RSV: When It's More Than Just a Cold with Dr. Frank Esper

Podcast Transcript

Cassandra:  Hi, thanks for joining us. I'm your host, Cassandra Holloway, and you're listening to Health Essential Podcast by Cleveland Clinic. Today we're broadcasting at Cleveland Clinic's main campus in Cleveland, Ohio and we're here today with Dr. Frank Esper. Thanks for being here.

Dr. Frank Esper:  Yeah, happy to be here. Thank you.

Cassandra:  Dr. Esper is a pediatric infectious disease specialist at Cleveland Clinic Children's, and today we're going to be talking about Respiratory Syncytial Virus, also known as RSV, and giving parents some advice on how to protect your child. Before we began, we want to remind our listeners that this is for informational purposes only, and should not replace your doctor's advice, or your child's doctors advice. So each year in the United States, an estimated 57,000 children younger than five years old are hospitalized due to RSV infection, and that's a scary statistic, right? For any parent.

Dr. Frank Esper:  Yeah, it is and you want to keep going scary, it's about 3.3 million cases around the world each year with over millions of hospitalizations around the world. We have a lot of children that get hospitalized. This is one of those things where every pediatrician knows it's winter season because the hospital just fills up with small infants, mostly under the age of one with bad, bad breathing problems due to RSV.

Cassandra:  Can you start off by just explaining what is RSV?

Dr. Frank Esper:  Yeah, RSV is a cold and flu virus. We talk about this all the time of the year, where it's the cold and flu season anywhere between late autumn to early spring. This is when the viruses like to come out, and there's a huge number of these viruses, and they all show up in their own little different sequence. For whatever reason, RSV showed up a little earlier this year, but it always shows up. Usually January, February is its main target for this neck of the woods, but it can show up anywhere or any time. Every year is a little bit different, but this year it came in, and it was pretty bad. This year we were filling up beds, and we would have times where we were wondering where all the beds would be for all these infants who needed a little support.

Dr. Frank Esper:  Thankfully though this virus itself is something that comes in, it causes a lot of problems breathing, it can cause pneumonia, and it can cause breathing problems, but many of these infants will actually ultimately do well. It just as a matter of time.

Cassandra:  What are some of the hallmark symptoms of RSV?

Dr. Frank Esper:  As a cold and flu virus, mainly the thing that you see is cold and flu symptoms, which is you get a lot of coughing, you get a lot of runny nose, you get a lot of congestion. Usually those types of symptoms last for about three to five days or so. More times than not, that's the end of it, and you're done. As long as you can take a decent amount of runny nose and cough, you're fine. However, in some infants it can actually lead to worse breathing problems. Sometimes it goes full on pneumonia, sometimes it gives what's called bronchiolitis. Bronchiolitis is where your wind pipes get so swollen, and so irritated that you have a hard time moving the air in and out of your lungs, because the wind pipes are so swollen, and that's leads to a lot of wheezing.

Dr. Frank Esper:  A lot of times we see a small infant with a lot of congestion, runny nose, and they just wheeze out of nowhere. We're saying, "Yeah, we know what this is, and this is RSV." Sometimes they have such hard times moving their air in and out of their lungs, that we need to help them out. We need to give them oxygen, or we need to give them a little support until their immune system can kick this virus out.

Cassandra:  You keep saying infants, can you talk a little bit about the ages of RSV, is it primarily infants that should be a concern, or is it a little bit older children?

Dr. Frank Esper:  Actually it is primarily younger children, so mostly under the age of two, but really under the age of one, six months to one year. The smaller the infant, the smaller the air pipe, the smaller the air pipe, the worse the problem. However, what is more unrecognized is that there are a lot of adults that have this problem too. In fact, over 30 to 40% of all the RSV that we recognize are actually in the adult population, and so adults, while they are big wind pipes, sometimes their lungs are not as strong, or sometimes they have other medical problems like COPD, or they're smokers, or they are on medications for cancer, et cetera. They can get really, really bad RSV too. It's really not just a pediatric disease. There's a lot of adult problems with RSV as well, but the biggest problem that we see in children are those children under six months of age, who also have other problems.

Dr. Frank Esper:  Just like I said, when adults have lung problems, they can get bad disease, well you can have a child who has lung problems too. So babies who are premature, when they're born really, really early. Babies who have heart problems, babies who have lung problems, and sometimes those two go hand in hand, or babies who are born with a bad immune system. Those individuals can lead to really bad problems, and really bad disease with RSV, and those are the ones that we watch out for the closest.

Cassandra:  Keep an eye on for sure. I want to go back to symptoms really quick. You mentioned runny nose, fever, a little bit of a cough, are ear infections or pinkeye ever a sign of RSV?

Dr. Frank Esper:  That's not so much a sign specifically of RSV, as it is any virus can lead to those types of things. RSV by itself, is not one of the hallmark pink eye causing viruses like let's say adenoviruses, but it can. And ear infections, believe it or not, the lungs, the ears and the sinuses, when we talk about sinus infections, they're all the same tube, it's just different branches off of the same tree. You clog up one, you back up fluid into the others. RSV along with any of these others can lead to backup of fluid into your ears, leading to an ear infection, or leading to a sinus infection just because you've got so much gunk in your nose and upper airway. So yeah, it can lead to ear infections, although it's not specifically the cause of ear infections, it and every other virus out there can lead to infection.

Cassandra:  Sure, makes sense. I read that RSV is so common that most children have been infected with the virus by age two. What factors contribute to if the virus runs its course like the common cold or flu, or if it turns more serious into RSV?

Dr. Frank Esper:  Yeah, so every child pretty much gets it by the age of two. The reason is that this virus knows what it wants to do. It wants to infect babies, it wants to infect kids. These children for the most part, are basically passing the virus from one child to a next. Sometimes the adults, we can also get RSV, but for us we just feel it's a small cold, and this small cold we still take care of our babies, but then we can pass the small cold, which becomes a much bigger problem in a small child. So it knows what it wants to do. Also, what we do see is that usually it's not just one child in the family, usually there's several other children. Those several other children may be at the three age, four age, the five age, they're going to preschool, they're going to kindergarten, and that's just basically viral culture media. They're bring up all sorts of viruses, including RSV, and then that can come back to the home, where a smaller infant who doesn't go to daycare basically can get infected.

Dr. Frank Esper:  The main thing is that almost everybody gets RSV by the time they're two, certainly before the time they're at their five years of age, but not everybody gets bad RSV. What is it that really makes it bad RSV? Again, the smaller you are, the smaller your airways are, the more problems you're going to have. The youngest infant, certainly the ones under six months of age, definitely the ones under six weeks of age. Children who have, as we said, lung problems, heart problems, immune problems, people who have also neurologic problems can also lead to bad RSV. Down's syndrome has also been well associated with bad RSV problems.

Dr. Frank Esper:  Then you have children who are exposed to tobacco. This can lead to lung problems in an infant that they don't have it themselves, but because they've inhaled tobacco or tobacco smoke, that can lead to bad RSV. Or small infants who aren't breastfed, we've well been that breastfeeding by mom gives a lot of immunity to a baby, and that babies who are breastfed do not have nearly as bad RSV as those babies who do not get breastfed.

Cassandra:  Wow, that's really interesting. So as an adult I could have RSV right now, and I could be completely fine?

Dr. Frank Esper:  Yes, in fact I feel like I have RSV right now, but I also have five kids at home. It's one of those things where for adults generally little cough, little cold. We feel, "Ugh, it's just a virus," but again, what's not necessarily bad in one person can be a lot worse in another. It's one of the reasons why, and we'll talk about how to prevent is very important, to prevent even when you think you only have a minor minor cold, is always very good to talk about strategies in order to prevent the spread to others.

Cassandra:  Sure, you mentioned that January, February are the main hot points of when RSV kind of manifests. Can it come about anytime of the year, even in the summer or spring?

Dr. Frank Esper:  The answer is yeah, there's always a little bit of, this July patient with RSV, we're like, "Where the heck did that come from?" For the most part there's always a little bit of things that are happening. The warmer climate you get, the longer the RSV season is. So here up in the North, we have this big six week period where there's RSV everywhere, and then it's gone. You go down to Florida, their RSV season lasts for months because it's just a little more tropical, it's a little more wet, and for whatever reason, RSV is pretty much there for many, many months out of the year.

Dr. Frank Esper:  Also, you have to understand though that when we're in July or August, and we're saying, "Hey, we're in the summer, it's completely the opposite of respiratory viruses," and well, that means all the viruses are down in South America, and down in the Southern hemisphere. There's lots of RSV going on in the Southern hemisphere during the summer, and then we flop back over to our winter, and we see a lot of RSV happening here. For individuals who are traveling, or for infants who are traveling with their family on vacation, maybe going to Peru or maybe going to Australia, you go there in August, September, or in July, that's actually their RSV season.

Cassandra:  Interesting. Makes sense. Walk us through if say I had an infant under six months, and I suspect that they have a cold, and they're at risk for RSV, and I take them to, I guess let's start there. Where do I take them? Do I take them to my regular pediatrician, or the emergency room?

Dr. Frank Esper:  Yeah, RSV it's a common foe of pediatricians. We know this germ a lot, every pediatrician knows RSV. The first person, the first stop should be with your pediatrician. Now not everybody is going to need to be seen by their pediatrician, but certainly any child who is under three months of age, and if they spike any fever, you should be calling your pediatrician right there. Whether there's a virus there or not, any child under three months of age we definitely want to know about it, because children under the age of three months are at risk of getting really, really bad infections. They get really sick, really quick, and so we usually like to see those children no matter how good they look, or no matter their symptoms, any fever we want to see them. But certainly any child under six months of age, certainly if they're having the runny nose, the cough, and it's the RSV season, if they're wheezing, we generally want to see them as well.

Dr. Frank Esper:  Obviously any age, if they're having troubles breathing, if they're breathing really, really fast, if they're wheezing really, really hard. If they just looks like they're tiring out or working, then we want to see them. Believe it or not, a lot of children that get admitted to the hospital for RSV are usually not because of breathing problems, but it's usually because they're breathing so much that they can't drink, and they can't eat and they get dehydrated. Usually the problem is not so much that the virus has affected their lungs, as much as the viruses affected their lungs to the point that they're just not drinking their bottles, and they're not able to hold anything down, or they're just too busy breathing that they don't want to eat, and so we have to bring them into the hospital just to make sure that they don't get too dehydrated.

Cassandra:  Let's talk more about when you bring them into the hospital, you work on dehydration. What are some other steps of action that you would take?

Dr. Frank Esper:  The main thing we would do when we see any child in the hospital, is we make sure that the first thing is we always make sure that they're not dehydrated, and if they are dehydrated we have to give them fluids. We can do that by just putting in an IV, and tanking them up as we say. We go ahead, and we give them, and they usually, when you give someone who's dehydrated, you give them fluids, it's actually really fun to see them turn around as quickly as they do. Dehydration is a very, very serious problem, but it is very easily rectified if it's identified, and it's one of those things that all pediatricians are cued in on. The second thing though that we do is because this is a respiratory problem, we have to make sure that there's not pneumonia. A lot of times we may get a chest X-ray to see if there's a pneumonia going on.

Dr. Frank Esper:  Germs are sneaky, they like to pile on. They kick you when your down, so when you get sick with one virus, sometimes a second germ tries to piggyback off the first. Sometimes it's a bacteria, sometimes you get a virus that leads to a bacterial pneumonia. This happens a lot more with flu, but it can happen with any virus, and so we get a chest X-ray to make sure that we're not missing a pneumonia. A lot of times we're listening to make sure that you are, we measure the amount of oxygen that's in your blood, we make sure that you have enough oxygen in your blood. If you don't, we give you extra oxygen usually through a mask or a nasal cannula, makes them feel a little bit better, they breathe easier, and then we just kind of wait until the baby's own immune system is able to kick out the virus.

Cassandra:  How long do they typically, an infant stays at the hospital?

Dr. Frank Esper:  It's different for every infant, most infants that don't have any other problems can be in and out within a matter days, sometimes one day, sometimes a couple. It depends really on whether they were dehydrated, and how long does it take for them to start drinking again? I can't make a baby drink as much as I would love to say I could, so it's really up to them when they start drinking again. But also from an oxygen standpoint, we have to make sure that they're able to hold up, and get enough air in their lungs, and so we just kind of watch them, and take it day by day.

Dr. Frank Esper:  Now if you have lung problems or heart problems, or you were born premature, then it can be for quite some time. Those are the babies that sometimes end up in the intensive care unit because they need even more help to breathe, and in those cases it can last days to weeks.

Cassandra:  Is there ever an issue where it's so serious that quarantine would be involved?

Dr. Frank Esper:  Quarantines always involved, but it's not so much quarantine, as much as it is isolation. This is a virus again, we well know it, it fills up the hospital and by such we do not want to pass RSV around from bed to bed, and person to person. It is something that, one of the things that we quickly recognize well before they get into the hospital, we have quick tests that allow us to determine whether or not someone has flu or RSV, or a whole host of other different viruses. We test them as soon as they get into the room, or right before they even come into the hospital, and we always put them on what's called isolation.

Dr. Frank Esper:  In this case, we put on these lovely blue gowns, but in some hospitals it may be yellow, or some hospitals may be pink, I don't know, but there are all these plastic gowns that are disposable that we crinkle up, and throw away after we see every patient. We also wear gloves so that we are basically protecting ourselves from getting the RSV on us, and then when we go into the next patient's room, we don't pass it on to them. We wear gloves, we wear gowns, we wash our hands before we go into the room, we wash our hands when we come out of the room, we take off all our gowns and gloves, and we go to the next room where we may even put more gowns and gloves on again, washing our hands and doing it over, and over, over again.

Cassandra:  You can see how serious that spreading it is, that you guys take seriously.

Dr. Frank Esper:  We take it extremely serious because just because someone's in the hospital with RSV, doesn't mean that everybody in the hospital has RSV. There are people who have surgeries, there are people who have cancer and they're receiving treatments, or people who just broke their leg and needs some help with that, and we don't want to, like I said, these germs love to kick you when you're down. They will take advantage of any of those cases to cause more infection.

Cassandra:  So for parents who might be bringing their infant into the hospital, they see this type of protocol, know that it's a good safety protocol, basically that you're following this for a reason.

Dr. Frank Esper:  In fact, a lot of times you'll see this type of protocol actually in the waiting rooms of both the emergency department, as well as your pediatrician's office. They'll have masks available, they'll have sanitizers available right in the waiting room that you guys can use. Or if your baby is coughing, you can put a mask on her or him, to prevent the spread of germs within the waiting room.

Cassandra:  What are some complications of severe RSV?

Dr. Frank Esper:  Well when it gets really bad, when the wind pipes swole shut, and you can't get air to your lungs, that's what we try to avoid, and we try to make sure that we give them as much oxygen as you can. But in the worst case scenarios, it leads to what's called respiratory failure, you can't get oxygen to your lungs. Thankfully that does not happen very often in the United States.

Dr. Frank Esper:  In developed countries, RSV causes a lot of hospitalization, but not a lot of death. In developing countries it's flipped. There's a lot of death, a lot more death from RSV, because they just don't have the ability to test, or the ability to support infants who have really, really bad breathing problems. In the worst situations, we have to actually put them on a breathing machine to basically breathe for them, or in the most extreme examples, they go on cardiopulmonary bypass which we call ECMO, which is basically we just say, "Don't worry about the lungs. Don't worry about the heart. We will oxygenate the blood for you, until the lungs have healed enough that they can go back online, and start breathing on their own."

Cassandra:  Interesting. Just as a rule of thumb, under three and your child has a fever, call your doctor, if they're having trouble breathing, call your doctor.

Dr. Frank Esper:  Yes. Anytime, it doesn't matter what age, you could be 59, go ahead and call your doctor if you're having trouble breathing. Period.

Cassandra:  Absolutely, yeah. You talked a little bit about treatment once they're in the hospital, kind of that breathing treatments. Are there any medications that you would typically give a child with this?

Dr. Frank Esper:  Unfortunately, no. There are a lot of medications out there that are trying to prevent RSV, and prevent people from who have RSV from getting really, really sick. Unfortunately, we haven't really, there are multiple ones that are on trials right now, but for the most part they really have not shown to be a lot of benefit. We actually have a medicine that's been around for decades called Ribaviran, and unfortunately the medicine side effects are worse than the disease itself. The answer is that we just, while it does kill the virus, it doesn't help the patient, so that's our problem right now. The biggest ones that we're working on right now are fusion inhibitors, and these seem to show some promise, but here's the deal with these viruses, I'm going to show you, "What is a viruses MO, how does it operate?"

Dr. Frank Esper:  It basically get in, replicate, and get out quickly. Get in, get out, that's what it does. That's why most people are only sick for three days. Most people get sick and get better, but that's the three days is all it needs in order to replicate a whole bunch, and spread to the next person. The problem with medications is that you get sick on the first day, you say, "Well, let's see how it goes." Maybe tomorrow you'll be better, and then that's on day two. Day two, yeah, you're really, really sick, let's go ahead and call your physician. Okay, the physician sees you on late day two, or now I'll see you in the next day on day three. By day three the virus is already out the door, or is on its way down. So it's hard for us to say, "Hey, I'm going to start this medication on day three," when the virus is already leaving to begin with, and so how are you going to show that it's really helped?

Dr. Frank Esper:  Well, most patients get better on their own. That's why we really don't have a lot of good medication options. Now for those children who are really, really sick or have some sort of underlying problem like bone marrow transplantation, or they have a really, really bad immune system, for those patients who are like transplants, we do use the Ribavirin. Because then if you're really, really sick, and they have no immune system, then we got to give them what we've got, and we deal with the side effects as they come.

Cassandra:  Interesting. Is there a vaccine for this?

Dr. Frank Esper:  No vaccines. We do have what's called a prophylaxis, and that is we know what this virus is, we know what it looks like, and we can make a bunch of antibodies to it. So what we do is we have targeted mainly this protein that's called the fusion protein. It's the main protein for the immunologic response against RSV. We can make batches of it, we can make gobs of the stuff, and we find those babies who are most at risk of getting hospitalized. Those are the babies who are born premature, or those are the babies who have heart problems, or underlying lung problems, or neuro problems, or immune problems. And we say, "Okay, hey in the first year of life we're going to give you this medicine during the RSV season." Basically we're pretending to be, we're basically boosting the immune system with all these antibodies, and it really helps prevent hospitalization. It doesn't necessarily prevent disease. They may get a cold from the virus, but they don't get nearly as bad as they would have in those kids who didn't get the immune globulin, and so this is what we have used.

Dr. Frank Esper:  Now unfortunately, it doesn't really work for adults or older kids. We can't give older kids or adults this medication, and it doesn't help once you already have the infection, so it doesn't help from a treatment standpoint. But that's the best thing. There are several vaccines, and we've been trying vaccine, I mean we've known RSV for decades. We actually did have a vaccine, a neutralized vaccine in the 1960s I want to say, and it actually led to worse RSV, believe it or not, the vaccine completely backfired on us, and we had to stop it really quick. Because of that vaccine backfire back in the 60s, we've been extra cautious about getting an RSV vaccine. We had to make sure that it's extremely safe, but we have several in the pipeline right now, and some of them are in basically in the phase, one early phase one trials.

Dr. Frank Esper:  Some of them are actually moving forward, and into in phase twos, and phases threes, and we're going to see where it happens. But that is like the Holy grail of pediatrics is preventing RSV, and if we do get a vaccine, then I certainly know that there are going to be a lot of happy pediatricians out there, because we are dealing with so many babies, and we feel bad for them. They're struggling so much, they're wheezing, they're unhappy, they've got runny noses, they're just miserable. A lot of times they do have to come into the hospital, and so a good vaccine will be a really big boon to pediatrics, and to infant health.

Cassandra:  Fingers crossed for that. The last thing I want to talk about here is prevention. You mentioned you might be feeling under the weather today, and you have children at home. What can adults do to protect their children? What steps can they take? What advice do you have?

Dr. Frank Esper:  The advice to prevent RSV is the same thing that we do for most of these viruses. It really begins in the hands, and the hand washing. The way that this virus goes from person to person, and place to place isn't that you got coughed on by somebody, and then those cough droplets go right into your mouth, or into your nose. Nom usually you cough into your hands, and then your hands go on to something else, and then that something else goes onto somebody else's hands, and then that goes into their mouth. So the best thing to do, to prevent, to basically break that transmission cycle is to wash your hands. Every time you wash your hands you are breaking the cycle. You are preventing any of these viruses who jump onto your hands by washing them. You clean your hands, and so those viruses can't get to you.

Dr. Frank Esper:  But also any viruses that you coughed, maybe got onto your hands from you, you can't spread to anybody else. So washing your hands every time you cough, or every time that you're interacting with individuals, preferably before you interact with them is the best thing that you can do. It's one of the reasons why we always wash our hands before we go to see a patient, and we wash our hands again after we see a patient. Now a lot of kids, and remember this is a baby thing, right? This is a two year old, two year old's can't really wash their hands very well. They don't have the coordination to use soap and water, and to do it for 20 seconds. They don't have the attention span for 20 seconds. What you can do though is the alcohol based rubs, especially for the younger age groups seem to do a lot better.

Dr. Frank Esper:  They understand how to rub this around their hands, and so if you use the alcohol-based rubs for the youngest children, and then for the older children, once they're in preschool they can definitely use either soap, or those alcohol based rubs. That really helps. Talking to preventing also, is not telling people to touch their nose, to rub their eyes, to stick their fingers into their mouths. Again, we're talking about two year olds, they're going to do that anyways. Sometimes they're going to scratch the butt and pick their nose, sometimes at the same time. That's what we call normal two-year-old, but what you can do is again with good hand washing, and trying to educate them, that helps.

Dr. Frank Esper:  Again, RSV, I just want to also make sure that everybody understands. Remember RSV is also an adult problem too, it's an under-recognized adult problem. So when your child who's at two or three years of age, and is home with a runny nose, cough, maybe a little wheezing, who's going to be watching? Most of the parents have to go to work, usually it's the grandparents that sometimes come over and they watch the babies, and so it was very important to make sure that the grandparents know to wash their hands, to wash the baby's hands, to make sure that they don't get the RSV. That can then cause a lot of problems in the adults too.

Cassandra:  Is getting the flu shot part of that?

Dr. Frank Esper:  The flu shot is always a part of every winter season, but it doesn't help against RSV, what it does do is it helps against flu. RSV is like the number two cause of all our respiratory virus problems. The flu is number one, and so we see tens of thousands of deaths each year, and then in this case the flu really, really is a bad problem in adults, especially over the age of 65, but under the age of two also causes really bad infections. So getting the flu shot, if you haven't gotten the flu shot this year, it is absolutely important for you to go ahead and get the flu shot. The flu season isn't over, it goes on until March, early April, so there's always something to do.

Cassandra:  Absolutely. That's great advice. Get your flu shot. Wash your hands.

Dr. Frank Esper:  Yes.

Cassandra:  Awesome.

Dr. Frank Esper:  You're in a good place if you could do both of those, yes.

Cassandra:  Perfect. Well that's all the time we have today. Thank you Dr. Esper for being here.

Dr. Frank Esper:  Happy to be here. Thank you very much.

Cassandra:  To learn more about RSV, and reducing the risk for your child. Visit clevelandclinicchildrens.org. If you want to listen to more Health Essentials Podcast featuring Cleveland Clinic experts, subscribe in iTunes or visit Clevelandclinic.org/hepodcast, and don't forget, follow Cleveland Clinic Children's on Facebook, and then on Twitter at cleclinickids, All one word. Thanks for listening.