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Kids could be worst off in winter illness surge – Expert Q&A

Cases of RSV and Influenza B are on the rise this winter – both illnesses which predominately affect our youngest and most vulnerable.

Meanwhile, the FDA in the US is recommending infants get a new monoclonal antibody treatment to ward off RSV infection. The government here has also recently released a five-year roadmap on tackling rheumatic fever and rheumatic heart disease.

The SMC asked experts about winter illnesses. 

Associate Professor Dame Teuila Percival, Paediatrician, South Auckland; and Director, Moana Connect, comments:

What illnesses are you seeing in children turning up to hospital?

“We are seeing a lot of babies and young children with RSV and also influenza B and A.

“There are lots of babies with bronchiolitis which is dominating our work, along with infants and children with pneumonia and flu like illnesses. We are also seeing pneumonia complications such as empyema and lung abscesses.

“Children are still presenting with Covid-19.”

The FDA in the US is recommending infants get a new monoclonal antibody treatment. Is this something Aotearoa should consider?

“The FDA approved monoclonal RSV treatment will be very welcome and has great potential to reduce a lot of the RSV disease burden in young children.”

No conflict of interest declared.

Dr Sarah Jefferies, Public Health Physician, Health Intelligence and Surveillance Group, ESR, comments:

Are there any winter bugs that are unusually prevalent for this time of year?

“Nationally, we have seen a steady increase of influenza-like illness consultations in the community since April, in line with average seasonal trends for this time of year. Some parts of the country have shown higher activity than usual, including Counties Manukau, Waitemata and the Hawkes Bay districts. More serious viruses such as influenza B, influenza A (H1N1) and respiratory syncytial virus (RSV) are circulating in the community, as well as common cold viruses like rhinovirus.

“This is the first time influenza B has circulated significantly in New Zealand since 2019. Influenza B tends to hit young children the worst and its return to New Zealand is a good reminder that the flu vaccine is now free for children aged 6 months to 12 years old.

“Certain groups of people are at more risk of severe complications of flu, such as pneumonia, which is why the annual flu vaccine is also free for pregnant women, Māori and Pacific people over 55 years, older people and those with certain medical conditions. The Ministry of Health is a good source of information for further advice on preventing the spread of influenza, and self-care. The flu vaccine is our key line of defence and provides protection against all four seasonal influenza viruses: A(H1N1), A(H3N2), B/Victoria and B/Yamagata.

“We are currently seeing increasing rates of RSV-related hospitalisations in children aged 1-4 years old in the Auckland region. RSV also tends to affect young children most severely. RSV caused a lot of serious illness in June 2021 as a result of the COVID-19 restrictions in place in 2020 reducing the circulation of RSV and therefore reducing levels of community immune protection. The Ministry of Health has advice about RSV.

“Influenza B and influenza A (H1N1) are also causing severe illness across a range of age groups in the Auckland region in recent weeks. COVID-19 related severe acute respiratory infection (SARI) hospitalisations detected through this surveillance system are slightly higher than this time last year but nowhere near the peak of the first Omicron wave in March 2022.

“Normally influenza is most active in July-August, but we have seen that this year’s flu season started earlier than usual. Flu-positive SARI hospitalisations in Auckland first surpassed the seasonal baseline in April. Both severe illness activity and community illness activity have remained low overall but have been steadily increasing in the past month.”

No conflict of interest.

Professor Cass Byrnes, Department of Paediatrics, University of Auckland, comments:

The FDA in the US is recommending infants get a monoclonal antibody treatment. Is this something Aotearoa should consider?

“The RSV virus is the most common cause of bronchiolitis and pneumonia in infancy and early childhood. It accounts for 6 per 1,000 children less than 5 years of age being hospitalized every year for respiratory infection in Aotearoa, New Zealand, higher than other similar countries.  It demonstrates health inequity with the burden of disease falling on Maori and Pasifika children, and those from the 20% most deprived households. The RSV season has once again commenced with hospitalisations increasing over the last two weeks.

“Although two RSV vaccines have been recently approved for use in certain groups of adults in the USA, no vaccine has been approved for these very young children. These traditional vaccines stimulate the person’s own immunity to develop antibodies against the virus.

“However, another type of protection is available where the antibody can be given to infants and these antibodies would react directly against the virus when exposed. This is known as passive immunization as the recipient doesn’t need to do anything to be afforded protection. A new such preparation ‘Nirsevimab’ has been unanimously recommended by the Food & Drug Administration advisory committee in the USA for prevention of RSV respiratory disease in infants. This would be a single dose given for infants born during or when entering their first RSV winter season. Trials involving over 3,000 children showed a 76% reduction of RSV disease in those receiving Nirsevimab, including reduction of severe disease.

“PHARMAC has approved a much earlier similar product ‘Palivumzab’ from 2022 to 2023 for high risk infants – those with prematurity, underlying cardiac disease or chronic lung disease. However this requires a monthly injection for 5 months which is impractical for widespread use. Also while this gives protection to high risk infants, the majority of hospital admissions for RSV are previously healthy children.

“Access to Nirsevimab here would significantly reduce the numbers of children requiring hospitalisation and the severity of acute respiratory disease. It will likely also have a long term benefit as hospital admission for respiratory illness at an early age is associated with the development of chronic lung disease in later childhood  such as pre-school wheeze, asthma and bronchiectasis (lung scarring). It would certainly have an immediate impact on reducing hospital admissions in peak winter months, reducing the pressure on our emergency departments and paediatric wards.”

No conflict of interest declared.

Dr Sally Roberts, Clinical Head of Microbiology, Pathology & Laboratory Medicine, Te Toka Tumai Auckland, Te Whatu Ora, comments:

What do you make of the relatively high rates of RSV throughout Aotearoa this winter?

“Yes, rates of RSV for all patients tested at Te Toka Tumai Auckland have increased since late May. I want to reinforce the message about cough etiquette, good hand hygiene and staying home if unwell.”

What do you make of the relatively high rates of influenza B throughout Aotearoa this winter?

“Yes, we are seeing higher numbers of patients with Influenza B (almost double the number) compared to Influenza A. I can not comment on the age range.”

No conflict of interest declared.

Dr Emma Best, Medical Advisor and Paediatrician specialist, Immunisation Advisory Centre, University of Auckland, comments:

What do you make of the relatively high rates of influenza B throughout Aotearoa this winter?

“We have seen a noticeable increase in the influenza B virus this winter. The past few years have changed our circulating seasonal respiratory viruses, and between 2019 and 2023 influenza B had been less common in Aotearoa.

“Both influenza A and B cause a febrile (feverish) illness, muscle aches, cough and runny nose type symptoms in young children.”

How dangerous is influenza to young chlidren?

“Influenza can affect all children mildly or seriously, even those who have never been sick. For those with mild asthma and those who have other medical problems, influenza is more likely to be a very serious illness.

“Although influenza A more often causes younger children to need hospital or medical care, influenza B also affects young children and school age children – and can make them unwell enough to need to go to hospital.

“Influenza and other respiratory virus infections provide the pathway for serious complications such as pneumonia and life threatening sepsis following on from the fever, runny nose and cough.”

How can we avoid the worst of influenza this winter?

“To manage influenza, prevention is the best approach and for the first time New Zealand is providing the influenza vaccine free to all tamariki aged from 6 months to under 13 years. The vaccine contains two strains of Influenza A and influenza B matched to the viruses which have circulated in the past.

“With the rising influenza B cases we really need to keep on preparing – it is not too late to have an influenza vaccine. And check other infant and childhood vaccines are all up to date as these also protect people from serious complications, such as pneumonia and meningitis, that can happen as a consequence of initial influenza.”

No conflict of interest declared.

Dr Joanne Hewitt, Science Leader, Health and Environment, ESR, comments:

What is the latest on Covid-19 wastewater surveillance?

“ESR continue to monitor COVID-19 trends and variants through the analysis of wastewater across Aotearoa New Zealand. Currently, just over 60 sites are regularly tested for SARS-CoV-2 RNA as part of COVID-19 surveillance. This data supports other COVID-19 surveillance activities including reported COVID-19 case numbers, and hospitalisations. An increasing trend in levels may give an early warning of increases in cases. Wastewater testing is also independent of RAT/PCR testing and reporting by individuals so is unbiased.

“Nationally, SARS-CoV-2 RNA levels in wastewater have been relatively low and steady from February 2023 but noting there are some regional and site differences over that time. As of 9 June 2023, wastewater data does not indicate an increasing number of COVID-19 infections at the national level.”

No conflict of interest.

Dr Rawiri Keenan (Te Atiawa/Taranaki), Adjunct Senior Fellow, Medical Research Centre, Te Huataki, University of Waikato; Senior Research Fellow, Dept of Primary Care and General Practice, University of Otago Wellington, comments:

How might we avoid the worst of winter illness this year?

“The winter we have been worried about with COVID, RSV and Influenza is well and truly here.

“The school holidays are coming up, and not too soon enough in many ways. If we look previous data on COVID numbers, the holidays generally give a small drop off as children are no longer crammed into classrooms with inadequate ventilation and minimal masking. That said there are still two weeks, then next term as well, and COVID is not the only thing going around.

“Currently it’s specifically influenza that seems to be really doing the rounds. Influenza compared to the common cold, has much more widespread symptoms (fever, headache, body aches and tummy upset) and lasts closer to or longer than a week.

“Masking indoors and crowded spaces helps with the prevention of many bugs, not just COVID so I would totally recommend people keep this up (or restart). Having had the flu (and even better if you haven’t) getting the flu vaccine is still really important and worth getting (as are COVID boosters where eligible).

“Of course the big topic is childhood immunisation for measles, whooping cough etc. Our numbers nationally here are poor (hence the increased media coverage recently) but specifically they are really low for our Māori and Pacific communities/tamariki. I’d just really encourage anyone considering it to find a trusted health professional and ask those questions regarding these really important vaccines.

“We know that due to staffing issues (chronic shortages, but also more acute ones due to the same winter bugs affecting staff and their whānau) getting appointments can be tricky, but childhood immunisations are free, as are those for COVID, and many people are eligible for a free flu vaccine too. Any other ‘bills’ with a clinic or pharmacy etc does not affect your eligibility for any of these funded vaccines. Many of these same vaccines are also now uncoupled from needing to be at your registered GP clinic, you can do this through the website, so check it out if that’s something you prefer as well.”

No conflict of interest declared.

Associate Professor Amanda Kvalsvig, Department of Public Health, University of Otago Wellington, comments:

How can we avoid the worst of winter illness this year?

“Every year when the weather turns cold Aotearoa New Zealand sees a huge surge in respiratory infections. The large numbers put pressure on a GPs and hospitals but even when people aren’t unwell enough to need healthcare, highly disruptive impacts ripple through communities when infection levels go up. As as every working parent knows, it’s challenging to meet work expectations when children are constantly coming down with coughs and colds brought home from school and daycare. For many families, not being able to work means no income, generating huge worry for families that are struggling. We shouldn’t accept this situation happening every single year now that we have the knowledge and tools to change it.

“The pandemic has shown us just how preventable many of these infections can be when the right protections are in place. Respiratory infections spread through the air, which is a major reason why the numbers jump up in winter: people are indoors, crowded together, and breathing other people’s air. Recent studies are showing that ventilation and air filtration are vital infrastructure for public health because they’re effective protection against multiple pathogens. The CDC in the United States has also recently updated its rules to set a target of five air changes per hour for rooms and buildings. Once we get indoor air quality right we should start to see benefits right away.

“In terms of where to start there are some key settings where infection transmission really matters. Schools and early childhood settings need to be made safe because they’re highly connected within their communities, enabling infections to pass from school to home to daycare and back. Another key setting is healthcare: everyone, including people who are immune compromised, needs to be able to access healthcare safely right through winter. These settings need to be resourced to excellent standards of safety to protect New Zealanders’ right to education and health.

“Another important strategy is financial support and an organisational culture of enabling sick leave to ensure that people can stay home when they’re unwell. Time to rest is important for recovery, and staying home avoids the risk of spreading infections on public transport and in workplaces. Self-testing is a very promising innovation that we’ve experienced with Covid, and it would be good to see New Zealanders gaining access to newer testing kits that can test for Covid, influenza, and RSV. Rapid tests are a great way to help people make good decisions on the day about whether to join a large gathering.

“With these protections in place and new vaccines on the way for RSV, we’ll be in an excellent position to reduce the current massive load of winter infections down towards the low levels we see in summer. This would be truly transformative change and I suspect that once we experience it, we’ll never want to go back. Additionally, we know that if our respiratory health infrastructure is working efficiently and well through winter, we’re well-prepared to face the next pandemic.”

No conflict of interest declared.

Dr Tara Officer, Lecturer in Applied Health Sciences, Victoria University of Wellington; and Registered Pharmacist, comments:

How could telehealth help us cope with the winter illness surge?

“During the winter season, primary care services face surges in demand, particularly given concerns about rapidly increasing influenza rates.

“To address this challenge, telehealth offers an excellent opportunity to manage many conditions effectively. However, healthcare providers need to be proficient in delivering care through this medium, and patients must feel at ease using it.

“To ensure safe and effective consultations, it is essential to establish guidelines for telehealth consultations, and healthcare service providers should document patient preference for appointment type carefully. Failure to provide adequate infrastructure and training for all primary care staff, including receptionists who control access to services, may lead to a disparity in the quality of care provided to patients via telehealth, causing them to miss out on the care they require in the way that best meets their needs.

“Without appropriate support, telehealth may potentially create issues between patients and their preferred primary care providers, which is a growing concern given the anticipated increase in demand for services.”

Note: other experts previously commented on telehealth, or phone and online health support. The government announced extra support for this as part of a winter health package to come into effect next week on 23 June.

No conflict of interest declared.

Associate Professor Dianne Sika-Paotonu, Immunologist, Associate Dean (Pacific), Head of University of Otago Wellington Pacific Office, and Associate Professor, Dean’s Department, University of Otago Wellington, comments:

How might the most vulnerable in Aotearoa fare through the winter illness season?

“Our health and associated support systems in Aotearoa New Zealand are continuing to experience pressure. These systems were already overloaded prior to the start of the Covid-19 pandemic, and now into the winter months and with Covid-19 still causing problems and this year’s seasonal illnesses, there is added stress and strain.

“The actual true Covid-19 case numbers in Aotearoa New Zealand are still likely to be higher than those figures currently being reported.

“For Covid-19, antivirals still need to reach those who require them quickly, and the sooner the better – within 5 days of symptoms, in order to prevent severe illness and hospitalisation – and try to help our hospitals and support systems, primary and community care.

“In addition, the bivalent Covid-19 boosters are still available for those aged 30+ years and those at high risk, and contain mRNA coding for the original virus strain– giving broad protection against Covid-19, plus an mRNA code common between the Omicron variant BA.4 and BA.5 lineages– giving better protection against Omicron specifically.

“Regular (non-Covid-19) childhood vaccine schedules for children tamariki and tamaiki in Aotearoa New Zealand have also been significantly affected by the Covid-19 pandemic. As a result, there remains risks of outbreaks for measles and other serious illnesses that could be prevented through immunisation.

“This situation leaves some of our most young unprotected from serious conditions. We need to keep our little ones safe and protected and remember that all vaccinations for our children, tamariki and tamaiki are important – particularly at this time.

“The Covid-19 pandemic has exacerbated pre-existing and significant inequities for communities and groups here in Aotearoa New Zealand and this includes for Māori and Pacific peoples, and for children, tamariki and tamaiki – highlighting the need for more Equity based approaches.

“Equity based approaches take into account the specific and different needs of respective communities in seeking to address inequities effectively and efficiently by reducing barriers and building trust with people along the way.

“We saw examples of Equity based approaches in action during the Covid-19 vaccination roll out when Māori and Pacific-led, community driven, properly resourced, targeted and tailored vaccination efforts that involved and included Pacific leaders and health professionals, helped drive up vaccination levels for Māori and Pacific peoples here in Aotearoa New Zealand.

“Addressing current inequities in health and society are also important steps in working towards being prepared for potential future health challenges and outbreaks.”

No conflict of interest declared.

Dr Janine Paynter, Senior Research Fellow, General Practice and Primary Healthcare, University of Auckland, comments:

What do you make of the relatively high rates of RSV throughout Aotearoa this winter?

“Oh no, this isn’t good news. The sooner we have a vaccine option or the new monoclonal antibody treatment the better!”

The FDA in the US is recommending infants get a new monoclonal antibody treatment. Is this something Aotearoa should consider?

“Yes, NZ should definitely be looking into this as a priority. Modelling work in Canada and another study focussing on low and middle income countries shows it is cost effective. Some modelling work in the US indicates that the cost effectiveness can be variable depending on who is being vaccinated and when, e.g. it might not be cost effective if giving to older healthy babies in the non-RSV season.”

What do you make of the relatively high rates of Influenza B throughout Aotearoa this winter?

“This year the eligibility for a free flu vaccine (which includes influenza B) has been extended and is available for all children aged up to 12 years and older Māori and Pacific (55-64 years old) New Zealanders in addition to those already eligible. I encourage parents and whānau to get themselves and their children vaccinated if they haven’t already.”

Conflict of interest statement: “I work on a research project that has been funded by GSK. I have been on an advisory board for Novavax and paid for my time.”

Associate Professor Joanna Kirman, Immunologist, University of Otago, comments:

US health authorities are recommending infants get a new monoclonal antibody treatment for RSV. Is this something Aotearoa should consider?

“Nirsevimab is a preventative treatment (known as passive immunisation) and works differently from our usual vaccines. It gives the antibodies directly to the individual, rather than asking the body to make its own antibodies. So, it is generally quite short-acting lasting weeks or months – whereas many vaccines last for years or decades and are a lot cheaper to make.

“We have something similar to Nirsevimab in NZ – it is called Palivizumab and needs to be administered in multiple doses during the RSV season rather than just one dose, which is the benefit that the newer medicine, Nirsevimab offers.

“I should add both passive immunisation treatments are offered to “high risk” infants – those at risk for severe disease (eg pre-term infants, infants with chronic lung disease etc) rather than the general population.”

No conflict of interest.

Dr Natalie Anderson, Senior Lecturer, University of Auckland; and currently-practising Registered Nurse, comments:

How can we avoid the worst of winter illness this year?

“Get vaccinated. Stay home if you’re sick. Wear a mask. Optimise ventilation wherever people gather.

“These actions saved New Zealanders (and our healthcare system) from the catastrophic and deadly COVID outbreaks and associated trauma, and loss experienced by other countries 2020-2021.

“The same simple individual actions for the benefit of the collective can minimise the harms of influenza and RSV. How quickly many seem to have forgotten.”

No conflict of interest declared.