Patient Populations at Greater Risk of Contracting Respiratory Viruses
Tina Tan, MD; Wendy Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP; Priya Nori, MD; Jacinda Abdul-Mutakabbir, PharmD; and Kevin Michael Reiter, MD, PA, discuss patient populations that are at greater risk of contracting and suffering from complications related to respiratory viruses.
Tina Tan, MD: Hello, and welcome to this ContagionLive® Peer Exchange entitled, “Expert Perspectives on Testing Guidance for SARS-CoV-2, RSV, and Influenza Viruses.” I’m Dr Tina Tan, a professor of pediatrics at the Feinberg School of Medicine of Northwestern University in Chicago, Illinois. I am also a pediatric infectious diseases physician, medical director of the International Patient and Destination Services program, codirector of the Pediatric Travel Medicine Clinic, and medical director of the International Adoptee Clinic at Anne & Robert H. Lurie Children’s Hospital of Chicago. Joining me today are a very esteemed group of my colleagues. The first is Dr Wendy Wright. She is an adult and family medicine nurse practitioner at Wright & Associates Family Healthcare in Bedford, New Hampshire. We have Dr Priya Nori, who is an associate professor of medicine and infectious diseases at the Albert Einstein School of Medicine in the Bronx, New York. We have Jacinda Abdul-Mutakabbir, who is an assistant professor at the Loma Linda School of Pharmacy in Loma Linda, California. Then we have Dr Kevin Michael Reiter, an assistant professor of family medicine at the Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, and associate medical director with Northwell Health GoHealth Urgent Care, in Uniondale, New York.
In today’s discussion, we’re going to be sharing thoughts on the upcoming flu season, the importance of testing early to differentiate between COVID-19 and influenza, and the role of clinicians and pharmacists in early testing and patient education. So welcome, everyone, why don’t we get started? The first question is, we are in the midst of a really marked respiratory viral season, and in your experience, are there populations at greater risk for both contracting and suffering from complications related to respiratory viruses? Why don’t we start with Priya?
Priya Nori, MD: Tina, thank you so much for having us. I would love to kick off the response to that question. I think overwhelmingly, with what we’ve seen with both COVID-19 and now influenza, and of course RSV [respiratory syncytial virus] in pediatrics, I worry the most about the medically infirm, immunocompromised individuals, and of course the elderly, ages 65 and up. For a number of reasons, we’ve seen over and over that this is the most high-risk group. For instance, if we only had so many doses of antiviral medications, if it ever came to that, that would be the group we’d prioritize. And of course, pediatrics, the population that is least likely to have immunological support against these viruses.
Tina Tan, MD: Yes, I completely agree with you there. In pediatrics you’re looking at children under 6 months of age who can’t be immunized and who are going to be at the highest risk. Wendy, do you have some more to add to that?
Wendy Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: I do. As a family NP [nurse practitioner] who sees children from birth to older folks—my oldest patient is 102—I definitely agree with Priya that our elderly are at risk. But I also believe that all patients are vulnerable, and with these viruses, we often can’t predict. We’ve seen with COVID-19 that these folks who are otherwise well end up not doing well with the viruses. So I think we’re all vulnerable, but I agree, it’s the older folks. But it’s also the extreme for all ages. My babies can’t be immunized, so it’s important that we protect those folks around them because they’re truly at risk. We have a lot of patients who are immunocompromised, ie they have cancers, they’re HIV positive, but we also have a significant number of patients who are on biologics, drugs that can make them immunocompromised as well. I guess the last thing I would add is those individuals who have concomitant diseases, conditions like diabetes or COPD [chronic obstructive pulmonary disease], asthma. We know that flu isn’t just a respiratory illness, just like COVID-19, it’s a multisystemic kind of illness. So those are the patients I’m certainly most worried about. But I’ll tell you, these viruses don’t care how old you are, what you look like, and how much money you have in the bank. These viruses have been pretty challenging this year.
Tina Tan, MD: Absolutely. I think RSV is the perfect example. Most of the time you think that the most severe disease occurs in individuals at 2 and 3 months of age, but this year, we’re seeing it in individuals of every single age. And even in the pediatric population, we’re seeing individuals 2, 3, 4 years old who are having severe RSV disease, and they’re totally healthy otherwise, so it’s been a very interesting viral season. Kevin, do you have other things to add?
Kevin Michael Reiter, MD, PA: Yes, I’d like to piggyback off of what Wendy said. I think an important factor is to protect our household members. So protecting those at lower risk is really the best way to protect those at higher risk, especially in the under-6-month population, who cannot receive a flu vaccine. By vaccinating their 3-, 4-, 5-year-old, siblings who are in daycare, prekindergarten, and nursery school, I think it’s really important to protect them.But also unique to my perspective as a family physician, I work in outpatient primary care, I work as a hospital medicine physician, and I oversee a very large Northwell Health GoHealth Urgent Care. So I see patients on varying spectrums of illness and presentations, and I think the one consistent thing is those folks on the hinges, on the low end and the high end, definitely suffer the most, especially those adults with congestive heart failure.
We see a lot of folks who get pushed into congestive heart failure when they become symptomatic with the flu. New onset atrial fibrillation we see a lot of, MIs [myocardial infractions], and coronary disease. We know that the flu vaccine is actually protective against myocardial infarctions in folks who have coronary disease. So there’s a lot to be done and a lot to be said for the folks with chronic conditions, chronic liver disease, chronic kidney disease. These are the folks who need to be the most protected because they are, by far, the most vulnerable, and I think that starts with protecting the younger, healthy folk.
Tina Tan, MD: Agreed. JAM [Jacinda], do you have things to add to this?
Jacinda Abdul-Mutakabbir, PharmD: Yes. Just a small bit, and I love everything that everyone said previously. But I would even state racially and ethnically minoritized individuals are definitely those I would consider to be the most at risk, especially when we think about vaccinations in general. Of course, we know that Black, Hispanic, and Native American individuals lag in terms of vaccination status, not only for COVID-19, but also for influenza. For the last 10 years they have lagged in vaccination rates. With that being said, when we think about immunity and just being protected and those people who will be affected, I’m definitely looking there. But then also when we think about those individuals who have essential working positions, I’m looking there. Where do we think these diseases are transmitted from person to person to person? Well, these individuals are more likely to occupy these positions just due to systemic and structural racism. I definitely want to make sure that we highlight these communities being those at risk, and those children who are racial and ethnic minorities being those that are at risk.
Tina Tan, MD: I think the COVID-19 pandemic really brought out the disparities that exist in all these different populations. I think all of us as health care providers should make a true effort to provide access to the needed, not only vaccines, but health care, as well as the treatments that are available for some of these diseases. I think that’s going to be incredibly important.
Transcript edited for clarity
