There was a time, perhaps a century ago, when the only virus we really worried about was RSV. Children, snot dripping from their noses, would come in coughing, and struggling to breath and, as days grew shorter and nights grew longer we knew that bronchiolitis season was upon us once more.
But things have changed. We worry about a different virus now and there is plenty of evidence to show that the usual seasonal variations in RSV have flattened. It was heartening to see the data showing that the mid-winter peak was no more as we kept ourselves to ourselves. Non-pharmacological interventions – physical distancing, respiratory hygiene and restricted movements – meant that the scourge of the paediatric emergency department was held at bay. Until…
Half a world away…
Bronchiolitis presentations peaks in June – July in Australia (remember it is our winter in the Southern hemisphere). Last season there was a 98% reduction in RSV (and a 99.4% reduction in cases of influenza (Yeoh et al., 2020). But let’s take a look at the surveillance data from Western Australia to see what has been going on of late.
McNab et al. (2021) looked to see what had been going on in Victoria, a state that had much stricter lockdown measures than WA. Whilst there was clear suppression of the winter cases of bronchiolitis, these began to increase by the beginning of the year, coinciding with the return to school after the long Christmas break Normally, in February, the Royal Children’s Hospital would return 5.6% positive RSV swabs. In 2021, they returned 32.8%. More worryingly, this peak is higher than the pre-COVID winter peak (30.4%)
But this snapshot doesn’t give you the whole picture. Let’s just slide the data along a few short weeks…
These data have been echoed all over Australia and New Zealand with a ramping up of out of season RSV positive cases. What is most concerning is that numbers appear to be higher than the usual peak and the patients older (mean 18.2 months compared to 7.3 – 12.5 months). Why could this be? It could be, as Foley et al. (2021) suggests due to an increase in RSV-naïve babies born during that first wave coupled with waning herd immunity.
What does this mean for paediatricians in the Northern hemisphere who are about to face this surge in cases?
Paediatricians at the frontline need to be able to see what is going on and so PERUKI will shortly be launching BronchSTART. The aim of this prospective observational study is to both track the potential surge so that health policy is informed as much as possible but also to describe its epidemiology. As highlighted above the data suggests a potentially wider age range and steeper spike but these are from retrospective studies By reporting potential cases (in children under two years of age) presenting to over 50 Emergency Department across the UK, in real-time, clinicians and researchers will be able to really understand the impact and outcomes of this respiratory disease.
Given the challenges of identifying and managing children who may have RSV, COVID-19, or both, some guidelines have been produced by the RCPCH.
What do the guidelines say?
The RCPCH guidelines focus on THREE key areas:-
- Reducing hospital attendances with mild cases
- Pathways and guidance for testing and cohorting
- Minimising patient time on High flow and reducing the exposures to AGPs
The guidelines are designed to reduce potential unnecessary referrals from primary care to the emergency department. Hopefully, reducing the number of children presenting (and then mixing with each other in the waiting room) will lessen the burden on paediatric emergency departments. It offers a traffic light system for reviewing patients, with suggestions of how to manage some borderline cases in the community with secondary care input.
When it comes to testing, the aim is to be able to minimise the spread of COVID-19 and protect clinically vulnerable children. As with what is happening in most hospitals, the recommendation is to only test patients being admitted to the hospital. Any further testing is then influenced by the patient’s condition and the prevalence of COVID in the hospital, as well as cubicle availability.
Using Point-of-Care-Testing (POCT)/rapid testing for patients going to PICU and HDU may limit cubicle occupancy, and improve cohorting of patients. Additional COVID testing then should be considered in cases where respiratory panels are negative (or suggest low-risk causative organisms such as bocavirus or rhinovirus). Additional testing should also be considered if aerosol-generating procedures (AGPs) are required or parents are displaying symptoms.
Given that AGPs provide a high risk for transmission, the recommendation is for rapid but weaning of high-flow with guidance provided by north and south Thames retrieval service protocol used.
For those of us in clinical practice, the guidelines remain largely unchanged. Non-pharmacological measures- physical distancing, good respiratory hygiene and use of appropriate PPE are key. Cohorting patients into red and blue, hot and cold or low/high-risk zones may add some value unless physical distancing can be maintained.
As case numbers rise, and cubicle capacity becomes an issue then departments need to come up with a risk mitigation strategy to protect the vulnerable.
- Weekly testing for all prolonged stays
- Test if there are new symptoms
- More emphasis on risk assessment for use of RPEs (respiratory protective equipment)
- If single room capacity is exceeded, patient may be risk assessed for cohorting
- If respiratory virus +ve and COVID –ve patients can be cohorted even if requiring an AGP
- We still need to advise those DC’d from CAT/ED with respiratory symptoms of the need for COVID testing via track and trace
- Parents should not be in hospital if symptomatic. Do not test asymptomatic parents
- Support community services to reduce strain on hospital services
- Use testing to help cohort and plan patient care
- Wean or reduce AGPs where safe to do so
Foley, D.A., Yeoh, D.K., Minney-Smith, C.A., Martin, A.C., Mace, A.O., Sikazwe, C.T., Le, H., Levy, A., Moore, H.C. and Blyth, C.C., 2021. The Interseasonal Resurgence of Respiratory Syncytial Virus in Australian Children Following the Reduction of Coronavirus Disease 2019–Related Public Health Measures. Clinical infectious diseases: an official publication of the Infectious Diseases Society of America.
Huang QS, Wood T, Jelley L, et al. Impact of the COVID-19 nonpharmaceutical interventions on influenza and other respiratory viral infections in New Zealand. Nat Commun. 2021;12:1001. https://doi.org/10.1038/s41467-021-21157-9
McNab, S., Do, L.A.H., Clifford, V., Crawford, N.W., Daley, A., Mulholland, K., Cheng, D., South, M., Waller, G., Barr, I. and Wurzel, D., 2021. Changing Epidemiology of Respiratory Syncytial Virus in Australia-delayed re-emergence in Victoria compared to WA/NSW after prolonged lock-down for COVID-19. Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America.
Oh, D.Y., Buda, S., Biere, B., Reiche, J., Schlosser, F., Duwe, S., Wedde, M., von Kleist, M., Mielke, M., Wolff, T. and Dürrwald, R., 2021. Trends in respiratory virus circulation following COVID-19-targeted nonpharmaceutical interventions in Germany, January-September 2020: Analysis of national surveillance data. The Lancet Regional Health-Europe, 6, p.100112.
Public Health England. Weekly national Influenza and COVID19 surveillance report: Week 49 report (up to week 48 data) 3 December 2020. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/940878/Weekly_Flu_and_COVID-19_report_w49.pdf. Accessed July 20, 2021.
Tang, J.W., Bialasiewicz, S., Dwyer, D.E., Dilcher, M., Tellier, R., Taylor, J., Hua, H., Jennings, L., Kok, J., Levy, A. and Smith, D., 2021. Where have all the viruses gone? Disappearance of seasonal respiratory viruses during the COVID-19 pandemic. _Journal of Medical Virology
Waterlow, N.R., Flasche, S., Minter, A. and Eggo, R.M., 2021. Competition between RSV and influenza: Limits of modelling inference from surveillance data. Epidemics, 35, p.100460.
Williams, T.C., Lyttle, M.D., Cunningham, S., Sinha, I., Swann, O.V., Maxwell-Hodkinson, A. and Roland, D., 2021. Study Pre-protocol for “BronchStart-The Impact of the COVID-19 Pandemic on the Timing, Age and Severity of Respiratory Syncytial Virus (RSV) Emergency Presentations; a Multi-Centre Prospective Observational Cohort Study”. Wellcome Open Research, 6(120), p.120.
Yeoh DK, Foley DA, Minney-Smith CA, et al. The impact of COVID-19 public health measures on detections of influenza and respiratory syncytial virus in children during the 2020 Australian winter. Clin Infect Dis 2020.