial cells just like start proliferating like crazy and dying off And brings in all this information and they start to fuse together. And that's why it's very very small airways. You get a lot of blockage. And that's why it could be particularly critical as you know, with the very young, particularly under six months old and the very old over 75 or so. And a major factor that causes all of this uh you know, all these cells coming together and merging is this thing called the F protein. And the reason why I'm mentioning that I don't really talk about a lot of basic biology a lot of times is that's the target of the vaccine. That's the target of you know, a lot of potential interventions. So this is just uh history pathology of the cells in the lungs which you probably haven't seen for awhile since probably step one for the boards. But it really to me tells me how much action is going on in the lungs in these very very small influence because you have these cells fusing and all of this debris in the al Viola area. So you can imagine why they're all like particularly clogged up and it makes it very difficult to breathe particularly for the youngest. So what what is happening now? But first I want to start off with what's happening with the other two viruses to really put RsV in context. So right now in covid we're about to start probably our eighth peak. I know everybody stopped counting covid peaks now um after a five month sort of slow burn which started off in probably early May. And the reason why that is important is because by the late fall early winter um much of the people who got infected in me uh their antibodies are probably going to start declining and dwindling meaning that they're going to be more susceptible to covid infection. When you look at the U. S. Hotspots for covid, although there's a lot of green when you look at hospital capacity for adults mainly. Um When you look at actual disease transmission which is the amount of virus in the community, you're seeing a lot of reds, particularly in Arizona and texas, the mountain states and some of the Northeast. And when you look at the rest of the world there's a lot of covid in Asia, south Korea, Taiwan, Southern japan, a lot of covid in europe Greece France Germany the U. K. Is kind of crested already and then the Northeast is picking up. So again California is being boxed in by these two covid waves coming left and right and much of it is due to these new variants have been cropping up so they have brought five of them and they all seem very confusing with random numbers and letters. But the big take home point is that they are all Children of omicron, they all descendants of B. A. Five in particular. So BQ 1.1 BQ one B. A. Uh Yeah BF seven. They're all related to be a five and the sense of them They tend to be more resistant to monocle antibodies. Um and of course be a five went from 90% to know about 40%. What it means is that if you get a booster or if the child gets a boost and everybody over the age of five is eligible for boosters now it will probably help ward that off but probably wouldn't last as long as if just be a five was around only. So that's covid influence is also seen record numbers but we haven't really hit it as hard in the bay area. Although when I show you the UCSF numbers it is creeping up in the community but not hitting the hospitals yet. But we expect that to happen at some point sooner. The rate of influence is highest in the south and the Southeast It's the highest levels of influence in the us since 2010. And this is kind of like what we expected because in Australia when they had their winter it was higher than the years before COVID as well. So far in the US have been at least one child has died 730 deaths overall. And you can see that this this curve is really steep and still you know going up. So in the last week or so we've had a doubling of flu cases, a doubling of hospitalization and almost a doubling of deaths in the past week alone. So I guess this is all giving you context for RsV and as you know, RsV is on fire. Um I think in in Benioff san Francisco and Oakland, we haven't seen this level for more than five years. So even before Covid and this is showing the peak that happened last summer and it looks big. But this blue line is really the rapid antigen tests. Uh and the the the darker purple line is the PcR test. You can see that there there's a lot more PcR is being done now which suggests that a lot of these kids are coming into the hospital. Whereas in last summer there weren't as many admissions, a lot was just diagnosed to rapid engine in the community uh practices. So when you add these two numbers up there really high and they are continuing to hire and like I mentioned we're just at the beginning of a typical RsV peak. If you look at a plateau. When you look at last summer for example, it, it pretty much took about four or five months as well. So if we're just starting, this is probably going to go up and be about five months as well, which will intersect with covid and with influenza. So this is just the numbers from U. C. S. F. And I think in september was literally like almost nothing. And then you can see that in RsV in the blue numbers they started going up. Um, and this is only until 10 29 but they haven't been updated for this week yet. I'm sure it's much higher now. And then you can see that influenza, which is the blue, these two colors here, they're kind of steadily in the back room. If you look at the rest of the country, they're really, uh, really, really high levels, particularly in the south, like I mentioned and rhinovirus like, you know, year long, uh, still continues to be high. So a lot of colds going around a lot of RsV fluids starting covid is in the background. All of these are coming together and as you know, Orange County declared a health emergency around the beginning of the month due to the RS decision giving flexibility of adult beds to take care of kids pediatric populations giving flexibility to personnel. Um, and a few weeks, uh, go before this, even there was this news report of 1000 kids being sent home from high school in San Diego. And everybody thought it was influenza all the time. But they weren't doing a lot of RSV diagnostics but in hindsight it probably all was RSV while a lot of it was RSV even though some kids had influence as well. So what are some of the clinical and diagnostic paroles? Um So who does worsen R. C. Uh Very young, very old as you know younger than six months premature born under 35 weeks of gestation. An interesting risk factor as you might know is secondhand smoke. So one of the risk mitigation factors is really honing in on parents who do smoke not to have their kids around because that uh is a risk factor for severe disease for older kids. It's really kids. So I mean compromise as well as those with lung and congenital heart disease. Those with Down syndrome, adolescents and adults are very similar. In fact, you know, we always think of it as a kid's disease primarily. But I take care of a lot of RsV and immune compromised adults. Um And it skills probably about 14,000 adults every year in the U. S. And 177,000 hospitalization. So I expect that to also happen in an adult population, although we're seeing it mainly in the kid population. Um Right now how does it present mainly uh like a cold as you know for most people right area cough and fever. But I would say that one interesting um presentation is really a really high predominance to cause otitis media and sinusitis. Uh That's really important because I'll show you data showing that we have an amoxicillin shortage now, particularly in the suspension because so many people are prescribing amoxicillin mainly because RsV is causing the otitis media and sinusitis and it's not bacterial causes. So I just want to alert you to that, you know, when the kid comes in with all of the other stuff, it more is likely than not going to be caused by a virus rather than a bacterial infection. All the really tough to distinguish sometimes in some populations. So in influence as you know, bronchiolitis, wheezing can have lower tract disease like pneumonia apnea is a really interesting uh syndrome that's uh not fully understood but definitely seen in in the population and then kids and young adults, Otitis media, you ri sinusitis in the elderly and immuno suppressed. Uh it can cause like very severe pneumonia. I want to just pause and talk a little bit about immune compromise. RsV um in the bone marrow transplant population uh there's a higher likelihood of that upper restaurant tract infection progressing to lower tract disease and as high as 40% mortality rates up to 70 to 80%. Um and a lot of sort of like leave consequences of viral infection like lung injury and bronchiolitis obliterans in solid organ transplant. It's mainly a problem in lung transplants with up to 20% mortality risk, and then again, subsequent later on lung injury, the kind of like, I guess the long Covid version of RSV with uh this lung scarring. How do you diagnose it very similar to covid tests, as you know, except that the rapid engine test is very more sensitive and influence compared to older adults, but PcR is sensitive in both. Um, and as you know, PcR is often part of a multiplex test. So you kind of get uh influenza and you can get covid done around the same time, or influenza are a influenza B and RsV. Um, and then the rapid engine test is faster as you know. But the rapid engine test is a little less sensitive, the older you get. So in adults we tend to end up defaulting to uh PcR because it's more sensitive, particularly in the hospital wise, adult, critically ill patient. So now it really gets confusing because covid symptoms are now looking more and more like RsV uh and influence of course, is probably the most different from covid RsV because of the systemic symptoms. But the Zoe study has been looking at hundreds of thousands of people with covid during the pandemic and now the top five symptoms of covid and fully vaccinated are sore throat, runny nose nasal congestion, cough and headache. If you're unvaccinated, you have a higher chance of fevers, but it's very, very similar. That's because omicron tends to be more upper rest story rather than lower tract disease. Uh And if you're vaccinated you tend to have fewer systemic symptoms. So everybody just seems to have a code. So you really can't tell if it's covid or influenza or RsV a lot of times unless somebody declares themselves, you know like in the RsV in the very young infant or um you know by doing a diagnostic test. That's why diagnostic tests are so important in this particular season. How do you treat RsV as you know most of it now from the Academy of American Academy of Pediatricians is supportive. We've kind of de emphasize driver Vyron uh and inhale hypersonic saline. Uh Currently given the data that I don't have time to present showing that there wasn't really much benefit in the vast in the general population of pediatric population. Those things that we took for granted. So like when I when I was doing my uh on the P. S. I. D. Unit and even in as a resident and medical student, all these things were kind of like part of part and parcel. But now uh you know very very rarely uh is robert Byron used in the pediatric population. Um there's less evidence for antibiotics like I mentioned. Although there's a lot of overlay with otitis media right now and sinusitis with RsV. Um we talked about river vayrynen hill hypersonic ceiling uh in most cases unless you have asthma flare or you're an older kid steroids and broncho dilator haven't been shown to be that helpful without bronchial reactivity. An I. V. I. G. Again not as born out to be helpful in and when you look at the data, so it ends up being supportive for the most cases. And like I mentioned, there's an unmarked still in shortage now because the sudden demand and Mark still is leading to the shortage nationwide and giving, you know, the analyses and systematic reviews um have shown that really when you give antibiotics for upper restorations symptoms for fewer than seven days in particular, it makes no difference in the symptoms with this placebo. And some of the guidelines are, you know, you kind of wait 10 days, then you might have a little bit more benefit for the antibiotics and if you give it certainly for less than seven days of symptoms, um just you know, to be complete. And uh there are three forms of River Vyron, we use it more in adults. Um so in the Eula adolescents you may see them being offered robert Byron. Um and then select kid population. So there's a parasol vision which is was previously a Senate of Care. It's toxic. It can be telegenic. So health care workers had to dress in really full gone and garb. We didn't allow pregnant persons to go in the room had to be cleaned in between patients thoroughly by um by the staff And uh the I. V. Uh it's available with poor outcomes and toxicity as well. So most of it defaults and oral vision now um similar outcomes as the aerosol vision. And we just have to watch the hemolytic anemia. So an emu compromise in general for adolescents and adults. We typically would give oral ribavirin plus I. V. I. G. But for two main populations uh bone marrow transplant population uh really during in grafton right after transplantation or everybody in those two populations lung transplant and uh human pathologic stem cell transplant with lower tract disease. And this is the data. Just showing that um you know these are just retrospective small studies but the reason why we end up using I. V. I. G. In the older patients is because of you know there's an association with lower mortality although no good not even great observational studies and certainly no randomized control data. So when do you hospitalize in general poor feeding, lethargy dehydration very similar to what you do anyway. Uh And then in for the lung disease, moderate to severe restaurant distressed nasal flaring retractions restoration. Great in 70 Disney era. And then many people use uh to sort of less than 95 as a guide post um apnea of course. And or if their social support that's challenging Amy schumer's son. Was there a lot of celebrities whose kids have had rsv recently. So that's sort of like bringing it to the forefront again. So she had to actually miss saturday saturday night live because of that. This is a very interesting study showing that um de saturation is on their own is not associated with hospitalization. So in this study they recruited uh kids who were visiting the department, gave them to sad monitors without um giving the parents an idea of when it was going in danger zone. And then followed up hospitalizations and you can see that whether or not they were de saturation. These first of all, there are a lot of people with the saturation, uh more than half of the kids and when they whether or not they were de saturation, not de saturating. Um you know, they weren't uh there was no real difference in hospitalizations, although it was a small study. So I guess it really means to say that at one time the saturation isn't the be all and end all and it's really like the overall picture. What about prevention? So it's really like with every story, virus masks, even a surgical mask, because again, it's mainly more droplet rather than airborne washing the hands is coming back uh staying home when you're sick. You know, typically at least no fevers to 24 hours if you've had uh fevers and the kids and then the other things that are interesting avoiding secondhand smoke, given the risk of kids exposed to secondhand smoke and more serious disease and just getting up to date on influence and covid boosters to reduce the noise and the variability and who knows what interaction is going to happen. And then of course uh as many of you know, um again it's targeting that f protein causing those cells to clump together on a monocle antibody against it prevents hospitalization in high risk groups. And some of the groups include broncho pulmonary dysplasia, prematurity, less than 2098 weeks. Others on as a case by case basis, including skid patients, other immune compromised individuals and as you know, the typically a dose a month starting off like in a typical season we started off in end of october november. But obviously this season is abnormally early. So five doses max is what the best data is now. This is the excitement for next year. Um It's an RSV vaccine study and as you know, it's common practice to vaccinate pregnant persons to protect the newborn via antibodies that cross the placenta like T. Dap and influenza. In this study, they looked at 7400 pregnant people and infants. The mom gotta by violent RSV vaccine, which is a traditional technology protein based. And there was 82% reduction, which is pretty impressive and severe RSV in the infant by three months. It's defined by rapid breathing, low oxygenation, Ido visits and a decrease in 50% and even just outpatient visits. Uh they've also studied this vaccine in older adults greater than 6, 60 years old. And I remember I told you that about 100 and 77,000 adults are hospitalized every year with RSV. And that study was also really good at 86% efficacy. So it's like this FDA filing is expected in late 2022. So coming back to the other viruses, uh you know, this is kind of like um again the vaccines continue to show great benefit and mortality um for covid now, you know, 14 times at least. And I would say that most of the adults who We are seeing more and more vaccinated people die. But it's vaccinated people who are all in 75 without a single booster. So in terms of conversations with parents and grandparents to keep that home safer really, vaccinating the adults is going to be um you know, really important and obviously the kids as well, but everybody needs to have that force field to really keep that kid healthy. Um in terms of questions I get commonly get about the Covid booster shot, who the boosters approved for everybody above the age of five years. When should you get the booster don't get it too soon after a recent infection Or recent vaccine, you want to give it at least two months. Most people say 3-4 months. And the reason why is that you have a lot of antibodies floating around after your recent infection or vaccine. And if you get a new formulation of vaccine, those antibodies are definitely gonna jump up that Anna John. So the new the new vaccine would basically be senseless if you got it too soon after a recent infection or vaccine. But I think. if you haven't had one in certainly four or five months now is really a good time to get it. How long would boosters last? Um We think it will still last. So even if the variants are not a complete exact fit to be a four NBA five because they've already evolved to these Children of B A five. Uh they will at least last for you know, 3 to 7 months on the three month side. If you get infected with one that's more immune invasive on the seven month side, if you get infected with like a B A four B A five. So you know, that's kind of, it's more the duration of protection rather than being protective or not. And again, it's a risk reduction rather than an absolute protection. When will boosters be next updated? We think that covid boosters will be updated uh probably annually. Um and there'll be, you know, a combination flu covid shot probably available in 2023. Again that I'll talk about in a second. When will boosters be available for under five year olds for the updated booster. We think by the end of this calendar year or early 2023. Um some studies about the influence of vaccine efficacy now. So we talked about the Covid vax, the RsV vaccine that's coming on board next year. The Covid vaccine. Uh the influence of vaccine. So it always gets a bad rap because people say it's not that effective but it varies from 40 to 60% in terms of preventing hospitalizations. We got some early data from chile published in mmwr who had their early flu season which was very abnormal because january is is summer in in chile but yet they started their flu season there but it also gave them an opportunity to study it. The type of flu type that was circulating is the same one that's circulating right now in the U. S. It's a three and two which is a particularly nasty strain. Um But luckily we have it included in the vaccine. Um So even though it's only 40 60% effective and the the chili data shows that it's about 50% effective in their flu season. Um It still prevents a lot of, you know, millions of infections and at least more than 100,000 hospitalizations of the CDC estimated in 2019. So that means a lot to society um as a whole. So what what are some of the new developments in flu shots? Um Well, first of all there's going to be an influenza M. RNA vaccine that's currently under study and the phase three and many of you might have gotten invited even from Walgreens or CVS to take part in this. I know I have, it's kind of interesting uh the ways of recruiting patients now. Um, so it's a 25,000 person study 18 and older. If M. RNA vaccines for flu come on board. The idea is that it will be much more agile, nimble, flexible faster. It takes six months to make a flu shot based on what happened in the southern hemisphere in their winter. It will take six weeks for M. RNA has shown to be effective and maybe it might be more effective than the regular flu shot. We don't really know. So that's on board. And then most excitedly if you can get both the flu and the Covid booster in the same needle, that will be amazing. So there's a fighter Phase One study Moderna Novavax also studying that. Looking at combining two M. RNA vaccines. That new Covid M. R. Any vaccine as well as uh the Covid vaccine, the regular one plus the new influenza M. RNA vaccine together. Same vial one needle. So where we headed. So it's it's it's really difficult to predict. But you know, given what we know about a typical run of an RsV season. Unfortunately, I think we're just at the beginning of this. Um, I think flu is starting to come on board, particularly in the west coast, mainly in the southeast and that will definitely come. Um, and then Covid will likely come. Um, but probably not causing a lot of serious disease, hospitalization and death as in the past few years, two winters. So I think of maybe a winter flu and RsV and you know, I remember somebody asking me, oh, tell me that the patient only wanted one shot and they had and they were older and they had to sort of like prioritize and the patient already gotten like three shots of Covid through someone, not the updated boost. And I said just prioritize the flu shot just because I'm expecting a really tough flu season again, uh, levels in at this time, not seen since 2010. Um, at this time of the year in the United States, a lot of people have had antibodies for Covid, but again, this is a snapshot and these antibodies decline at different times. So some of these folks will still gets very sick in if cases and when in cases increase in the winter and when Covid settled down. I think most of us, I'm worried because it's kind of a new game in town Before, you know, not present since 2019 and it's going to eventually cause at least 100,000 deaths a year, which is more than diabetes, kidney disease and flu and pneumonia. So again, it's something we have to grapple with as a society, particularly since most of those deaths are preventable even in an unvaccinated person with early therapy. So, you know, all this is kind of somber thinking that we're gonna not have covid emergency dollars in the spring and it means that um you know we'll probably have to do a lot of advocating and uh and care particularly of our most vulnerable patients. And finally this is me trying to find my 14th booster pass for the omicron variant so I can buy a sandwich always like good Seinfeld. So thanks a lot for your attention. I put R. C. Very huge because if you think about the good the bad and ugly, that clint Eastwood movie uh R. C. Is definitely ugly right now influences bad and SARS COv two is I would say not really good but not quite as bad. So with that I will stop sharing, Take any questions. Thank you very much dr chin Hong and thank you steve again for that update. Um We have some great questions coming in through the chat. So I'm going to start with, what type of diagnostics do you recommend for? Outpatient clinics? The antigen tests for flu are very expensive now. Yes I mean that's really really tough. I would say that. I mean start with a less expensive tests and if it's positive it's very very unlikely although possible to have more than one infection. Um So if if you're going to go buy a hierarchy of tests and you can get an answer back quicker and you're worried about cost. That's the way I would do it. Um in general um you know, depending on the the kind of test that you do. You know the the you know if somebody and it also depends on how sick the kid is, the sick of the kid. I definitely want to know the answer regardless of the expense. If the if the kid just seems to have a cold, um you might also just want to watch and wait for the expensive test. Although uh you know, the earlier you get a diagnosis with influenza, the earlier you could potentially intervene depending on the age of the kid with uh with Tamiflu and early therapy. So these are all considerations. Not a great sort of answer. But you think about all those factors when you think about the cost of the test. Thank you. Next question. As you said, there is a flu M RNA vaccine being trialed. What kind of flu vaccines are we currently using and why are M RNA vaccines faster to produce? Yes. So that's a great question. So right now, we're using protein based flu vaccines in the old days was only grown on like uh chicken embryos or like egg yolk. So but now they're cell free technology so that people with egg ology is can get have a vaccine available as many people know. So they're all protein subunit vaccines, you chop up the virus bits and you put it with an achievement and then that's the way the vaccine is produced with flu. But with the M. RNA technology like with Covid, what they can do is just basically like they already have the sequences for the flu and different flu types. So they just cut and paste. Uh The parts the energetic parts of the flu vaccine, the parts that we know wake up the immune system and you just cut and paste that could put it in fatty bubble put in the body and the body starts making these proteins and then you get the antibodies to it. The reason why it's faster is because you don't have to kind of grow it in these words sort of like old fashioned technology and you literally just cut and paste it and put the code in this fatty bubble. Like the Covid vaccines. And that's why the Covid booster. When the the manufacturers went to the FDA in the beginning, they thought they would just do be A one plus the original. But the A one was all news and the FDA said, hey we don't want the A. One anymore. You should give us something that's going around which is B. Four and B five. So the manufacturers hadn't done any B. Four and B. Five stuff. But within six weeks they were able to like cut in peace this code, put it in the bubble. So that's why we think the flu vaccine if M. R. N. A. And shown to be effective would be a potential game changer because you can modify the vaccine during the flu season if it only takes six weeks and a season might take four or five months. Next question many patients are worried about frequency of viruses in their kids. When should we do an immune work up and what type of work up? Oh so that's that's a that's a great question. Um So in kids with recurrent serious infections um I think about doing a work up in kids with um with weird organisms like aspergillus or fungi that are bizarre bloodstream infections uh that happened on a recurring basis. Those are sort of wake up calls of course. Um You know you can get more subtle than that. So any kid would like frequent um streptococcal infections etcetera, particularly the cosmos serious disease. You know a general food step will be like just an immune globulin test. You just want to see if they have like I. G. A. Deficiency something very gross. And then if you know I always even as an infectious disease doctor always work very closely with my uh allergy and immunology colleagues to really help me figure out what other tests to do if it's a vaccine challenge and then following antibodies or not. So it's it's more specialized but I think just starting off with immunoglobulin panel and the kids are suspicious of. And then talking to your favorite immunology biologists would would really be helpful. Thank you. Next is please share your experience with treating bronco spasm with albuterol and Children with rsv bronchiolitis is family history of asthma. A factor in the decision. Um generally uh and speaking, you know, I've only treated only a very few kids myself but in adolescence which I have more experience with. Um and then with from leaving from my colleagues who treated a lot of kids with with bronco spasm, I'm sure many of you in the audience have a lot more experience than I do for that in younger kids. I would say that secondhand smoke even without a history of allergy with asthma um or um you know chronic cough parents with asthma. Not not so much so that's basically how we approach it. But I think, you know if you're really on the in the you know on the fence we tend to be more conservative and treat rather than not particularly if you're hearing wheezing. Okay, is your recommendation to defer treatment of a O. M. If related to RsV infection? Yes. I think if it comes with a landscape of RsV meaning um a lot of RsV going around now the adults in the family might just have had a cold at the same time. Um and the kid is coming early with the same symptoms happen to have otitis. Um you might it probably is more likely related to R. S. V. So you can always see the kid back again. And if the air is staying with symptoms out of proportion to the rest, you can then treat. So those are those are just some of the pros I think in the regular season or like in a non RsV peak season when things are more normal. It's hard, it's hard to not treat that kid otitis media, but I think right now, coming in with all these other things with RsV so high, it's more likely than not that that Otitis media is going to be viral and not bacterial and and with um you know, other entities like you know, up arrest or attracting infections in general and bronchitis. Most of these are viral infections. So in those guidelines, uh people tend to wait like 5 to 7 days with persistent symptoms then treat with antibiotics with an RZ search. You might want to think about that in Otitis although cultures related treat otitis more rather than not. So, it will be kind of like you take into consideration what else is going on? Okay, next question. I'm using 93% as my 02 cut off when assessing outpatient. Is this dangerous? No, I don't think it's dangerous, particularly following the patient over time and they can come back to you or call you if they have any. I just put 95 as a starting point for conversation but there's no real firm cut off from guidelines And then 93% what we use for adults anyway. Okay, this next is more of a comment, she says from dr julie kim I had mentioned that I am seeing really sick kids with various respiratory viruses who have had a covid infection this summer, reverse li I am concerned about kids who get RsV now and then get covid later given R. S. V. P. R. S. V has lasting lung issues. This may be another pathway to get more kids vaccinated and boosted. I think julie's comments are really prescient. Um there is uh it's more observation than data yet, but certainly a lot of people are seeing kids who had say covid during the summer and they tend to have like a really exuberant immune response, which is how people get sick anyway with RsV and with Covid. So whether or not that 12 punch with immune activation is really causing more severity of disease. In addition to not having had a lot of population immunity I think is a really interesting hypothesis. Um and and but definitely is a conversation point with parents in both directions. Like you pointed out because that immune activation is definitely going to come at a cost. We did get another point of conversation some data that was just released yesterday about long covid. Um so basically showed um that when people uh got there when they have decrease of virus in the bloodstream. Either from vaccines boosters or an adults who or older kids who can get packs a little bit that has a reduction in the propensity to get long covid. So again, more conversations with parents, even if even to get them immunized that it's not just about preventing a mild cold or that remote history of hospitalization if they feel that they're healthy. But some of these chronic symptoms, including an exuberant response to some other infection in the future, like julie had mentioned. Okay, two remaining questions. The next is who would you treat empirically for flu without a positive test? That's a tough question. Um, I think uh, I think the the ones that I worry about would be say somebody over 65, a grandparent of a kid, for example, who's in the household with somebody else who's tested positive flu. Um or uh, you know, a kid who has um uh some whose immune compromised and maybe some adults in the household has it and they also getting another symptom So those might be times where you might empirically start in the hospital, be empirically start treatment sometimes before getting the confirmatory test back when the pretest probability is so high. So outbreak settings or risky individuals when the symptoms are kind of very classic, uh, that might cause you to empirically started stop it if it's negative, but I would always want to tend to get a diagnosis if possible, even though I know some of the testing is tough. Okay to follow up on the comment from dr julie kim regarding back to back Covid and RsD infections would then those kids be benefit benefited from oral steroids. Um No evidence for the impact of oral stories yet. Although it's kind of an interesting uh thought we know that oral stories in the RsV treatment studies anyway hasn't shown to be beneficial. Um I think it's something that should be studied but not something that we should do in the absence of say uh you know, exacerbation of asthma when you wouldn't typically do it but not for any of these infections but it's a great hypothesis. Okay, this is the final question for the last couple of minutes. Can you please go over the Rsv epidemiology again? Yes. So um right now just to give you some numbers, we have about, so most of the most of the cases right now in the U. S. Who are hospitalized are in the under six months old group. So that's about four per 1000 in the country. Um To put 1000 in those under a year, six months a year and about 1001 to 2 years old. So much of the hospitalizations occurring kids right now in the country. Um and most of it is in the south. Well like with influenza. Uh it's sort of like the East coast and the midwest but starting to come to California with a vengeance. Um uh They've had treatment tents set up in other hospital systems in the East coast um Kind of like what we did for covid and adults in the beginning. So that's kind of where we are in terms of the big area. Um you know, see mentioned um you know the sort of extremist state that UCSF Pediatric Hospitalist Hospital is in right now. Um It's just the I mean, I hate to say it because I'm very optimistic person, but it's kind of like the beginning of the Bay Area on the West Coast. Um you know, it kind of started very very steeply up rather than sort of gradual and I think it may continue. So that's kind of like the epidemiology if you want a silver lining, it's kind of stabilizing in the southeast according to some reports right now. But again, if we look at every other RSV season, it typically takes about five months for 75% of the cases. So if we're in month one, it's just kind of like in the first part of the season. All right, well that concludes this webinar, thank you again, Dr Chin Hong we are so grateful for your time today and I am seeing one more question that just popped up. We do have one more two more minutes. So um do you mind answering one more? Okay. Um though rsV typically last five months given we may be seeing many many Children get our RsV RsV during the surge. There may be less kids left to get it later in the winter. Is it possible? We won't see it the last five months. That's a really interesting hypothesis is possible because you only can affect so many people as a virus and you do have immunity from the time you get it. In fact, there's a large study showing the second time. If you get it, it's less severe than and the third time is even less severe and immunity tends to last two months once you get it at least from serious disease. So if everybody gets it now then it may be a very sharp peak. So I I love that optimistic hypothesis and it's something nice to end on. Yes, lots of thank you's coming in. So again, thank you so much. If we don't have any other questions, we will end the webinar and again, this will be available on our med connection page in about a week after editing for you to view later, we'll share dr chin Hong slides. Thank you so much for being here everybody