RSV and Vaccine Hesitancy: Global Impact of RSV

Podcast Transcript

Respiratory Exchange Podcast Series

Release Date: July 24, 2024

Expiration Date: July 23, 2026

Estimated Time of Completion: 30 minutes

Global Impact of RSV

Maria-Fernanda Bonilla, MD

Description

Welcome to a special series by the Respiratory Exchange Addressing the Impact of RSV and Vaccine Hesitancy. In this series, we explore the efficacy of RSV vaccines and discuss preventive strategies aimed at reducing the occurrence of severe RSV respiratory illness in infants, children, and older adults.

In this episode Dr. Fernanda Bonilla will discuss the Global Impact of RSV including the health implications, the challenges and opportunities in vaccinology, and the importance of collaboration in healthcare worldwide.

Learning Objectives

• Explain the global burden of RSV disease, particularly among vulnerable populations.
• Evaluate the challenges of RSV vaccine rollout and the impact of related public health interventions.
• Analyze the role of global collaboration in addressing disparities in access to RSV vaccine and achieving health equity.

Target Audience

Geriatricians, infection disease physicians, intensivists, nurse practitioners, nurses, obstetricians/gynecologists, pediatricians, pharmacists, physician assistants, primary care physicians, pulmonologists, and other prescribing and non-prescribing providers.

Accreditation

In support of improving patient care, Cleveland Clinic Center for Continuing Education is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Credit Designation

• American Medical Association (AMA)

Cleveland Clinic Center for Continuing Education designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Participants claiming CME credit from this activity may submit the credit hours to the American Osteopathic Association for Category 2 credit.

• American Nurses Credentialing Center (ANCC)

Cleveland Clinic Center for Continuing Education designates this enduring material for a maximum of 0.50 ANCC contact hours.

• American Academy of PAs (AAPA)

Cleveland Clinic Center for Continuing Education has been authorized by the American Academy of PAs (AAPA) to award AAPA Category 1 CME credit for activities planned in accordance with AAPA CME Criteria. This activity is designated for 0.50 AAPA Category 1 CME credits. PAs should only claim credit commensurate with the extent of their participation.

• Accreditation Council of Pharmacy Education (ACPE)

Cleveland Clinic Center for Continuing Education designates this knowledge-based activity for a maximum of 0.50 hours. Credit will be provided to NABP CPE Monitor within 60 days after the activity completion. Universal Activity Number List:

- Pharmacist UAN: JA0000192-0000-24-527-H06-P

• Certificate of Participation

A certificate of participation will be provided to other health care professionals for requesting credits in accordance with their professional boards and/or associations.

Cleveland Clinic Planning Committee for Addressing the Impact of RSV and Vaccine Hesitancy Series

Cecile Foshee, PhD
Co-Activity Director
Director, Office of Interprofessional Learning

Steven Gordon, MD
Co-Activity Director
Chairman, Infectious Disease Department

Kaitlyn Rivard, PharmD
Co-Activity Director
Department of Pharmacy

Nichole Brown, MSN, RN, CHSE-A, PhD(c )
Nursing Institute

Neal Chaisson, MD
Department of Critical Care Medicine
Department of Pulmonary Medicine

Frank Esper, MD
Pediatric Infectious Disease
Cleveland Clinic Children’s Hospital

Debra Kangisser, PA-C
Director of Education
Physician Assistant Services

Aanchal Kapoor, MD, Med
Department of Critical Care Medicine
Department of Pulmonary Medicine

Steven Kawczak, PhD, CHCP, FACEHP
Co-Medical Director, Center for Continuing Education

Neil Mehta, MBBS, MS
Center for Technology-Enhanced
Knowledge and Instruction
Associate Dean of Curricular Affairs, Cleveland Clinic Lerner College of Medicine

Anne Vanderbilt, APRN
Senior Director, Advance Nursing Practices
Center for Geriatric Medicine

Hannah Wang, MD
Director, Molecular Microbiology & Virology

Faculty

Maria-Fernanda Bonilla, MD
Infectious Disease
Cleveland Clinic Abu Dhabi

Host

Steven Gordon, MD
Cleveland Clinic Chairman of Infectious Disease Department

Agenda

Global Impact of RSV

Maria-Fernanda Bonilla, MD

Disclosures

In accordance with the Standards for Integrity and Independence issued by the Accreditation Council for Continuing Medical Education (ACCME), The Cleveland Clinic Center for Continuing Education mitigates all relevant conflicts of interest to ensure CME activities are free of commercial bias.

The following faculty have indicated that they may have a relationship, which in the context of their presentation(s), could be perceived as a potential conflict of interest:

The following faculty have indicated they have no relationship which, in the context of their presentation(s), could be perceived as a potential conflict of interest: Maria-Fernanda Bonilla, MD, Nichole Brown, MSN, BSN, Cecile M Foshee, PhD, Steven Mark Gordon, MD, Debra Kangisser, PA-C, Aanchal Kapoor, MD, Steven Kawczak, PhD, Neil Mehta, MD, and Anne Vanderbilt, APRN.

CME Disclaimer

The information in this educational activity is provided for general medical education purposes only and is not meant to substitute for the independent medical judgment of a physician relative to diagnostic and treatment options of a specific patient's medical condition. The viewpoints expressed in this CME activity are those of the authors/faculty. They do not represent an endorsement by The Cleveland Clinic Foundation. In no event will The Cleveland Clinic Foundation be liable for any decision made or action taken in reliance upon the information provided through this CME activity.

HOW TO OBTAIN AMA PRA Category 1 Credits™, ANCC, AAPA, ACPE Contact Hours, OR CERTIFICATE OF PARTICIPATION:

Go to: http://cce.ccf.org/ccecme/process?site_code=main&activity_session_code=EHCE05707

to log into myCME and begin the activity evaluation and print your certificate. If you need assistance, contact the CME office at myCME@ccf.org

Acknowledgement:

The Cleveland Clinic Center for Continuing Education acknowledges an educational grant for support of this activity from ModernaTX, Inc.

Copyright © 2024 The Cleveland Clinic Foundation. All Rights Reserved.

PODCAST TRANSCRIPT

Dr. Raed Dweik:

Hello and welcome to the Respiratory Exchange Podcast. I'm Raed Dweik, Chairman of the Respiratory Institute at Cleveland Clinic. This podcast series of short, digestible episodes is intended for health care providers and covers topics related to respiratory health and disease. My colleagues and I will be interviewing experts about timely and timeless topics in the areas of pulmonary, critical care, sleep, infectious disease, and related disciplines. We will share information that will help you take better care of your patients today, as well as the patients of tomorrow. I hope you enjoy today's episode.

Dr. Steven Gordon:

Welcome, everyone. My name is Steve Gordon. I'm Chairman of the Department of the Infectious Disease, and this is our ongoing series on vaccinology with a focus on RSV vaccine. Today's topic is going to focus on global health. We have a wonderful guest, a friend and colleague of mine, Dr. Fernanda Bonilla, who clearly is a global citizen born in Medellin, trained in Ohio, and has been in Abu Dhabi, I think for almost a decade now. And she's going to provide us with a wonderful perspective as we move forward into 2024.

And just to reflect, the COVID pandemic has really underscored the critical role that vaccines can play in global health and disease prevention. Not only protecting individuals from severe disease, but also contributing to the broader goal of achieving some sort of herd immunity to protect society. And I think the emergence of COVID also highlighted the potential for the emergence of maybe even more severe respiratory diseases for the next pandemic as we're now focused on H1N1 and H5N1 in terms of bird flu. But nonetheless, I think that this is a nice opportunity for us to review the state of global vaccinology, some of the challenges and opportunities. And there's no better person that I can think of to discuss that than Dr. Bonilla. And Fernanda, I wonder if you could, as background, give our audience a little bit about you.

Dr. Fernanda Bonilla:

Thank you very much. Thank you for having me. I grew up in Cali, Colombia, and after finishing medical school, moved to the U.S. to pursue residency and fellowship. That was more than 20 years ago. I landed in Cleveland, and during one of my first clinical rotations before residency, I was very fortunate to rotate in the infectious diseases service with Dr. Carlos Isada, one of the best educators and mentors you could ask for. And that's when my passion for infectious diseases started. I was really drawn by the high standards and the diversity I found at the Cleveland Clinic, and I stayed there for several years until moving to Abu Dhabi. Almost a decade ago, it's going to be 10 years in August, yes. I moved here with my family, and it's been a fascinating journey to be able to build a Greenfield Hospital as an extension of the Cleveland Clinic model of care.

We are providing the best healthcare in the region, so patients don't need to travel abroad for treatment. And we are a quaternary hospital with about 400 beds, 84 of those ICU beds. We are the Center of excellence for cardiac, stroke, and neurological care. In the city we are doing multi-organ transplants. And most recently, we have a brand new cancer center. So, it's been fascinating to live in the UAE, which is a melting pot. And I have enjoyed the experience of living abroad in this region of the world, yes.

Dr. Steven Gordon:

Well, thank you for sharing that. It's been truly amazing to watch your personal identity formation in your career development. I want to now reflect back when we talk about vaccination for respiratory viruses, one of the most important interventions is obviously prevention of infection diseases, influenza. Everyone is used to that, right? greater than six months of age, universal recommendation here in the States. As we approach now 2024, we have some new armamentarium in the focus, a new focus on prevention of RSV with two new vaccines. And I'm wondering if you can just give the audience a little background on the burden of disease in RSV, especially in certain populations.

Dr. Fernanda Bonilla:

So, yes you are correct. We are very used to influenza in the seasonal outbreaks and having the vaccines every year, and especially in the health care systems. I think all health care workers are very aware of that, but RSV is a pervasive pathogen that also causes respiratory infections across all age groups and across the world. Because today's world is a global village. So, we have more than 1.8 million airline passengers crossing international borders daily, and that's creating routes where infections can spread around the world within hours as we saw it firsthand with COVID-19.

I think what contributes to a higher burden of infections in general and respiratory infections in low and middle-income countries are the variables that we all know: poverty, limited access to health care, inadequate sanitation, and poor hygiene practices. But there are additional factors such as migration and overcrowding that really contribute to these disparities in the world and the spread of infectious diseases. As we have learned in prior episodes of these podcasts, the burden of RSV is most profound in infants, young children, older adults, and those immunocompromised and with several comorbidities. And although RSV is the third viral cause of hospital admissions among respiratory viruses in people older than 60 in the U.S.  It is associated with more severe diseases than COVID and flu. So, this is very important. We have a lower incidence, but worsening morbidity and mortality, and we see that around the world. And now many Western countries have included detection of RSV as part of their surveillance system. So, we know that globally around 64 million infections happen annually and about half of those, 33 million, in children younger than five years, with over 100,000 deaths.

As for low and middle-income countries, unfortunately, the information we have is scarce because many don't have surveillance networks, but it is estimated that 99% of those kids who die from RSV every year in the world are from these developing countries. Another important point is that 80% of those young children who are hospitalized have no underlying medical conditions, they are all healthy. So, this is important for parents to know.

In comparison, I found a multi-center prospective study in Europe following more than 9,000 infants for a year, and they found that the incidence of admissions was only 1.8%, 145 kids were admitted to the hospital, and from those, 5% were admitted to the ICU. We are talking about single digits. So, it is clear that in low- and middle-income countries, young children are disproportionately affected by respiratory syncytial virus.

Dr. Steven Gordon:

Thank you for that overview. As we talk about low and middle income, it's clear to us that global immunization programs have made significant progress in reducing the burden of vaccine preventable diseases. But there are still many gaps, as you're pointing out, that may hinder treatment effectiveness. Some of these, obviously, access and equity, supply chain, systems. I'm wondering if you can speak, how you see that the RSV program could be rolled out, when there's so many other competing needs in targeting those population as you mentioned. Those at highest risk, including obviously the pregnant women, as well as the elderly with underlying respiratory conditions.

Dr. Fernanda Bonilla:

Okay. Yes. Public health interventions here are key. Diverse approaches to managing RSV and similar viruses around the world stem from cultural, medical, and socioeconomic factors. For example, preventive measures such as healthcare maintenance visits and vaccines may be common in some countries but challenging in others. Why? Because those regular checkups and preventive care visits, when we discuss vaccines, are not really covered by your health insurance in some countries or are just not part of the regular care in some areas of the world. Of course, socioeconomic status also plays a role in this disparity, even within the same country.

Health literacy is another key factor, and it's very important, especially now in the digital era, when we are just a click away to access everything, trying to fill this gap in that aspect. But the problem is that you have access to a lot, and hopefully your health care provider is going to be there to clarify everything. In terms of these, there are several studies on surveys done to understand the factors that could inform decision making on uptake on vaccines and monoclonal antibodies. And most of them in the low and middle-income countries have similar findings of low RSV awareness, and therefore the management not being prioritized. So, for example, not knowing what RSV is and attributing it to drinking cold things, being exposed to cold weather is something very common in some countries. But usually, their key questions are going to be related to vaccine safety and, more specifically, side effects. So that's when we, as healthcare providers, can significantly make an impact.

It's important to remember that vaccines do not save lives, but it's vaccination that does it, and that's why education is key. Now, the three key interventions that I see with this, especially with these new pharmacologic tools, are vaccine campaigns, hygiene education and surveillance programs. In terms of vaccine campaigns and outreach programs to do them before the availability of vaccines and at the beginning of the season or the peak of cases. Targeting these high-risk populations and remembering that vaccine not only protects the one that got the shot, but also contributes to herd immunity, reducing the overall transmission of respiratory syncytial virus within the household and the community.

In Abu Dhabi, we just got the RSV vaccine, so our N is very low. It's probably in the single digits now. But we have had very strong vaccine campaigns to educate the health providers for several months now.

The second intervention is hygiene education on preventive measures such as handwashing, cough etiquette, and avoiding contact with a sick person. I find very interesting the cough etiquette because it must be something common in some countries, but not everywhere. So, I read a study from one of the countries in the Indian subcontinent looking at community perceptions of respiratory infections. And the concerns are again being hot or cold. And yes, the person-to-person transmission is known, but the methods to prevent that like cough etiquette and handwashing felt, to some, as not really feasible or practical.

And the third one is surveillance programs and early detection of outbreaks. In the UAE we are very fortunate to have a robust health care regulatory entity doing very strong surveillance and on top of vaccine uptake and everything else. And this worked very well during the pandemic, reaching one of the highest vaccine uptakes in the world.

Dr. Steven Gordon:

I like how you frame that as a multimodal approach in something relatively new, but maybe something old. I wondered if you can comment, Fernanda, one of the things we appreciated probably more than I did before the pandemic was vaccine hesitancy and the importance of messaging. And we ran into, I would say, a lot of challenges. You know me as an old clinician, a lot of things were kind of turned upside down and I've changed my approach. Motivational interviewing, more of a curiosity in terms of why people feel strongly about such things. And again, trying to get a yes by trying to find some type of understanding in terms of why certain patients might be hesitant. And I wonder if you can explain maybe some things that you witnessed, culturally in the Middle East. But also, some of your techniques as we approach education but also messaging to our patients who have to make the decision to receive or not to receive the vaccine.

Dr. Fernanda Bonilla:

The patient may put different values in terms of gender to the doctor. So, in the past, male patient would not show weakness and would not be so confident to a female doctor like me because that's what they are culturally used to do. Same as with a female patient. It may not look at male doctor on their eyes just because, culturally, it is not what they are used to do. But in this digital era, when we, our patients, have the world at their tips in their mobile phones, things have changed significantly. The UAE is also a melting pot. So, we have around 10 million people, but about 8 million are expats like me living here. So, we are in contact with many different cultures and the exposure that we get with these cities being a hub for the world has been significant and has changed everything significantly. In general, they tend to listen to the doctor and accept their advice more as advice well-meant with, of course, all the background that they have read in Google, and they have in their digital devices.

But in general, and we saw it with the COVID-19, we do see that they are very accepting of vaccines as well, because in the past they experienced many diseases that were prevented by vaccines. So, I find that a little bit different here, I would say. Something that I also tend to do is to discuss with them several things at the time I have read about and sandwich them in between several recommendations. So when I talk to my patients about continuing the antibiotics for chronic suppression, I also talk to them about preventing other diseases like today you are probably a great candidate for the pneumococcal vaccine and the RSV vaccine because of your comorbidities and also discuss something else that I need to discuss during that visit, making it something not difficult to discuss if they want to ask me any questions.

Dr. Steven Gordon:

No, thank you for that. I appreciate those techniques. It's interesting, Fernanda, I think messaging becomes important where people get their information. I know that that was a struggle here in the States. Sometimes we approached patients with Kaplan-Meier curve or data. And some of the more effectives were probably in a TikTok format and getting patients meeting where they are. I think some of the examples I point out now is CDC's campaign going from wild to mild.

So, I think that was very effective. Now, it's not that you're going to prevent infection, but there's a good chance the vaccine can mitigate disease so that you still might get infected, but you're not going to get a severe disease. And I think there was a lot of confusion, especially with SARS-CoV 2. People getting positive tests and say, "I got the vaccine. I got a positive test. The vaccine doesn't work." Where again, I think some of the focus for the respiratory vaccines is really going from wild to mild. I don't know whether you experience some of the same situations in trying to get, how can we say, influencers. I think physicians here are still viewed as a trusted messenger, but the problem is, of course, many people in America don't have a primary care physician.

The other thing that was notable to me is that 15% of people still don't want to get any shot because of the needle. And so different ways of vaccine delivery. So, I think we're learning a lot, but I'm just wondering as in reflection in terms of whether you witness some of those same things practicing in Dubai.

Dr. Fernanda Bonilla:

Yes, of course we do. The COVID-19 pandemic was a great example of how the learning curve had to increase significantly because at that point, the knowledge on respiratory viruses was very simple, I would say. Not the top priority of everyone. So it was, I agree, very confusing to hear that a vaccine would prevent an infection when it really didn't prevent the infection. But what we were trying to do was to mitigate the adverse events of an illness.

And I think the message is more clear this time because the studies on RSV vaccines were specifically directed against mitigating the effects of and the severe illness, morbidity and mortality from this infection. So, they never look at preventing infection as such but targeting those vulnerable populations such as older patients with an immunocompromised condition or with several comorbidities and also the parents and the mothers’ expecting babies. Targeting those groups, they focus on severe illness, morbidity, and mortality. So, I think that is more of a common knowledge and that is more clear for the general community.

Dr. Steven Gordon:

I completely agree. I know you as a parent, me as a parent, now as a grandparent, we're remembering our kids with the croup sometimes having to be hospitalized. There's nothing more heart wrenching than to see a vulnerable one- or two-year-old, obviously in the hospital with a respiratory illness that potentially now can be vaccine preventable. And I think that's a strong message. And the data, it's interesting to hear, is the uptake for women in pregnancy has been very robust. And I think the messaging is very clear there in terms of what most mothers will do anything to prevent harm for their children. I think that's being reflected in some of the data that we see here in the States as we've rolled out that first year of the RSV vaccines. And I anticipate you'll see the same globally as well.

If we can pivot now in terms of public health, intervention. You mentioned collaboration. I think it's clear that you cannot have a fortress America. That is to say, you cannot keep these respiratory viruses out of your country through immigration and things of this nature. You mentioned Abu Dhabi now is one of the world's leading transit points throughout the world in terms of the airlines and things.

So, surveillance detection I think is extremely important. I think some of the exciting things that come out of COVID too is that ongoing surveillance. So, as you know, wastewater surveillance, which I think is also probably going on in Abu Dhabi. Looking at a different way of passive kind of surveillance without depending on patients accessing healthcare to look what's in our wastewater symptoms, whether it's SARS-CoV 2, whether it's polio viruses, whether it's RSV.

So, I think things have become increasingly robust for early detection and then hopefully targeting and then interventions. I wonder if you can comment on how, you see the world continuing to “walk together” in terms of, a collaboration for prevention and for global health, as opposed to more of a nationalistic approach?

Fernanda Bonilla:

Yes, I cannot agree more with you. Absolutely. In terms of global collaboration, for all these reasons that we have mentioned, it is really imperative to address those disparities to promote health equity in the world. We have to work to make RSV vaccines available, affordable, and suitable for use in resource limiting settings. As I told you, it has been several months. It has taken several months for us to get the RSV vaccine. And in general, these vaccines are usually developed in the high-income countries. So, by the time that they get to the low- and middle-income countries, there is usually a gap that, hopefully, we can decrease in the future. Not only on vaccine, but also, we need to work on strengthening the lab infrastructure to make detection and surveillance efforts. As you mentioned, more robust worldwide by investing in portable and easy to use point of care testing. For example, I think the pandemic really helped that aspect because antigens and PCRs are more readily available even in low- and middle-income countries now. But, yes a global collaboration is essentially reducing those disparities for achieving health equity and for mitigating the global impact of respiratory syncytial virus and other respiratory viruses.

Dr. Steven Gordon:

Well, thank you for that perspective. As we conclude, Fernanda, I wonder if you have any concluding thoughts for the audience in terms of your vision for the future and perhaps maybe a recommendation in terms of a book or something that you found particularly of interest or maybe of interest to our listeners?

Dr. Fernanda Bonilla:

So, yes, I would like to highlight the topic of global disparities because it's near and dear to my heart. Because despite the interconnectivity and the global impact of RSV that we know well, those disparities are there and not only in healthcare infrastructure and in resources but also in availability of pharmacologic measures such as vaccine and especially monoclonal antibodies with the new one that is available. So, as we saw it with COVID-19, many countries face significant challenges in accessing vaccines and the limited financial resources, the deficiencies. And also, the competing health care priorities often create difficulties in the distribution of vaccines and pharmacologic therapies.

So, as we have seen, it's only the vulnerable populations in these regions that remain largely unprotected against severe infections. I would like to highlight something that I see in common in several areas of the world, which are the multi-generational households. Where grandparents are living and sometimes even providing care for grandchildren while parents are working, and that puts them at higher risk of getting infected by the children. So that's something also to keep in mind.

In terms of books, what do I have on my night table right now? I have the book by Trevor Noah, which I find very entertaining. And he has a great take on the world, being from Africa. Another great book, that I found very interesting and very helpful when I moved here, it's the culture map. I don't know if you had a chance to read it, but it's been very important, I think. And I learned a lot from it when moving to this area of the world as well.

Dr. Steven Gordon:

Well, I want to thank our guest, Dr. Fernanda Bonilla, for just a wonderful discussion in terms of global challenges and opportunities with the vaccine, with the focus on RSV. Again, my name is Dr. Steven Gordon and I want to thank you all and wish you all a very good day.

Dr. Raed Dweik:

Thank you for listening to this episode of the Respiratory Exchange Podcast. For more stories and information from the Cleveland Clinic Respiratory Institute, you can follow me on Twitter @RaedDweikMD.