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RSV in Pediatrics: Immunization Strategies and Treatment Insights · Pediatrics in Practice: A CME Podcast

• 0:01
  Dr Mike Smith (Host): Welcome to Pediatrics in Practice, A CME Podcast.
• 0:05
  I'm Dr.
• 0:05
  Mike, and joining me today is Dr.
• 0:07
  Maria Daisy Leon from Children's Mercy.
• 0:10
  We'll be discussing a critical topic in pediatric health RSV,
• 0:14
  in pediatrics, immunization strategies and treatment insights.
• 0:18
  Welcome to the show.
• 0:20
  Dr Maria Deza-Leon: Hi.
• 0:20
  Thanks for having me.
• 0:22
  Dr Mike Smith (Host): So what are the biggest challenges pediatricians
• 0:24
  are facing during RSV season and how have the trends shifted?
• 0:29
  Post pandemic.
• 0:31
  Dr Maria Deza-Leon: As you probably know, RSV is the leading cause of bronchiolitis
• 0:36
  and pneumonia in infants, and it is the number one cause of hospitalizations
• 0:42
  in kids under two years of age.
• 0:45
  Causing about like 50 to 80,000 hospitalizations a year, all
• 0:50
  within that limited period that we called RSV season, which leads to
• 0:54
  overcrowding clinics and hospitals.
• 0:57
  And this strain is felt everywhere throughout the healthcare system,
• 1:01
  but particularly in primary care settings, which often serve as.
• 1:07
  That first point of contact before hospitalization.
• 1:10
  And as most viral infections, there is no specific treatment other than supportive
• 1:15
  management, which can be very frustrating for parents that see their child is ill.
• 1:21
  so these kids are often gonna need close follow up additional
• 1:25
  visits, and this can really be a challenge for pediatric offices.
• 1:29
  And after the pandemic started, there was this whole year there,
• 1:32
  there was no RSV, but then.
• 1:35
  Seasonality was completely disrupted with 2021, having a peak in the middle of the
• 1:42
  summer and 2022 having an early fall peak, which we were definitely not prepared for.
• 1:49
  throughout the next couple of years, we have seen that it has gone back to
• 1:52
  its pre pandemic seasonality, but as much as we would love to predict how
• 1:56
  viruses will behave, we really can't.
• 1:59
  So we have to be prepared at all times, and that is definitely a
• 2:02
  challenge when it comes to RSV.
• 2:04
  Dr Mike Smith (Host): Yeah.
• 2:04
  Meaning the viruses don't necessarily follow our schedule.
• 2:08
  Dr Maria Deza-Leon: Yes, exactly.
• 2:09
  Dr Mike Smith (Host): right, right.
• 2:10
  you said something there that, you know, with RSV, the treatment is
• 2:14
  really supportive for the most part.
• 2:15
  Right.
• 2:16
  Which means prevention's key, which brings us to vaccines.
• 2:19
  can you tell us a little bit, now there's a new vaccine out.
• 2:22
  How does that differ from the traditional, RSV vaccines?
• 2:27
  Dr Maria Deza-Leon: So there's actually a couple of different,
• 2:30
  new immunization strategies.
• 2:33
  Two of them are NEV and Umab, which are a very similar product that, We're approved,
• 2:39
  one in 2023, the other one earlier this year, and are both monoclonal antibodies,
• 2:45
  so they're not technically vaccines in the traditional sense, but they provide
• 2:50
  passive administration, meaning they can confer long lasting protection
• 2:55
  from RSV through specific antibodies.
• 2:58
  And this protection is expected to last at least five months, so around
• 3:02
  the length of a regular RSV season.
• 3:05
  And the wonderful thing about these antibodies is that they have
• 3:09
  excellent data for effectiveness.
• 3:11
  studies have shown reduction in severe disease of up to 80% in the trials,
• 3:16
  meaning less hospital admissions, less ICU stays if children acquire the infection.
• 3:22
  And there's now real life data from multiple countries such as Chile,
• 3:26
  where Universal Vaccination with NEV was implemented, and some early
• 3:30
  data from the United States that have seen a dramatic decrease in
• 3:34
  RSV associated hospitalizations.
• 3:37
  So this has truly been game changing for pediatric health as we've all been
• 3:41
  marked by those BCU winter months with multiple admissions from bronchiolitis
• 3:46
  and kits that were gasping for air.
• 3:48
  And those who benefit most from these interventions are gonna be children on
• 3:52
  their first RSV season as both monoclonals are approved for up to eight months of
• 3:57
  age for kids, for their first RSV season.
• 4:01
  And NEV is also approved for up to 19 months of age in a select group of higher
• 4:08
  risk patients for a second R RSV season.
• 4:10
  Dr Mike Smith (Host): Okay.
• 4:11
  What's the current guidance on RSV vaccination during pregnancy and how
• 4:16
  does that impact infant protection?
• 4:19
  Dr Maria Deza-Leon: current guidance is for moms to receive maternal RSV
• 4:23
  vaccine between weeks of gestation 32 to 36, just as moms are recommended to
• 4:30
  receive that TDAP vaccine to provide passive immunization through maternal
• 4:34
  antibody passage through the placenta.
• 4:37
  Same thing would happen with the maternal RSV vaccine, and it has also
• 4:42
  been proven to be quite effective with decreases on severe disease by almost 70%.
• 4:49
  And current guidance only recommends the vaccine to be given once for a pregnancy.
• 4:54
  However, there are ongoing trials to evaluate a second
• 4:58
  dose in subsequent pregnancies.
• 5:01
  as well as evaluating how long lasting the immunity from
• 5:04
  that initial vaccine has been.
• 5:06
  So we're hopefully gonna have more data about this in the coming years.
• 5:10
  And regarding its impact on infant protection strategies, it is very
• 5:15
  important to know if a mom received the maternal vaccine and when, as this
• 5:20
  may affect the baby's eligibility for a monoclonal antibody for that nev
• 5:24
  and umab that we were talking about.
• 5:27
  So we have to know in advance.
• 5:29
  To allow for better planning.
• 5:31
  Now in the real world, pediatric offices will not really be part of pregnancy
• 5:35
  immunization guidance unless the parent of a current patient is expecting.
• 5:39
  So unless we are having early prenatal visits, guidance may be up to our ob
• 5:44
  gyn colleagues, which have been doing a wonderful job at offering this.
• 5:48
  And if the mom has received the vaccine, but the baby was born before two weeks
• 5:52
  after getting the vaccine, then monoclonal antibodies are still recommended.
• 5:58
  As we don't know if there was enough time for those
• 6:00
  antibodies to cross the placenta.
• 6:02
  but if it's been more than two weeks since the mom got the, vaccine baby was born,
• 6:07
  then they do not need to get monoclonals as they should have acquired protection.
• 6:11
  Dr Mike Smith (Host): Now for children who do develop severe RSV, the most
• 6:15
  effective treatment approaches today?
• 6:18
  And are there any emerging therapies on the horizon?
• 6:23
  Dr Maria Deza-Leon: this is actually a very, exciting
• 6:25
  thing about RSV, therapeutics.
• 6:28
  as we have talked before, similar to many other viral infections, treatment for RSV
• 6:33
  is gonna be primarily supportive, so you might need to do airway clearance, some
• 6:38
  oxygen ventilation support when necessary.
• 6:41
  Along with having lots of patients as these infections are gonna
• 6:45
  be typically self-limiting.
• 6:47
  and currently there are no approved antiviral drugs specifically for
• 6:52
  managing severe RSV infection.
• 6:56
  Rine is sometimes used in severe infections, but it's really expensive.
• 7:01
  It has some potential toxicity and it has very limited
• 7:05
  efficacy that has been proven.
• 7:06
  So we don't really support its routine use.
• 7:10
  But there are several investigational agents that target RSV and are in
• 7:15
  various stages of clinical trials.
• 7:17
  There's one that's called ZA Reservoir that already has a phase three data
• 7:22
  suggesting that it has very good efficacy and a very favorable safety profile.
• 7:29
  it has not yet been approved for a widespread use, but I
• 7:31
  think that's getting closed.
• 7:33
  But even once antivirals become available, their greatest benefit
• 7:37
  happens when they're administered very early in the course.
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  So this reinforced that prevention is still gonna be
• 7:44
  our most effective strategy.
• 7:47
  Dr Mike Smith (Host): You know, in many households today, you will often
• 7:51
  find young children with either older parents or grandparents, you know, people
• 7:56
  say 60 or over all living together.
• 7:59
  how much of a problem is household transmission?
• 8:03
  Dr Maria Deza-Leon: It is actually pretty big.
• 8:06
  most studies suggest that transmission happens from younger patients to
• 8:11
  adults, so children are gonna be main infectious vector for RSV.
• 8:18
  so hopefully by implementing.
• 8:20
  These immunization strategies, we can decrease the amount of RSV that
• 8:24
  gets transmitted in households.
• 8:26
  Now, there's also a vaccine that's available for adults that are
• 8:31
  older than 60 years of age and.
• 8:35
  This is available because even though when we hear RSV, we think
• 8:39
  mostly of kids with bronchiolitis.
• 8:42
  However, older adults, especially those that have comorbidities,
• 8:46
  are gonna be at higher risk of developing severe RSV infection
• 8:49
  that can lead to hospitalizations.
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  and this vaccine has actually been approved, and it shows 70%
• 8:57
  efficacy against RSV related acute respiratory illness, which is huge.
• 9:02
  So if we can get all grandparents and all the babies immunized for
• 9:07
  RSV, who are gonna be the people at highest risk, then our transmission
• 9:11
  is gonna decrease significantly.
• 9:13
  Dr Mike Smith (Host): I'm gonna make sure I heard this right.
• 9:15
  ' did you say a 70% reduction in severe RSV for that older population?
• 9:21
  Dr Maria Deza-Leon: Yeah.
• 9:22
  Dr Mike Smith (Host): Yeah.
• 9:22
  Okay.
• 9:22
  Let's get everybody vaccinated.
• 9:24
  Right.
• 9:26
  Dr Maria Deza-Leon: absolutely, absolutely.
• 9:28
  It's really impressive.
• 9:29
  these interventions have been game changing.
• 9:33
  Dr Mike Smith (Host): Okay.
• 9:34
  So obviously immunization strategies are, key.
• 9:38
  even though there's some, treatments in the horizon, all that stuff, that's great.
• 9:43
  It's still always easier to prevent.
• 9:45
  Right?
• 9:45
  And that's,
• 9:46
  I.
• 9:47
  Exactly what we do with immunization.
• 9:49
  so here's the tough question now, what advice do you have for pediatricians who
• 9:54
  are trying to navigate the supply of these uh, medicines, the timing, even insurance
• 10:02
  coverage for these immunization products?
• 10:05
  Because I know that has to be a headache.
• 10:08
  Dr Maria Deza-Leon: Absolutely, and this can be quite tricky 'cause we
• 10:12
  went from having no preventive options.
• 10:14
  To now having three approved choices with a few more down the pipeline.
• 10:18
  So it's gonna become a nightmare for every pediatric office.
• 10:22
  and this is an absolutely positive shift that provides alternatives
• 10:26
  in case of any shortages, which we have experienced in the past.
• 10:29
  When Nev Map first came out, there was a lot of issues with supply, so having
• 10:35
  multiple options is really a great thing.
• 10:38
  But logistics are gonna be very difficult to manage for pediatric offices.
• 10:43
  another thing that can be a bit of a headache is that, for
• 10:46
  example, for NEV Map, there are two different formulations available.
• 10:49
  One that's a 50 milligram dose and another one that's a hundred milligram dose.
• 10:54
  And it depends on whether the child weighs less or more than five kilos.
• 10:59
  So you need to carry two separate formulations and unfortunately.
• 11:03
  It would be great if you could just carry the 50 milligram and you could give two
• 11:07
  doses, but insurance will not cover that.
• 11:10
  or if you could do the a hundred milligram and just use half of it, but unfortunately
• 11:14
  that is not an option either.
• 11:16
  Dr Mike Smith (Host): From the insurance
• 11:17
  standpoint,
• 11:18
  Dr Maria Deza-Leon: yes, from the insurance standpoint, but
• 11:21
  the a hundred milligram dose, you cannot actually divide it.
• 11:23
  So it's difficult for pediatric offices.
• 11:28
  Basically have to make sure that they carry all formulations available
• 11:32
  Dr Mike Smith (Host): Yeah.
• 11:32
  You have to have a nice inventory of it.
• 11:35
  Dr Maria Deza-Leon: Exactly.
• 11:36
  for these other, monoclonal antibody that has recently come out, umab,
• 11:41
  it doesn't have a weight-based restriction, so you can give the
• 11:45
  same dosing for kids of all weights.
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  The only problem is that you cannot give it for children that
• 11:53
  are older than eight months.
• 11:55
  So it might be difficult to decide which one you want to stock in your office,
• 12:00
  and this takes very careful consideration of your practices patient population.
• 12:05
  Dr Mike Smith (Host): Now we know RSV does follow some seasonal aspect right to it.
• 12:10
  Although you did mention it's kind of all over the place here and there.
• 12:13
  We've been surprised.
• 12:15
  But with that said, I, is it best to go ahead and stock up during the
• 12:19
  season of RSV or do you think it's best just to have a supply all the time?
• 12:25
  Dr Maria Deza-Leon: Right now the guidance is to give the
• 12:27
  immunizations only for the SV season.
• 12:32
  So if you wanna have it throughout the whole year, it can be helpful
• 12:37
  If we start seeing changes in seasonality, Pretty sure.
• 12:42
  I would be hopeful that if that were to happen, that insurance would be able
• 12:46
  to cover all of these, but because of how insurance works right now, offices
• 12:53
  are only recommended to provide the monoclonal antibodies during this specific
• 12:58
  timing.
• 12:59
  Dr Mike Smith (Host): Gotcha.
• 13:00
  And so that's obviously when you need to be ready, have your supply.
• 13:04
  and follow that scheduling, this has been fantastic, any last words for
• 13:09
  the listening audience about RSV, about immunization strategies and even what may
• 13:16
  be coming down the line in, treatment.
• 13:19
  Dr Maria Deza-Leon: I had to say that one of the things I am most excited
• 13:22
  about right now is how the success of these RZ prevention strategies has
• 13:27
  really opened up the door for broader innovation, and we're starting to see
• 13:31
  series investment in other preventive approaches for respiratory viruses like
• 13:36
  human met Pneumo virus and parainfluenza.
• 13:39
  Which along with RSV are some of the major culprits behind
• 13:44
  bronchiolitis and cruin kits.
• 13:46
  There's an ongoing study of combination monoclonal antibodies that would
• 13:51
  target multiple viruses at once.
• 13:53
  So imagine just like you have NEV and TRO right now, you could give one that
• 13:58
  would cover RSV would cover human meum.
• 14:01
  Avir could cover para flu.
• 14:03
  And as a parent who's experienced the stress of a child hospitalized with
• 14:07
  severe group, and as a pediatrician who has seen this infections causing
• 14:11
  life-threatening disease in my patients, I can tell you this is truly personal to
• 14:16
  me too, and it's incredibly exciting to think about what these breakthroughs could
• 14:21
  mean for families in the near future.
• 14:23
  Dr Mike Smith (Host): Yeah.
• 14:24
  Fantastic.
• 14:24
  This has been great.
• 14:26
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• 14:31
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• 14:35
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• 14:38
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• 14:47
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• 14:51
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• 14:52
  Mike.
• 14:52
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