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Forest W. Arnold, DO, MSc: Hello. I'm Dr Forest Arnold. Welcome to Medscape's InDiscussion series on respiratory syncytial virus (RSV) in adults. Today we'll be discussing RSV in the community setting with Dr Brittanie West. Dr West is a family medicine specialist practicing in West Virginia. Welcome to InDiscussion.
Brittanie N. West, DO: Thank you for having me.
Arnold: Dr West, you are in Bridgeport, West Virginia, a relatively rural setting, and you went to the West Virginia School of Osteopathic Medicine, which U.S. News and World Report ranks as number one in graduates who go on to practice rural family care. Could you describe for us a typical adult patient you see who has RSV?
West: Absolutely. I do live in Bridgeport, West Virginia. We have about 9000 residents, so it's a very small town. This is a conglomerate of my average patient. I have an obese 67-year-old male patient. His past medical history includes chronic obstructive pulmonary disease (COPD), uncontrolled type 2 diabetes, and his last A1c was about 9.5. He has coronary artery disease (CAD), he has had multiple stents in the past, and he has a 20 pack-year smoking history. He's presenting to our outpatient clinic with a 2-day history of fever, productive cough, wheezing, and fatigue. He states his grandchild, whom he lives with, also recently had respiratory infection last week. He's not sure whether the child was tested for RSV, flu, or COVID. As far as the exam goes, his vitals — he's a little tachycardic at 104. His respiratory rate is 16, his temperature is 99. 6 degrees, but he has been medicating with Tylenol and NSAIDs as well. His pulse ox is 88% on room air, and his blood pressure is 150 over 90. On his exam, he has rhonchi and wheezing bilaterally. He also has decreased breath sounds overall. He has regular heart sounds — no S3 or S4. He has no edema in the lower extremities and no jugular venous distension (JVD) as well. The rest of his exam is largely nonfocal. The initial differential of an acute respiratory complaint in this patient, an adult patient with comorbidities, is different than our pediatric counterparts. In the pediatric world, if it coughs like RSV, if it wheezes like RSV, it's RSV or flu or COVID. With our patient, just off his history components, he could have a COPD exacerbation. He could have pneumonia. He could have a viral illness depending on what's circulating in the community like RSV, flu, or COVID.
In our ambulatory setting, we're really lucky to have access to point-of-care ultrasound (POCUS). With that, I can diagnose a little bit more before I send people for further studies. For him, I would do a bedside lung ultrasound in emergency (BLUE) exam or a pulmonary exam. And we know that POCUS is more reliable than our physical exam, particularly in diagnosing pneumonia. What I would be looking for to rule in pneumonia would be B lines, or as I tell my residents, they are bad lines. They mean that there's fluid consolidation, particularly in a focal area. We would also look for consolidations in that area, and that would help rule in pneumonia. And on the flip side, to rule it out, we'd be looking for the absence of that, which would mean that we don't have any fluid consolidation anywhere. That would suggest a COPD exacerbation or viral illness like COVID, flu, or RSV. POCUS, particularly in a rural community, is essential. It helps to prevent delays of care access to imaging or other testing modalities.
Ultimately, our patient here would have to get diagnosed with a reverse transcription-polymerase chain reaction (RT-PCR) for flu, COVID, and RSV plus minus, maybe a complete blood count (CBC). If you have access to chest x-ray, that would be great. [We may do] a comprehensive metabolic panel (CMP). And sometimes we do a procalcitonin if we really think they may be sick with a pneumonia just to turn them out. Given his comorbidities, if all this was negative, we would probably consider an extended respiratory virus panel for him, because he's at risk of getting pretty severe illness.
Arnold: The cause of pneumonia certainly could be RSV. He does have a broad differential. I'm sure RSV doesn't rise to the top, but it's definitely in the differential for somebody like you just described. As you know, last year's RSV season was big news in large cities because that was where pediatric ICUs were filling up. What was it like for the rural physician?
West: I think first we have to dispel the myth that RSV is a pediatric disease. It is absolutely not a pediatric disease. Just like COVID or any other virus, it doesn't really see an age. It doesn't care if you're 8 months or 80 years old. It just wants to replicate and pass on its genetic material. It wants to survive. Each year in adults, we have about 60,000-160,000 hospitalizations. Last year, we were definitely closer to 160,000 hospitalized for RSV. There are somewhere around 6,000-10,000 deaths. Compare that to a pediatric population, they top out at about 80,000 hospitalizations a year and about 100-300 deaths.
For perspective for our listeners, I work in a residency at an inpatient and outpatient basis. Our hospital is about 300 beds, but we have a tertiary care center about 40 minutes up the road. We're the referral center for a lot of critical access hospitals and a lot of lower acuity hospitals.
One of my feeder hospitals has approximately 25 beds. I had our infection control team pull our RSV results over the past couple of seasons. In 2020, our positive RSV swabs that presented through our multitest swab tanks — we had a flu/COVID/RSV tent — was about 245 positive for RSV. In 2022, we had 688 positives. As far as the admissions go, I had them pull that as well. And our admissions are specifically for adults in this data set. We had 86 adult admissions last year compared to about 16 in 2020 during the October through December season. That was still our peak. Ours didn't really shift like the urban areas did, and we were also the overflow hospital for our pediatric tertiary care facility. We are not used to taking care of kids on tiny bilevel-positive airway pressure (BiPAPs). It was a lot for the hospital. Like most rural hospitals, when you have viral pandemics, whether it's flu or COVID or RSV, it really hits our nursing staff hard. Donning and doffing the personal protective equipment (PPE) for that isolation status that they're under for respiratory eats a large chunk of their day, and they already are staffed at a higher acuity. They have more patients per nurse anyways. That's really difficult.
Arnold: Were you also the overflow for adult patients who might have gotten RSV? I'm sure you were for COVID.
West: We retained a lot of our RSV admissions. Our tertiary care hospital stays pretty full, so we're almost always taking care of those. We also had a lot of transfers from the smaller hospitals for RSV care that they were worried may end up in an ICU setting or needed more intensive pulmonary consultation.
Arnold: COVID, as we know, had a high incidence rate. How did that compare to the RSV that you saw last year?
West: We had more RSV last year during the October-December season — we admitted and diagnosed way more people with RSV. We had a couple of co-infections in some of our really sick patients. We would have a flu and RSV, or a COVID and RSV co-infection. Those were tough on those patients, and they almost always got hospitalized. One of our residents got RSV as well, and they had had COVID and RSV. They said RSV was way worse. We re-swabbed them a couple of times because we thought they were co-infected, but they were not. It was just RSV. In a rural community, the effect on the community is just so much more than an urban center. These patients can't afford to be off for the 8 days isolation that you have when you have RSV. I think we all have to take that into consideration as well.
Arnold: You mentioned swabbing, and that's available in the hospital I'm sure. What about as an outpatient? Is that also available?
West: We're really fortunate at our hospital that we have access to a 4-Plex — the RT-PCR for RSV, flu A, flu B, and COVID — inpatient or outpatient. We have access to our extended respiratory panel as well inpatient and outpatient. Some of my feeder hospitals don't always have immediate access to RSV. They do have rapid antigens for flu and for COVID, but getting the 4-Plex is a little bit more difficult at some of our really rural communities that we feed from. I think it's even more important now that we have antivirals for flu and COVID that we do test them for the 4-Plex. My patients are pretty practical. They say, "Doc, if you're just giving me supportive care, I don't really care what I have." They don't want the medical bill for that 4-Plex. If we can make a difference by giving them antivirals, then I think that that makes a big difference.
Arnold: What are some of the challenges you face as a primary care physician in a rural setting in particular?
West: Rural communities, particularly in Appalachia where we both practice, have patients with a lot of comorbid conditions. If you think back to my case, that was my average patient. They have COPD, they have CAD, they're older, they're immunocompromised from one thing or another, typically diabetes, and this places us at a higher burden than our urban counterparts. For example, COPD is highest in Appalachian areas. It's actually, unfortunately, the highest in West Virginia. About 12% of our adult population has COPD. Contrast that with Hawaii, which has the lowest rate at 3%. My patient here in West Virginia who has COPD would be at a lot higher risk than that patient who lives in Honolulu, Hawaii. We have higher incidence of heart disease as well, and we have about 382 deaths per 100,000 residents per year. That places us at a higher risk. We're also older. My state is one of the oldest states — 20% of our patients are over the age of 65. Compare that with other states like Utah, where 11% of their state population is over the age of 65. It also doesn't take into consideration things that are hard to quantify.
As an anecdotal example, in my patient population, I have a lot of multi-generational households — either grandparents living with mom and dad or grandparents providing kinship care for grandchildren. They get placed at high risk of exposure to all viral illnesses, including RSV. They're already the patients who are at the highest risk. The anecdotal things are hard to quantify in numbers, but it does create an issue in rural communities.
Arnold: What about vaccine hesitancy? Is that a factor that you deal with?
West: Vaccine hesitancy below the age of 65 in these communities is a really difficult issue. Above the age of 65 nationally, if you look at the COVID-19 booster data, more than 40% of adults over 65 got the COVID-19 booster compared to about 20% of the population between 18 and 65. In my elderly adults, I think rural communities in that age bracket are more likely to want to protect the other people in their community and be able to help them out when they're in need. I think that plays a role. But under 65, we have a bit of difficulty, and the COVID-19 vaccines also created a little bit of vaccine hesitancy.
West Virginia, as a whole, doesn't have religious exemption for a lot of our school age vaccines. Some patients are a little bit more accepting of all vaccines, because they were vaccinated when they were younger. I think the best thing that we can do in rural communities is to be good advocates for our patients. I'm an early career faculty, going on my fifth year, but I work with doctors who have had this same patient census for 30 years. These patients trust their physician. When they see Dr Hess, who works in my office, and then they've seen Dr Hess for 30 years, and she says, "I think you should get the RSV vaccine," or, "I think you should get the flu vaccine," they trust her. Or, for example, if they go to their local pharmacy, they see the same pharmacist they've seen for 15 years. When they're picking up their Advair inhaler for their COPD, the pharmacist says, "Your niece had RSV last year. We have a vaccine for that now." We know our communities a little bit better, and I think we can advocate and help persuade them. But vaccine hesitancy is always an issue.
Arnold: My experience was that the older patients felt like they were at risk of getting severe infection if they got the infection, and the younger patients felt like they would just get over it. Maybe that fits with what you're saying. It seems like there are risk factors that adults have that make their RSV worse, that they would have severe disease. How do you contrast that with the comorbidities that a younger patient might have?
West: My state is an interesting position in this way. We know COPD, CAD, diabetes, obesity, and smoking all play a role. Unfortunately, in West Virginia and some other rural areas, we have a higher incidence of type 2 diabetes and obesity, even in our adolescent population. One of the biggest issues and biggest thing I'm worried about is vaping. In West Virginia, the legal age to buy an e-cigarette or cigarettes is 18 years old. They did a survey and about 36% of West Virginia high schoolers admit to regularly using e-cigarettes. When they surveyed middle schoolers, it was 17%, which is five times more than the national average. Most of those teens — about 75% of them — said that their first exposure to tobacco products was an e-cigarette. My worry is that they're going to have pre-existing lung injury in that 14-18 age group. In a few years, the ones who are vaping heavily now may have vaping-induced lung injury and get more consequences of diseases like RSV, flu, and COVID in their 20s and 30s. We'll see COPD a little bit younger because of that.
Arnold: In your role as physician in rural America, how far do people travel to see you?
West: I am at a larger hospital. Like I said, I have a lot of feeder hospitals. Some of my patients travel 1.5-2 hours on good days. That's without snow. And those are on back roads, not interstates. I recently did sports physicals in Wetzel County, West Virginia, and their options to send patients are either to me, which is about an hour and 20 minutes away, or 45 minutes north to Wheeling, or 45 minutes down to Parkersburg.
Locally, they don't have a whole lot of access to care when they need to be admitted to a hospital. Rural physicians in West Virginia are in an interesting position. Like I mentioned before, many people who practice in rural environments stay there. We try to get people retained in those communities. People who choose to stay in a rural environment realize that it's not just a job. It's really a lifestyle, and you're taking ownership of that community. As far as things like RSV, flu, and pandemics go, it's our job to take care of those communities.
When I was a resident, I rotated in Big Sky, Montana, at a ski resort. I wanted to see some trauma. I wanted to see ski injuries. I thought that was cool in those days. One of my first jobs when I got there was to do a flu vaccine clinic.
I gave probably 200 flu shots to all these local dude ranches and resorts. I remember asking the physician why he was sending me to do that, and he said that a couple of years before I did the rotation with him, that their entire community was brought down by a huge flu pandemic. They have a four-bed critical access ER, and then they had tertiary care facilities that they had to be either life flighted to or were hours away. He told me that it was his responsibility as a physician in that community to make sure that never happened again. The next year, he went to all the resorts and the dude ranches and offered free vaccine clinics. He got the state to help sponsor that. The cool part was that the employers didn't have to require the vaccines of the employees like we sometimes do. I know our hospital does. Everyone agreed to get vaccinated because they wanted to help protect their coworkers and protect community. The previous experience really affected them.
Arnold: The Advisory Committee on Immunization Practices (ACIP) recently met and recommended the new RSV vaccines for adults greater than 60 or 65 years, depending on the maker of the vaccine. How will that vaccine fit into your practice?
West: We're really excited about this. As I mentioned, my patients have all the risk factors. They are the adults with chronic heart disease and chronic lung disease, and they have weakened immune systems. We have physicians in our area who take care of patients in the long-term care facilities, and I encourage the listeners to go back and listen to the episodes on those to see how that affects the patients in those environments. We know that 94% of people who get hospitalized for RSV have some underlying medical condition, about half of them have at least two or three, and that's my average patient. The Pfizer and GSK vaccines are wonderful, and they've been 50 years in the making. I think patients will uptake them if their providers, the nurses, pharmacists, and respiratory therapists they work with make a strong recommendation to do so. With GSK's vaccine, it reduced the risk of getting RSV by about 83% and severe disease by 94%-95%. Those are really great numbers.
Pfizer's vaccine that doesn't have the adjuvant still had really good numbers. It reduced the risk of getting two or more symptoms by about 66% and three or more by 86%. I think hearing those numbers and giving that data to patients and letting them choose is helpful. I also think we have to look at affordability. Recently, the Inflation Reduction Act got rid of copays for recommended vaccines under Medicare Part D, which is what a lot of these patients are going to be on. So, those patients are getting the vaccines. Regarding cash price, GSK said they're going to price their vaccine somewhere between $200 and $300, and Pfizer said between $180 and$270. For people who don't have Medicare, that might be a limiting factor. I think health systems need to look into how we're going to help with that and what funding we can get to be able to get that vaccine to those patients who fall in between the cracks.
Our practice's position on encouraging vaccination is to make strong recommendations and sandwich them. We do a similar thing with HPV vaccine or other situations when there is poor uptake. We say, "You're due for these vaccines and care today. You're due for your A1C or RSV vaccine. And we're going to order your mammogram today." When you sandwich it in the middle, they tend to have a better uptake. It's also important to be open minded about the fact that people are worried when there are new vaccines and new medical treatments. We need to take the time to talk with them about that.
Arnold: The two vaccines you mentioned from Pfizer and GSK are the two that are FDA approved at this time. They are indicated for the elderly, but the other adults aged 18-60 may be looking to see how they fit in. What can you tell us about pregnant women and the RSV vaccine?
West: They're looking at trying to passively immunize infants via their mothers. We do this already with pertussis, we give tetanus, diphtheria, and pertussis (Tdap) in the second and third trimesters to try to passively immunize infants. We also try to cocoon them, which means everybody in their family gets the vaccine if they aren't up to date, so that we can prevent them from getting pertussis.
A similar thought exists for Pfizer's vaccine. They're looking into the data of giving that to moms in that second and third trimester. The question then becomes, do you give them the vaccination, or do you give the infants Beyfortus (nirsevimab)? It is a huge advance over Synagis (palivizumab), and it's a one-and-done administration of monoclonal antibody to all infants, not just the ones who are at risk for RSV. We know that about 75% of them are healthy babies, they're term babies who had no other issues. I think moms have a good uptake of the vaccine and a good opinion of it. The University of Iowa/RAND and the CDC's values survey surveyed either women who were currently pregnant or had given birth in the last 12 months, and they said that 68% of participants knew what RSV was. They had a baseline knowledge, which is important. Sixty-one percent of participants said they would consider getting the vaccine if their provider recommended that to them. I think that is wonderful. The other patients may just need more education, but it's a great opportunity. I think by the next round of these podcasts, we may know a little bit more about what the ACIP and the CDC have decided on that vaccine for pregnant women.
Arnold: Today we've had Dr West discussing RSV in adults in the rural American setting. Three messages pop out: RSV in adults is a known entity, test for it, and vaccinate for it. Dr West, thank you so much for joining us. This is Dr Forest Arnold for InDiscussion.
Resources
Respiratory Syncytial Virus Infection
The Utility of Point of Care Ultrasonography (POCUS)
Noncardiogenic Pulmonary Edema Imaging
RSV-associated Hospitalization Surveillance Network
Inflation Reduction Act and Medicare
CDC Recommends a Powerful New Tool to Protect Infants From the Leading Cause of Hospitalization
Evidence to Recommendations for Nirsevimab
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Cite this: RSV in Rural Communities: Lessons From Appalachia - Medscape - Sep 07, 2023.
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