An emergency department sign.

RSV’s toll on health services – Expert Reaction

sharp spike in respiratory syncytial virus – a highly-contagious, flu-like illness – is especially affecting kids and babies, and stretching hospital emergency departments.

What are the impacts of this outbreak for New Zealand’s health services now, and how would services cope with a COVID-19 outbreak in the community?

The SMC asked experts to comment on the situation.

Dr Natalie Anderson, Senior Lecturer and Bachelor of Nursing Year 2 Director, School of Nursing, University of Auckland, comments:

“The sharp rise in the number of young children sick with RSV has overwhelmed our Emergency Departments (EDs) this week, with many experiencing a record number of daily presentations. The outbreak is taking a toll on the wellbeing of staff as well as the affected children and whānau. Caring for children and babies with breathing problems due to RSV is challenging, requiring both isolation precautions and close monitoring. Even where sick infants do not need hospitalisation, exhausted and anxious parents need guidance, reassurance, and support. As many nurses have young families or caregiving responsibilities, the RSV outbreak is also exacerbating understaffing.

“ED staff are overwhelmed and experiencing alarming rates of burnout. As highlighted in our recently-published paper, a lack of resources to provide quality patient care is a key barrier to workplace wellbeing for ED staff. Skilled, experienced ED nurses are resigning in record numbers, seeking safer, more-satisfying and better-remunerated roles. Hospitals are now struggling to recruit nurses, with some DHBs reporting hundreds of nursing vacancies.

“Our health system is constantly working at full capacity, with no room for this sort of surge demand. Efficiency may be ideal for an automated factory production line, but the health system depends on humans to provide care to humans. We need to work within a resilient system that allows us safe spaces and adequate time to care. No-one wants distressed children with RSV and their exhausted parents to be cared for on floors or in corridors by overwhelmed staff, but this is the reality in our EDs, right now. Imagine what will happen if we add a COVID-19 community outbreak into this mix.”

Conflict of interest statement: Dr Natalie Anderson is a Senior Lecturer, Emergency Department staff nurse and College of Emergency Nurses New Zealand committee member.

Professor Graham Le Gros, Immunologist, Director (Chief Executive) Malaghan Institute of Medical Research, Programme Director Vaccine Alliance Aotearoa New Zealand – Ohu Kaupare Huaketo (VAANZ), comments:

“The overwhelming effects on New Zealand’s paediatric emergency care from the recent Respiratory Syncytial Virus (RSV) outbreak in New Zealand infants and the elderly is an important ‘wake up call’ of how vulnerable health systems are to serious infectious diseases that get into communities of susceptible people.

“It gives us clear-eyed insight of what a COVID-19 outbreak in the community would look like in New Zealand.

“It is also an important wake-up call that we need to have a vaccine against RSV. There is none available, with the best one currently being trialled here in New Zealand. We need to do everything we can to support safe RSV vaccine development as soon as possible – so that future generations of mums and dads do not have to face the terror of this infection in their little babies.

“RSV is a serious disease that needs to be eliminated from the list of childhood infections that affect our communities.”

Conflict of interest statement: “Professor Le Gros is Programme Director of the Government-funded Vaccine Alliance Aotearoa New Zealand – Ohu Kaupare Huaketo, a partnership between the Malaghan Institute, the University of Otago and Victoria University of Wellington.”

Associate Professor Lynn McBain, Head of Department of Primary Health and General Practice, University of Otago, Wellington, comments:

The impact of RSV on primary care workload – A major effect of the increase in RSV relates to incoming phone calls and telephone triage undertaken by practice nurses and GPs. A lasting effect of the Covid pandemic is the preference to reduce primary care attendance by those with respiratory symptoms – so we take the extra step of telephone triage for all patients with respiratory symptoms.

“Then a certain proportion will need an in-person consultation and we try to reduce contact with other patients  so there is the extra coordination workload as well to protect others in the waiting room. Then of course the actual clinical assessment and advice, and often follow-up as some of the children are moderately (not mildly) ill. We are aware of the pressure on ED and hospital admission, so take considerable care in our assessments to provide the best care in the community.

“Interestingly – the term ” RSV” is worrying people as though it is a new type of illness, and this in itself generates more workload. At my practice there has seemed to be fewer cases this week but that may be an artefact. And of course we are trying to undertake business as usual  – and answer questions about Covid vaccines (from almost every person we speak to).”

Conflict of interest statement: “I am a general practice owner in Wellington”.

Dr Thorsten Stanley, Consultant Paediatrician and Senior Lecturer in Paediatrics, University of Otago Wellington and CCDHB Wellington, comments:

“RSV (respiratory syncytial virus) is a highly infectious RNA virus. It is one of the commonest causes of respiratory infections in children and can also affect adults, especially in old age. It is spread by coughing or sneezing or contact with the virus on exposed surfaces, where it can survive for many hours. It is very contagious. 

“Affected patients are usually contagious for 3 to 8 days, but this may last for up to 4 weeks in some infants with poor immunity.

“Most children do not get very sick, just appearing as if they have the common cold, but for reasons not fully understood, in a proportion of infants the virus can make them very sick indeed. Ex-preterm infants and children with immune disorders, chronic lung diseases, severe heart disease and chromosomal disorders are more likely to get sick, for example, as are very young infants.

“The pathology includes swelling of the airways, inflammation of the lung tissues and shedding of dead cells into the airways. This leads to narrowing of the small airways and air gets trapped in the lung sacs leading to wheezing, poor oxygenation, overdistended lungs, poor feeding and sometimes respiratory failure, with some babies stopping breathing. This condition is called bronchiolitis and is sometimes associated with RSV pneumonia.  Respiratory management can be very challenging, especially in babies requiring respiratory support. Co-infection with another respiratory virus significantly increases the severity of the disease.

“RSV bronchiolitis hits babies of every ethnicity and every socioeconomic and income group. 

“RSV appears in autumn and winter every year in temperate climates like NZ. Last year there was no RSV disease in infants in NZ for the first time since records began. This was almost certainly due to lockdown preventing the virus arriving from overseas. Once the bubble with Australia was established, we suspect the virus returned to NZ from there.

“Rapid diagnosis is available on nose swabs both by PCR and by an antigen detection method.

“Maternal immunity as generated by exposure to wild RSV does not generate a strong enough immune response to protect young infants.

New methods of control

RSV vaccine for newborns: An attempt to immunise infants directly with an experimental vaccine some decades ago was not successful; the immunised infants actually got worse disease than the unimmunised ones….

Unfortunately, (like the pertussis vaccine) the highest risk babies are the youngest ones, so a vaccine given to newborns (which takes time to have an effect) is unlikely to be the answer.

Vaccine for the pregnant mother with transferred immunity to the infant: Two vaccine trials we are involved with in Wellington involve giving the vaccine to the mothers before the baby is born, at 24 to 36 weeks gestation. Preliminary data suggests this is capable of generating very high levels of anti RSV immunoglobulin in the mother and also the newborn infant. This looks very exciting but we don’t know yet if this will translate to reduced disease in the infant – but this has been very successful with pertussis so we are optimistic. 

Passive immunity: A monoclonal RSV antibody that can be given to at risk preterm infants (palivizumab) has been available for some years but has been disappointing and short-lasting

“A new monoclonal has shown impressive protection in preterms (published last year) and only has to be given once to provide 6 months protection. This monoclonal is now also being trialled in full term infants in a study we are also involved with. Enrolment has been slow due to poor knowledge of RSV disease in the general population making parents hesitant to allow their [well] baby to have an intramuscular injection

“Anti-RSV drug treatment of babies affected by bronchiolitis: We were involved a few years ago with a trial of an oral antiviral that effectively stopped replication in adults artificially infected with RSV.

“Unfortunately, the results of the trial in affected infants with bronchiolitis was disappointing, perhaps because by the time the virus has led to bronchiolitis the virus has already replicated and it is too late to kill it. By this stage it is the dead cells that are causing the lung disease. The drug also had some unexpected side effects making its further development unlikely. 

“We are involved with trialling a new oral drug that also kills the virus, but we don’t know if it will affect the progression of the disease either. 

“I suspect anti-RSV drugs would need to be given when the baby is not yet very ill – which would mean swabbing every baby for RSV every time that they get a common cold in case it is being caused by RSV, and then we would end up treating a large number of babies who may never have gone on to get bronchiolitis. So I suspect maternal immunisation and passive immunisation of preterms will be the likely future scenario for control, but at this stage who knows?”

No conflict of interest declared.