New ‘cold’ vaccine is exciting but prevention is still best medicine

IN the last fortnight, radiators have been dusted off, the fans have gone back into storage and I’ve broken out the work jumpers once more. Yes, it’s the start of autumn and, along with the drop in temperatures, it heralds the start of another round of vaccinations.

We’ve become rather familiar with this process in recent years and of course covid, along with flu, will feature heavily in the vaccination schedule for certain patient groups, as well as pneumonia and shingles vaccinations for smaller eligible cohorts.

This year, however, there is a new kid on the block which a select few will be offered and is for something many will not have heard of — the RSV vaccine. RSV stands for respiratory syncytial virus (pronounced “sin-sish-uhl”) and you might be forgiven for thinking this has arrived just as suddenly as covid.

In reality, RSV has been a mainstay in the virus world for a long time and we’ve known about it since 1956, when it was first identified.

It is one of the many viruses that cause the set of symptoms that sit under the umbrella of the common cold, namely runny nose, sneezing, cough and fevers. With the common cold being largely self-limiting and harmless, one might ask why produce a vaccine for it?

I have written before about the difficulty in producing a “cold” vaccine and this is largely because there are so many different ever-changing viruses out there it is almost impossible to encompass them all into one vaccine.

If the common cold was all RSV was responsible for, I suspect a virus would not be on the priority list but it is the risk it poses for vulnerable groups that sets it apart from the rest.

RSV infection can cause quite serious complications and longer-term damage in more elderly groups, particularly those above the age of 75. But its main claim to fame is its ability to cause the condition known as bronchiolitis.

Bronchiolitis is an inflammation of the bronchioles, the smaller airways buried deep in the lungs, distinct from the bronchi which are higher up in the respiratory tract. When the bronchioles become inflamed, they produce more mucus and leave a narrower space through which air can travel.

In an older individual, this problem probably won’t manifest due to the more developed lung but the danger here lies in the less well-developed airways in babies and young infants.

Come October, GPs and more specifically paediatricians can be almost certain of a sudden influx of babies and young infants with symptoms of bronchiolitis.

On average in the UK there are more than 29,000 hospital admissions due to bronchiolitis and sadly about 80 deaths each season, which tends to run from October to March. GPs see an estimated 450,000 cases each year.

As the statistics show, the majority of cases do not require further escalation and constitute what would be a mild case consisting of runny nose and cough. Indeed, it is highly likely that a baby will develop RSV infection within their first two years — more than 80 per cent will do so before their second birthday — and that they will be absolutely fine.

But, in a minority of cases, it can develop into a more serious infection and it tends to be babies below the age of six months who are most at risk. During a bad case, the capacity of the lungs to exchange air is diminished and so as much room to expand as possible is needed.

The problem arises when the little stomachs nestled just below the lungs fill up with food and milk and restrict that expansion, whereupon one of two things happens. Either the baby has to breathe faster to get the same amount of air in, which can potentially tire them out fast, or they stop feeding, leading to dehydration. That is where it is important to get the baby checked and monitored in hospital to give them access to oxygen and fluids while the infection passes.

There is no specific treatment so it is this supportive approach that is needed but it really is a big issue. Paediatric wards during these months are invariably full and the vast majority of cases are due to bronchiolitis.

Although not all cases of bronchiolitis are caused by RSV, a significant proportion are and that is why a vaccine is quite an exciting prospect.

While babies themselves can’t be vaccinated directly, their mothers can and so, alongside a small cohort of patients between the ages of 75 and 79, pregnant women after the 28-week mark will be offered the vaccine in the hope that it can significantly reduce the number of severe cases of RSV bronchiolitis as well as complications in the more elderly population.

It will be interesting to see what impact the vaccine has on cases.

Of course, it doesn’t mean that we shouldn’t be trying to avoid RSV infections by other means, namely hygiene measures, in the meantime. It spreads by droplets in the air as well as contact with secretions from coughs and sneezes and can live on a surface or object for around four to seven hours, which explains why it spreads so easily.

Make sure hand washing is part of your routine and that you cover your mouth when you sneeze or cough, if you have a cold. It is not usual practice to test for RSV in the community, so if you have any sort of cold it is good practice to stay away from very young babies. Coronaviruses and rhinoviruses are a little more common but there is still a decent chance you may pass on RSV.

If a baby or young infant develops a cough and runny nose, as long as they are breathing okay and feeding normally, you can just monitor them. If, however, they seem as if they are breathing faster than normal, not feeding as much as they normally would, not producing wet nappies (a sign of dehydration), are less responsive or their breathing is audibly noisy, they need a check with a doctor.

A good way to see if they are struggling with their breathing is if you can see them sucking in their belly beneath their ribs with each breath, or if you can see the chest drawing in between each rib.

You also may see a sucking in at the bottom of their neck in the gap just above the breast bone (tracheal tug). If this is happening, they definitely need a check. Likewise, if a baby under three months develops a temperature of 38C or more or a baby over six months develops a temperature of 39C or more.

If they are struggling to get fluids on board, often it is worth trying to give them small amounts really frequently, even using a syringe if needed so they are getting enough fluid until things pass. Typically, bronchiolitis peaks at around five days after which it should start to improve.

Far from being just another vaccine therefore, the RSV programme is a good example of targeted vaccination that has taken years of hard work to develop. Time will tell how it impacts on hospitals and mortality rates but there is hope that it could make a big difference.