S2 Episode 2: RSV and Traveler Health

Health

S2 Episode 2: RSV and Traveler Health

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February 1, 2024

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This transcript has been edited for readability. For extra episodes, download the Medscape app or subscribe to the podcast on Apple Podcasts, Spotify, or your most well-liked podcast supplier.

Forest W. Arnold, DO, MSc: Hello. My title is Dr Forest Arnold. Welcome to season two of the Medscape InDialogue podcast collection on respiratory syncytial virus (RSV) in adults. Today we’ll focus on RSV in adults and its impression on traveler well being. First, let me introduce my visitor, Dr. Lin Chen, Associate Professor of Medicine at Harvard Medical School, the Director of Travel Medicine at Mount Auburn Hospital, and the previous president of the International Society of Travel Medicine. Welcome to the Medscape InDialogue podcast.

Lin H. Chen, MD: Hello, everybody. Thanks for having me.

Arnold: Dr Chen, I’m so excited to have the ability to interview you at the moment. This is a singular subject, and I’m certain it should be fascinating. First off, why is it vital to know the impression of RSV in adults, significantly in vacationers?

Chen: That’s an ideal query. I really haven’t discovered research particularly on RSV in vacationers. But the danger could also be much like COVID, and in the course of the SARS-CoV-2 pandemic, we noticed how respiratory virus incidence charges declined, not simply SARS-CoV-2 however influenza and RSV as nicely. There are many elements which can be contributors, together with the usage of nonpharmacologic interventions like carrying masks, avoiding crowded indoors, the recommendation on good handwashing, and decreased journey and decreased motion of individuals. I believe it will be vital to know how typically RSV happens in vacationers in addition to usually in adults.

Arnold: Right. It’s vital as a result of as a respiratory virus, we all know it may be transmitted. And touring, even when you are going to be by your self in an unlimited airplane, consists of crowding to get there. We’ll discuss extra about that — the touring particularly — later, but it surely’s definitely vital, and I believe it should be nice to handle it. What are the widespread respiratory infections that vacationers may be uncovered to?

Chen: Over the years, we have seen respiratory pathogens like influenza virus, coronavirus, and the widespread chilly viruses. Many vacationers have commented about how after they return dwelling from journeys, they’ve had chilly signs, higher respiratory sickness signs, and typically decrease respiratory. Tuberculosis (TB) definitely is one other pathogen that we’re involved about when it comes to journey and travel-related exposures. Although RSV belongs to a unique genus, so it is a utterly totally different virus from influenza and coronavirus and adenovirus, the respiratory route does convey up comparable issues.

Arnold: There’s in all probability no sure geography, aside from wherever it is winter, RSV generally is a downside. Whereas there’s different respiratory pathogens like coccidioidomycosis, we type of say, “Okay, in the Southwest and Central America, it’s a bigger problem,” perhaps for hantavirus, “In specific areas out west.” But RSV is so predominant that it looks like it ought to be actually paid consideration to or no less than mentioned and entertained by anyone who’s touring. What precisely is the burden of illness?

Chen: Again, there hasn’t been research on RSV in vacationers or travel-related RSV, however it’s among the many leading causes of hospitalization for acute respiratory distress in infants and young children, and we have identified that for a very long time. What’s much less identified is that it is also a big risk to adults, particularly those that are older. Sixty years or older is the age vary that is been assessed extra. So the RSV attributable loss of life is considerably larger in older adults than in infants. In the US, there are reportedly 6000-10,000 annual deaths that are attributable to RSV amongst adults who’re 65 years or older. And together with that, it’s estimated that there are about 60,000-160,000 hospitalizations attributed to RSV annually in that age group. Among the adults, it is the older adults that we’re most involved about. Severe RSV is typically unpredictable, and adults 65 or older and people with power circumstances or immunosuppression are at excessive threat for growing extreme RSV. These are additionally developments that we see with influenza, with coronavirus, and with SARS-CoV-2 in fact. These threat elements embody chronic obstructive pulmonary disease, asthma, cardiovascular ailments reminiscent of congestive heart failure, coronary artery disease, and average or extreme immune compromise. Many persons are taking immunosuppressive brokers or immune modulators these days along with the people who find themselves immunocompromised because of cancers or organ transplants. It’s a big inhabitants that’s in danger.

Arnold: Would you be capable of communicate to or no less than estimate the financial impression?

Chen: There hasn’t been good research on RSV’s financial impression when it comes to travel-related illness, however the Journal of Infectious Diseases recently published a study that was a value of sickness modeling on US adults aged 60 years or older. The mannequin estimated 4 million annual RSV instances on this age group of 60-plus and in addition an annual financial burden of $6.6 billion, which is sort of spectacular. About 4% of RSV instances are hospitalized, and that contributes to 94% of direct medical prices. Among adults which can be a bit bit youthful, ages 50-59 years, the estimated annual hospitalization prices from that modeling examine was about $422 million. These are usually not trivial, and when it comes to occupied with journey, if a traveler is ailing, then they should search medical analysis. Their journey could also be interrupted. Their households which can be accompanying them may additionally have to alter plans. If they’re hospitalized, there’s that price. If it is somebody that is touring for work and turns into sick with RSV, or for that matter any sickness, there’s the lack of productiveness for that particular person and for the employer. So the financial impression for vacationers who fall ailing is important although there isn’t any particular information on RSV as a travel-related price.

Arnold: Right. We extrapolate lots from COVID-19 and influenza, and we’re all aware of the shutdowns that occurred with COVID-19. Could any of that be extrapolated to RSV?

Chen: With COVID, it is a considerably totally different scenario due to the pandemic and the journey bans. Those brought on an enormous financial impression on the native financial system, and on the vacation spot’s financial system, particularly those who appeal to vacationers or enterprise conferences, and positively airways, leisure and the hospitality sector, was positively severely impacted. So if there have been to be a big outbreak of RSV amongst vacationers, the same scenario would possibly happen. Although I believe, once more, the pandemic is a considerably totally different scenario with all of the journey bans.

Arnold: Let me provide a abstract thus far. We’ve reviewed RSV in adults in journey, and clearly, now we have surmised that crowding is a part of journey, and that that may be an element when touring. Older adults are extra topic to getting respiratory viruses, together with RSV. The mannequin exhibits that over $6 billion may be spent in sufferers older than 60; for adults of their 50s, it is $422 million, each very massive numbers with a excessive impression. Let’s transfer on now. At what level in an individual’s journey are they at best threat?

Chen: Based on the expertise with COVID, the crowded gatherings and indoors actions could in all probability current larger dangers for publicity. Even although there have been some airline-associated or flight-associated instances, the cruise ships illustrated the crowded indoors, confined areas — these have been nice illustrations of serious threat for publicity for respiratory viruses reminiscent of coronavirus. That might be additionally utilized or extrapolated for RSV. Large conferences too: Large indoor conferences, for instance, have been additionally potential websites of publicity. You would possibly keep in mind the CDC conference around April of 2022, the place about 13% of individuals surveyed indicated that they’d a optimistic take a look at. It’s fairly spectacular. Early on in the course of the SARS-CoV-2 pandemic, there have been some smaller enterprise conferences that additionally reported the consequence of the enterprise colleagues turning into contaminated. So it is these indoors, extra crowded gatherings which can be of concern. Something I did not point out earlier than was that if we take into consideration the respiratory viruses, that if a traveler is ailing and is uncovered to a respiratory virus after which goes on to a different vacation spot, they’re carrying it with them as a result of journey is a loop. They could transit via airports. They could transit via a few stops en path to the ultimate vacation spot. With respiratory pathogens, I believe it is particularly a priority when it comes to exposures and potential unfold elsewhere.

Arnold: You talked about the CDC convention and that there have been plenty of attendees who have been optimistic or had been optimistic, and I assume you have been speaking about COVID-19, appropriate?

Chen: Yes, precisely.

Arnold: That’s spectacular. It sounds to me like, after I have a look at what is going on on at the moment, industries have been capable of bounce again and handle as a result of COVID hasn’t gone away. RSV looks like it is worse, and but, we’re nonetheless capable of have massive conferences and go on cruise ships and never get sick. But it’s definitely a threat. We must do what we are able to to steer clear of that. What measures have been in place beforehand with respiratory infections which may apply to RSV within the close to future?

Chen: That’s an ideal query; I might take into consideration the response to respiratory an infection outbreaks and pandemics, that there have been journey warnings and alerts from public well being authorities. Then typically, there have been suggestions towards journey. Sometimes, it is to particular locations. Sometimes, it is a lot broader. So testing and vaccine necessities could also be issued. We noticed that with the COVID pandemic, the place individuals wanted to have a unfavorable take a look at with a view to take part in some actions and typically, even to maneuver about and to attend sure gatherings, go to eating places, go to a play, or get on an airplane or on a cruise ship to journey. And then, COVID vaccine necessities got here into place for a few of these actions, typically together with testing. This additionally occurred in the course of the 2009 pandemic of influenza A H1N1. Vaccine necessities have been issued in some conditions. Probably the perfect identified at the moment was the Hajj pilgrimage. This is the place tens of millions of individuals take part within the pilgrimage in Saudi Arabia. There was really an H1N1 influenza vaccine requirement with a view to take part throughout that point.

Arnold: Tell us about focused genetic sequencing and journey.

Chen: So the traveler-based genomic surveillance was developed by the CDC’s Travelers’ Health Branch, they usually goal for early detection of recent SARS-CoV-2 variants and different pathogens and attempt to fill in gaps in world surveillance for the an infection. There are literally three elements. One is whereby vacationers, arriving worldwide vacationers, volunteer to self-collect nasal swabs. Then, these samples are shipped to the lab for SARS-CoV-2 polymerase chain response (PCR) testing. Positive samples then endure complete genome sequencing to find out the variants. Some samples endure additional viral characterization to take a look at their transmissibility, their virulence, and their response to remedies or vaccines. So that is one half. A second a part of that was the airplane wastewater sampling. Wastewater is collected from sure flights, and people samples are shipped, examined by PCR, and optimistic samples endure the entire genome sequencing additionally. From the CDC’s data, it appears to be like like that began round August 2022. The third half is airport triturator drain sampling. The triturator is a consolidation level that captures the wastewater samples from a number of flights, and it does not embody airport terminal waste. What is being examined is from arriving or incoming flights from numerous locations. These wastewater samples are collected after which examined. That apparently began round April 2023. Recently, I noticed an announcement that CDC expanded this traveler’s genomic surveillance to seven airports, and that features surveillance for SARS-CoV-2, influenza, RSV, and another respiratory pathogens. I believe it is a very fascinating program as a result of respiratory infections are comparatively widespread amongst vacationers. I did not point out earlier that GeoSentinel is a community of about 70 journey and tropical medication clinics all over the world that collaborate to trace travel-related ailments. In their analyses, respiratory sickness is No. 4 amongst numerous travel-acquired sicknesses. There have been plenty of survey-based research that checked out what vacationers expertise. There was a pleasant review published in the Journal of Travel Medicine in 2017 that illustrated once more that respiratory infections are so widespread. I believe, given the COVID expertise, this monitoring or surveillance for different respiratory pathogens might be actually useful sooner or later for detecting new pathogens.

Arnold: Yes. The genetic sequencing is comparatively fast, but it surely’s not so speedy that it should have an effect on the traveler whom they swab. It’s actually simply to do surveying and see maybe what pathogens are coming from what areas of the world.

Chen: Exactly.

Arnold: So inform us earlier than we end, what’s the position of RSV vaccination in vacationers?

Chen: Now that the RSV vaccines are FDA licensed, we are able to definitely contemplate RSV vaccination for the high-risk vacationers. The two vaccines are licensed for these aged 60 years or older. I believe, primarily based on the printed literature, the people who find themselves older definitely have an elevated threat for extreme illness, for growing decrease tract infections, pneumonias, requiring extra intensive medical use and medical care. I might suppose on that spectrum, in all probability people who find themselves 75 or older ought to actually take into consideration simply getting it, and people 60 or older ought to definitely take into consideration their comorbidities. If they’ve sicknesses reminiscent of bronchial asthma, emphysema, diabetes, immune suppression, cardiovascular, or cardiorespiratory compromise, I positively suppose they need to critically contemplate vaccination.

Arnold: One query about airplanes earlier than we transfer on: Have you seen experiences that they are not really as high-risk for catching different ailments as we’d suppose?

Chen: For a few of the research on respiratory pathogens, TB and influenza are in all probability the 2 that have been nicely studied till COVID got here alongside. It was typically cited that two rows from the index case is larger threat, and additional away could be decrease threat. I believe with COVID-19, plenty of individuals have commented that with the fashionable aircrafts with a excessive filtration price of air move — the HEPA filters which can be within the fashionable aircrafts — the air circulation and filtration ought to take away a lot of the respiratory pathogen. While the engine and these filtration methods are on, it could be extra reassuring that the pathogens are eliminated. But if the engine is stopped, if persons are boarding, deboarding, and are additionally within the crowded airports — these are locations the place I might nonetheless have nice concern about a few of the respiratory pathogens being transmitted. Those are conditions I might nonetheless advocate and nonetheless really feel extra snug carrying masks.

Arnold: Certainly. Today we have talked with Dr Lin Chen about RSV in adults and journey medication. And as we’d think about, buying respiratory viruses is definitely simpler in crowded areas. And airports and airways are performing focused genetic sequencing to make use of as surveillance. Thank you for tuning in. Please take a second to obtain the Medscape app to hear and subscribe to this podcast collection on RSV and adults. This is Dr Forest Arnold for the Medscape InDialogue podcast.

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