Respiratory Viruses in Winter 2023-2024: Influenza Update
In this video roundtable episode, Jaspal Singh, MD, MHA, MHS, interviews Lisa Davidson, MD, Katie Passaretti, MD, and Amina Ahmed, MD, about influenza vaccine uptake and efficacy, diagnostic stewardship and insurance coverage, the impact of influenza in pediatrics, preventing respiratory virus co-infection, and more. This is part three of a three-part series on respiratory viruses in winter 2023 to 2024.
For more influenza content, visit the disease state hub.
Watch part one of the three-part series on respiratory viruses in winter 2023 to 2024 here.
Watch part two of the three-part series on respiratory viruses in winter 2023 to 2024 here.
TRANSCRIPTION:
Jaspal Singh:
Hello everyone. I'm your host, Jaspal Singh, on Consultant 360. On this episode, this is part three of our three-part series about respiratory infections in the winter of 2023/2024. And with us today, again, our previous guests, Dr Lisa Davidson, Dr Katie Passaretti, and Dr Amina Ahmed. Thank you so much the three of you again for taking your time and joining us today. Obviously, it's great to have you again. If you don't mind introducing yourselves to our audience, please. Dr Davidson, we'll start with you.
Lisa Davidson:
Hi, I am Dr Lisa Davidson. I'm the Medical Director for our Antimicrobial Stewardship Network in Atrium Health. I'm also the Chief Quality Officer for Adult Medical Specialties in the Greater Charlotte market, and I'm a clinical associate professor in the Wake Forest School of Medicine.
Jaspal Singh:
Great. Dr Passaretti?
Katie Passaretti:
Hey, Katie Passaretti, I'm Vice President and Chief Epidemiologist for Atrium Health and a clinical professor in infectious diseases for Wake Forest School of Medicine.
Jaspal Singh:
And Dr Ahmed.
Amina Ahmed:
Hi, I'm Amina Ahmed, I'm the medical director for pediatric infectious disease and immunology, a hospital epidemiologist for Levine Children's Hospital, and a clinical professor at Wake Forest University.
Jaspal Singh:
Well, it's great to have you, all three of you actually, in terms of walking us through, and for those who don't know, the first part of this webcast series, if you weren't with us, we were talking about the RSV, or respiratory syncytial virus. Part two was about COVID-19 updates. And then this is the third part we're going to talk about influenza, the third part of the triple threat for this winter, maybe for every winter moving forward, maybe who knows how this looks moving forward?
Lisa, I'll start with you. Influenza obviously gets the least attention of the three now it seems like, but it's just as serious, just as deadly. Talk to us about this season's flu if you don't mind.
Lisa Davidson:
Yeah, so this season's flu is just... We're getting the results of the flu season from the Southern Hemisphere. It was a moderate flu season from the data that we've seen there. So not one of the worst, but not small. The flu vaccine estimates were about 50% effective, so for a flu vaccine, that's actually pretty good. Last year we had more flu than in the past, but we saw less COVID-19, but we had a lot of RSV, so we'll have to see what this year is going to look like. TBD, I guess.
Jaspal Singh:
No, that makes sense. And you said 50% effective, you said that's relatively good though, right?
Lisa Davidson:
Yeah.
Jaspal Singh:
What's normal? What's a good-
Lisa Davidson:
That's a pretty good one. We usually aim for a 50% efficacy in our vaccines. When we get to over 60%, that's considered extremely effective. We don't want to see something in the 30% to 40% range, but that has happened in some years. So it seems like this year will be a good year. Again, what that means is if you take the vaccine, there's a better than 50% chance that it's going to be effective in decreasing your symptoms, decreasing your rate of hospitalization, and particularly in high risk populations, decreasing risk of death.
Jaspal Singh:
That's very helpful. Katie, anything to add to that?
Katie Passaretti:
No. I think it's hard to predict what we're going to see in the Northern Hemisphere this year. The Southern Hemisphere was a mixed bag. Last year's flu season was really early, and in the Southern Hemisphere, some got hit early, and some got hit in the normal time. As Lisa said, not overwhelming numbers, but certainly more than we've seen at the height of COVID. So it's a little bit hard to predict. I would predict at the minimum we'll see a middle-of-the-road flu season, with some impact on our hospitals, and high-risk patients. And again, layering on those protective steps to prevent co-infection with respiratory viruses, and using vaccines we have available to help keep people out of the hospital is going to be super important.
Jaspal Singh:
Yeah. That's very helpful. Amina, pediatrics, talk to us a little about influenza here in the peds population.
Amina Ahmed:
Yeah, so let me take you guys back to pre covid days. Influenza used to hit school-age children, right? And it was the school-age children that were at the epicenter of the influenza epidemic. Every year you wanted to make sure you were vaccinated if you were around that age. And then COVID came and we're like, "Ah, COVID doesn't affect kids", but they were actually stealth transmitters of that infection, and silent transmitters definitely. So I think it's important to remember that it does impact school-age kids and it will return back to normal.
Like Katie was talking about, last year was just a bizarre year. We knew what had happened in Australia, so we knew it was going to be a bad influenza year for us, and it hit everybody, not just kids. But I think we're coming back to the pre-COVID days, and it's important to remember that the epicenter of that is really still kids. It's not as young as with RSV, but those school-aged kids will get you every time, so get vaccinated if you're around them.
Jaspal Singh:
Right. It sounds like you're pretty confident about this year's vaccine overall being relatively effective, a fairly effective vaccine overall, and that basically we just encourage our patients who are obviously, besides true allergies, to get vaccinated if at all possible.
But I'm thinking back to my job and thinking about our listeners a little bit, and patients come in and they have respiratory symptoms. We've talked about RSV, we've talked about COVID-19, and now we've talked about influenza. How do I know what they have? What do I tell them? How aggressive of a testing strategy do I employ? Obviously, I'm a pulmonologist and I do a lot of bronchoscopies, so I'm not going to go bronch all these patients. So walk me through. Lisa, start with you, talk to us about diagnostic testing in this population, and try to sort through this.
Lisa Davidson:
Yeah, so it's both more complex but also more options for testing. I think the first thing you have to think about is who you're testing. Is this a teenager? Is this an older person? Is this a child? Because even to date, some of the testing that we have available at home or in our ambulatory practices is only approved for certain populations. For instance, our clinic RSV tests are really only CLIA-approved in pediatric patients and not adult patients. So you have to be a little thoughtful about what you're going to offer.
Jaspal Singh:
And CLIA approved, for our audience, is for the laboratory, right?
Lisa Davidson:
Correct. Yeah, exactly. The next thing is what I always think about in my diagnostic stewardship, is this a bacterial versus a viral infection? And if it's a viral infection, will a diagnostic test make a difference in treatment? So if you're a young healthy person with no risk factors and you have flu-like symptoms, which could be a cough, or a sore throat, or a headache, or body aches, very difficult to tell, could it be COVID, RSV, or the flu? If I do a test, is that going to make a difference? Probably not in a healthy person. I'm going to advise them to stay home, to mask, to isolate, and to not go to work until they've recovered significantly from their illness.
I think with flu it's particularly tricky because the only outpatient treatment we have is really oseltamivir, which is the most commonly used one, and that's really only effective in the outpatient population in the first 48 hours. So if someone's coming into you on day four or five of symptoms, it's a little too late to treat them for the flu. Now, you may want to treat them for COVID-19 so it may be worth doing a COVID test in the office if they haven't had one at home because there may still be an option for treatment. That all gets a little bit different if it's a highly immunocompromised population, of course. Then you would really want to think about doing tests in the office. Typically, the PCR tests that we have in the office, or the rapid antigen tests we have in the office would be for flu, COVID, and in some offices RSV, and potentially obviously strep.
So you're going to have to think about who the patient is, you're going to have to think about their risk factors. And lastly, this year we're going to have to think about insurance coverage, because some of the tests that were covered before, particularly the more rapid PCR or NAAT tests that we did for COVID-19, are no longer going to be free because the government's not paying for them anymore.
So what I always like to say is, when it's January and all the patients whose high deductible plans roll over again, and someone comes into the office and is like, "I want to be tested for everything", that's great, but you may need to let them know that they could receive a very significant bill for all that testing.
Jaspal Singh:
Holy cow. My head is spinning just thinking about this. I'm just thinking about it, I work in a pulmonary clinic, and I can't imagine urgent care, emergency rooms, offices of many clinicians, adult and pediatrics, just respiratory infections in the wintertime, and patients not only coming for potential testing, potential treatment, they used to want antibiotics, but we tell them it's probably a viral thing, and now we're walking through this whole aspect of, "Well, you might also now, by the way, in your informed decision-making, you might get this massive bill if we start to figure out what this is about." That sounds like a lot of work. Katie, walk me through how to sensibly talk to my patients about this.
Katie Passaretti:
Yeah, I do think, coming back to what Lisa started out with, does the result of a test mean that I'm going to do something different for you as a provider? Lots of people want tests, they want antibiotics, they want antivirals. That's not necessarily what's recommended, or what will actually do any good. So if you're not in the right timeframe, if it's too late on in symptom onset if you're not someone that would have an indication for treatment, we really have to get in the habit of thinking through using those tests where we'll actually make use of the information, rather than making people, just here's a test result to give you a diagnosis, I would say.
The other thing related to testing I just want to hit on, specifically for antigen tests, that are the rapid tests people use out in the community. Just publicizing every household can get another round of four tests for free, so use the resources we have out there that are at no cost to us, and ensure that you know your patients know what's available.
Then know that no test is perfect, whether it's those antigen tests or a test that's done in a doctor's office or a big lab. If you have symptoms, and especially if you do an antigen test and it's negative, retest yourself, or still stay away from other people. I get a lot of, "Oh, my COVID test was negative so I can go to work as a healthcare worker", and then their COVID test two days later is positive, the test didn't have time to pick up the amount of virus it needs. So know your indications for testing, retest if you still have symptoms, and then what are you going to do with the information, and focus the patient-provider discussion on that. If I get this test result, then I will do X, Y, and Z, and that's the point of doing the test.
Jaspal Singh:
That's great information. It sounds like you're also saying to be cautious regardless of the testing strategy deployed. Just be smart.
Katie Passaretti:
Yeah, I mean, we are horrible, healthcare workers, but just generally, about staying home when we're sick. Unfortunately, that message, which at first during covid people internalized, has now gone away, so we just go about our business. But that's why we continue to see the spread, so we just reinforce erring on the side of staying home if you're sick, and that's actually a protective behavior for those around you.
Jaspal Singh:
Thank you. Amina, anything to add?
Amina Ahmed:
No, I think they covered it all for diagnostic stewardship. For babies, the question comes up about RSV testing all the time, and we have spent years training people not to do the RSV test because it wasn't going to change their management. I mean, most people taking care of babies can recognize RSV clinically, and so it's not going to change your management. There was really no antiviral available for that anymore, so we discouraged it. And I would still say, as Katie and Lisa have pointed out, if it's not going to change what you do, then don't spend the time and effort on the test.
Jaspal Singh:
Yeah, it still seems challenging. I mean, I can imagine a lot of people reading and researching on their own and trying to figure this out, and I'm sure I'll get many times called something about my inadequate research by people who have been reading a little bit about these things. Our audience is people of different disciplines and different backgrounds. A lot of this stuff is changing, we've talked about RSV, we talked about COVID, we talked about flu recommendations. Where do they go to make sure that they're constantly informed, and with good resources, and good information, if you don't mind? Lisa, where do you go? Where do you tell people to go?
Lisa Davidson:
Particularly for COVID-19, I think the number one place that I go to is the NIH guidelines. In most of my conversations now with people nationally, particularly for treatment, the NIH guidelines for treatment, diagnosis, and just general information around COVID-19, I go to the NIH. The Infectious Disease Society also has some good guidelines. And I think, honestly, most hospitals or hospital systems update their guidelines now, so it may differ slightly from hospital to hospital system. Depending on the formulary, and where you are, there are certainly different practices in different areas of the country. But that's probably where I would start with recommendations.
Jaspal Singh:
That's good. So they can be informed. I'm looking at the website right now. It looks pretty comprehensive and pretty easy to navigate, so thank you for that. Dr. Passaretti, where do you go?
Katie Passaretti:
Yeah, I would echo the NIH. As an infection prevention person, the CDC website for isolation, current isolation guidance, and updates. Not the easiest to navigate, and certainly room for improvement, but the information is there. The other thing I would say is to identify your trusted internal resources for this area. Most facility systems have that, and the insiders are more than willing to say... Because policies do vary by facility, at least on the infection prevention side, being aware that it may vary from site to site and talking to those internal people as trusted resources as well would be good.
Jaspal Singh:
That's great. Amina, where do you recommend our audience go?
Amina Ahmed:
Yeah, so definitely NIH, idsociety.org is actually accessible to anyone, you don't have to be a member of the society to get guidelines or get their recommendations, so you can get that pretty much off their website. A website that I thought was very helpful during COVID-19 was the American Academy of Pediatrics. They did a phenomenal job of providing COVID-specific data related to clinical presentation, and vaccination and numbers, and surveillance, et cetera, were always up to date, so I found that very helpful.
For laypersons, I do think, even though the CDC is difficult to navigate, they do a good job of providing plain language information, as opposed to... You can click on the healthcare provider instead if you want more specific information, but they do a pretty good job of getting patient-specific information with lots of nice infographics. As Katie mentioned earlier, that whole campaign about changes, vaccination changes covid from wild to mild, I loved that campaign. So just keep the CDC in mind.
The other place I used a lot was the North Carolina Department of Health and Human Services website.
Jaspal Singh:
That's great. I imagine other audience members in other states probably have a health department that hopefully is consistent with those guidelines and following those recommendations. I think what we did learn from COVID, at least I learned personally, was how important the infrastructure, information that's reliable, and trustworthy is, and when that breaks down, how difficult it can be to sort through, especially for our vulnerable population, or people who are just not informed, or following some other influence that may not be as evidence-based, how dangerous of a strategy that could be for all of us.
Lisa Davidson:
I definitely want to echo Amina's recommendation to look at your state recommendations, because often some of the discussions we get into are, 'Okay, but I work for a state entity", or, "I work for a school system", or, "My organization is following whatever the state recommendations are." Those may have differences between internally what we would recommend, so you may want to familiarize yourself with whatever your state recommendations are or know where to find them at least for those situations.
Jaspal Singh:
That's super helpful. Anything else you all have to add? We've covered a lot of ground. We've covered all the way from RSV to COVID to influenza and then talked about overall issues of information, where to get it, shared decision making, a whole bunch of different things about trying to make sure that hopefully our audience, and listening and thinking about, and they're more equipped now where to go, how to approach these issues going into this winter. Anything, closing remarks of any sort, Katie?
Katie Passaretti:
Yeah, we haven't really touched on the recovery that's needed. So recovery as healthcare workers after the past couple of years, and recovery of trust with the public, and the vaccine issue ticks a lot of those boxes. Because of how the pandemic played out, there's work to do by the scientific community, the infectious disease community, and the public health community, to rebuild the trust and relationships in messages that are given. And that's going to take a while, it's not going to be flip a switch, we're out of COVID and it's all back to... We've regressed very clearly over the past couple of years, generally. And just say, use the tools out there to help along that path to recovery, and just know it's not going to be immediate, but it's worthy work, it's important work for your patients, it's important work for yourself.
Jaspal Singh:
No, that's great. That hits home for a lot of us as well. Lisa, I think you were about to say something.
Lisa Davidson:
Yeah, so we've talked a lot about the outpatient world, but we didn't really talk at all about the inpatient world. One thing I will say that is critical for patients who are being admitted with pneumonia, and I used to say during pneumonia season, but now I think pneumonia season is all year long, what we really need to be better at is ordering appropriate testing on admission. That means whatever your respiratory pathogen panel of choice is, everybody calls it something different, we'll often see patients admitted from the emergency room now with just an influenza and a COVID test, but we really need to have the whole panel to look at all the different respiratory viruses and some of the atypical viruses, almost everybody has one of those panels now. Because you could potentially have a patient admitted on two antibiotics and two antiviral therapies, plus/minus a little steroids if you really don't know what they have. So we really need to make sure that when patients are admitted to the hospital for pneumonia, we're getting the full diagnostic stewardship workup of those patients, so we can quickly de-escalate or appropriately escalate therapy.
Jaspal Singh:
That's a great point. We talked a lot about limiting testing in the outpatient world, but here now we're saying we have a different population, high risk, high acuity, and we have tools now that are fairly rapid, they're less expensive and they're more accessible now to a lot of the population than they were in the past, so let's leverage that technology and find out quickly how we can manage our patients most optimally, who are the most at risk. Is that about right?
Lisa Davidson:
Yeah. Also, for my infection prevention friends on the call, it can really help guide who needs to be isolated, and who does not need to be isolated. It makes a huge difference.
Jaspal Singh:
Right. And for us, selfishly, as a pulmonologist, I don't want to bronch someone I don't need to bronch, or put myself and my staff at risk. When they call three days later, they don't have an etiology, and they could have just gotten it early on. Perfect.
Amina, come to you. What else did we not touch on or other things you want to add?
Amina Ahmed:
I would add that for healthcare providers at least, and Katie touched on this a little bit, it's going to be so important this season to keep the dialogue open in terms of vaccination, whether it's for pregnant women, whether it's for the elderly, whether it's for babies, just because I think people are feeling exhausted and overwhelmed with information, and frankly, a little bit distrustful. Although there's really no reason to be distrustful, just keep the dialogue open. I would encourage healthcare providers to do that.
For the public, I would just remind them, I mean, we've learned a little bit, right? I mean, wear a mask if you're going to be on a crowded plane if you really don't want to end up sick. I've even taught myself to space myself out from people in line. You don't have to be up close and personal with everybody in line ahead of you or behind you. So space yourself out and protect yourself that way, any way you can. It's been great not being sick for three years. Immune debt or no immune debt, I don't think [inaudible 00:21:52] there's an immune debt anymore because we're not masking regularly. But I think it's just common sense at this point.
Jaspal Singh:
I think that's a great thing to add to all of us. I have to say, I learned a lot in this. I live in this space, but I learned quite a bit in this hour of recording. Thank you all for all three segments, part one being the RSV update, part two the COVID update, and then part three the influenza and a whole bunch of sundry topics that we threw into there. That was really, really meaningful and really fun, so we're lucky to have all three of you on today's show.
On behalf of Consultant360, I'm your host, Jaspal Singh. I want to thank our guests, Drs Passaretti, Davidson, and Ahmed for their generous expertise and time.