RSV Vaccination for Older Adults

Welcome to a special series by Respiratory Exchange Addressing the Impact of RSV and Vaccine Hesitancy.  In this series, we explore the efficacy of RSV vaccines and discuss preventive strategies aimed at reducing the occurrence of severe RSV respiratory illness in infants, children and older adults.  

This episode will focus on the RSV Vaccination for Older Adults, and the importance of vaccination in preventing severe illness and hospitalization. Dr. Ronan Factora explains the risks and the benefits of the RSV vaccine while emphasizing the potential consequences of hospitalization including the loss of independence.

Transcript

Dr. Dweik:

Hello, and welcome to the Respiratory Exchange podcast. I'm Raed Dweik, chairman of the Respiratory Institute at Cleveland Clinic. This podcast series of short, digestible episodes is intended for healthcare providers and covers topics related to respiratory health and disease. My colleagues and I will be interviewing experts about timely and timeless topics in the areas of pulmonary, critical care, sleep, infectious disease, and related disciplines. We will share information that will help you take better care of your patients today, as well as the patients of tomorrow. I hope you enjoy today's episode.

Dr. Gordon:

Well, hello, my name is Steven Gordon. I'm chairman of the Department of Infectious Diseases. In this podcast, it's a pleasure for me to welcome a colleague and a friend, Dr. Ronan Factora, who is a geriatrician here at the Cleveland Clinic. The topic today we are discussing is focusing in particular on the RSV vaccine for the elderly. But before we delve into there, Ronan, I wonder if you can just give us your narrative and explain to our audience what a geriatrician does and what your passion for this is.

Dr. Factora:

Thanks, Steve, for the intro, and pleasure to be here. So, a geriatrician is a physician who takes care of people, technically sixty-five and older. But, you know, our focus often is on issues that can affect independence. And often, that runs the gamut of cognitive issues, physical frailty, mobility issues, the impact that a person's medical problems have on their ability to be independent and live the life that they want.

We are really focused on preserving that function, preserving that independence. So, it's not so much about treating the disease or diseases in general, but how that impacts your ability to live the life that you want. And we try to mitigate the impact that an illness may have on your independence and try to focus on independence and quality of life. That is really what a geriatrician does.

Dr. Gordon:

Well, thank you for that. As we're looking now in demography [CF1] here in the States, the boomers are now entering what we would say the golden years. So, obviously, this population is front and center in so many ways. And for us, our focus is obviously now on respiratory viruses. All of us have now come off what we'd say four years from the initiation of SARS-CoV-2, the pandemic, we’re in the post-pandemic era. There are a lot of lessons I think we learned.

As I reflect back, Ronan, if you look at whom the highest mortality was, clearly, it was in the elderly and clearly, it was in the long-term care facilities. As we look back, estimates are somewhere around 200,000 deaths in our residents of long-term care facility. So, can you help us explain the why, in terms of why our elderly are viewed as a vulnerable population for respiratory viruses and RSV in general?

Dr. Factora:

So yes, I think there are lessons from COVID that are striking. And it highlights that as a person gets older, there are certainly changes in a person's ability to fight off infections, all sorts. In this case, COVID, and be able to recover. So, it's not just about fighting off the illness, but what happens after the illness actually goes through you? What are you like after you go through the illness?

So, you will see individuals really at higher risk, not just based on age, because we understand that. But when a person has a lot more physical frailties, more cognitive impairment, more physical issues, then their ability to fight off and recover from that is also impaired. And then, it's not just a number when a person gets older, but all the things that you pick up along the way. And those are all the medical problems that you accumulate over time, heart disease, heart failure, COPD, diabetes.

There are a lot of individuals who are older who accumulate multiple diseases as a part of their life. All those factors can predict how well you are able to fight off an illness and what you do afterwards. The big concern for a lot of people who are older, is not so much living longer, but living well. Losing that ability to be able to move as well as before, the ability to think, the ability to be independent, the reliance on family members to do more for you that you were able to do before, that's a big deal for many of my patients. They want to be able to retain as much of that independence and ability as possible to enjoy their life.

When you're thinking about any illnesses that may occur along the way, particularly, these seasonal illnesses, respiratory illnesses. It is not just about whether or not a person is going to get sick, but how are they going to be able to live the life that they want to when they're able to recover from it?

Dr. Gordon:

Well, thank you. I know you do a lot of non-pharmacologic interventions because one of the things in your population are falls and unintentional injuries from the bars and immobility, as you said. Could you review the vaccines that you deal with it, in particular respiratory virus vaccines, why RSV? I mean, people will tell us, "Oh, RSV, I haven't either heard of it or isn't that for kids?"

Dr. Factora:

Right. Absolutely. As part of routine practice, we always recommend standard set of vaccinations that are recommended by the CDC as a way to avoid respiratory illnesses in persons who are older, and particularly those who are frail. Pneumonia vaccines have been around for a long time. We know that they prevent a number of different bacterial illnesses. It’s not going to be all of them, but we have a way to actually reduce the risk of getting bacterial illness. Which for people who are older, lands them in the hospital, can kill you, and then can lead to disability. Influenza, flu vaccines, been around for a long, long time. 

I think that we understand the cycle that flu gets worse later in the year, cold months, and then, there's a peak period. We also understand that we identify which strains of the viruses are going to be most likely to cause illness. And that’s what the vaccine protects you against, much like the pneumonia vaccines, again, preventing respiratory illness, hospitalizations in the sequela after that.

COVID, very much the same way, newer evolution, newer illness that we run into, lots of problems related to this, for sure, but still something that we can actually address with a vaccine that can reduce the risk of hospitalization, severe illness, much the same way that we work to prevent the flu and pneumonia.

And then, as with any medical evolution and advance, we have identified the RSV as one viral illness that has already been known to produce significant impacts on persons who are older, especially if you have medical problems like heart failure and COPD. We have a vaccine that can provide the same type of protection as we have had historically with COVID, with flu, and pneumonia.

So you have one more tool to protect yourself against an illness that can really cause problems for you. Not just in your overall health, but in your function. So, as I talk to my patients, that is one more tool to add in the armamentarium to help to protect them from illnesses that affect the thing that's most important to them, and that’s independence. So, you should consider it.

Dr. Gordon:

Well, thank you for that. If you look at the CDC and look at the estimated incidence of cases that are medically attended in the elderly each year, it's upward to about 170,000 with almost 10,000 deaths attributed to RSV. And to your point, influenza, obviously, we know about seasonality. In a recent CDC study, where they looked at both viruses and the impact in 2022/2023 respiratory season, although RSV did not cause the incidence cases of medically attended, the cases were generally more severe. I wonder, as a clinician, can you explain to the audience? Can you tell the difference between RSV, SARS-CoV-1, and influenza for a patient in front of you with symptoms?

Dr. Factora:

Clinically it is really hard. They present very similarly cough, shortness of breath, fever. There may be some distinguishing features from one compared to the other. SARS-CoV-2, you'll have maybe a more likely loss of sense of smell or taste. Generalized body ace can be present with flu as well as feeling tired, very much an overlap. That is the reason we have these tests to distinguish one from another, because we'll have different types of antivirals to treat fluent influenza versus SARS-CoV-2. That is something that may evolve in the future as well for RSV. But right now, we just have to know what we can do to protect from the illness in the first place. We will just have to wait until treatments evolve to know this is what we can do now if you have RSV.

Distinguishing between those is more from a laboratory perspective. But from the standpoint of a person, you just want to prevent yourself from feeling ill and landing in the hospital. Now, of course, you want to prevent risk of dying, but then you also want to prevent everything that may happen after you are sick and recovering.

Dr. Gordon:

Well, thank you. And to emphasize again, for SARS-CoV-2 and influenza, we do have antivirals that if used early enough may militate or mitigate some of the morbidity. There is no such treatment in the elderly for RSV. So, a vaccine would be recommended as a primary prevention. When you look at this, we have obviously two new subunit vaccines, so they're not live vaccines. Can you tell us, because a lot of patients want to know, "Well, Dr. Factora, this is new, is it safe?"

Dr. Factora:

Right, as these vaccines roll out, there's always hesitation with a new intervention, particularly, if you're going to be sticking yourself with something that you feel is really not proven. You know, when these vaccines come out, there are studies that are done to really show the effectiveness in reducing things like mortality associated with the illness, the morbidity associated with illness, all the symptoms associated with this.

They typically try to draw in individuals that represent the general population, so you know that the people who've been enrolled really are similar to who you are. And they really watch to see whether there are going to be any serious side effects and watch the efficacy. And they follow these people for a long enough period to demonstrate that it really does the job it's supposed to. I think that more people are worried about safety, and concerns about side effects, as opposed to efficacy, which is always an important factor as well.

A lot of people just don't want to have any side effects. They're worried about other unintended consequences. Those are well studied. The balance when you're thinking about whether or not you're going to get the vaccine is, what are the risks, because it's never a free ride. There's always a possibility of side effects. Mild side effects like soreness at the site of the injection versus generalized body aches. There are rare side effects as well that you have to consider. But you also have to think about the benefits. What is it going to provide for you, a reduction in risk of dying from this illness, reduction in risk of hospitalization?

But then for my patients, I worry about downstream things that may not have been necessarily studied in the initial trials but are top of mind for my patients. So, if you have underlying cognitive impairment, there is that risk of delirium in the hospital. If you are hospitalized, that confusion that can occur, most people recover from it. But individuals who have underlying cognitive impairment or dementia, they may not recover back to their baseline, down the line.

If you have problems with mobility already before getting sick, you think about what happens in the hospital. You are stuck in bed for a long period of time, you are going to get weaker. More often than not, you may end up in rehab. Some of the people that go to rehab they never recover to their prior level of physical functioning.

So, what are the consequences of loss of cognition and loss of physical functioning? That equates to loss of independence and more help in the home. In less frequent occasions, sometimes, you can't go home, and you end up going to a more supervised setting. So, those are the things that I also think about when I think of my patients that end up in hospitals.

Beyond what the studies look at, because they can't study everything, I think about these consequences in my patients that occur very frequently when they get sick from other things, like heart failure or an infection, cellulitis or, COPD exacerbation. They are in the hospital, and they’ll have the same kind of consequences and I have seen this all the time in my population. That is really what I want to try to avoid, because as a geriatrician, preserving independence is the most important thing for my patient. If I can do something to help to preserve that and prevent that decline, it is a worthwhile intervention.

Dr. Gordon:

Well, thank you for that explanation. Pragmatically, in your patient population, CDC allows us to give all three jabs at once. For instance, if you wanted your COVID booster, your influenza, and in your population is going to be a high dose influenza, which is different that less than 65, and of course the RSV. So, in your practice, how are you administering these respiratory virus vaccines in the current season?

Dr. Factora:

A lot of it revolves around opportunity. If a person only sees a doctor every once in a while, and you have one chance to give the vaccines, and it is safe to give all three, I give it.  Knowing and warning that person that you're more likely to get muscle aches and pains, you're more likely to get sore at that spot. You may feel tired and achy for a couple of days, but it is going to recover. You are going to resolve from that.

And I know that after that point, they are protected. In an ideal situation I try to spread out the pain, so to speak, that you have all three vaccines. You do not have to have that kind of big peak of feeling terrible for the days after the vaccine. Then there is some data that shows that when you spread out the vaccines, the efficacy may be better or enhanced.

There is an argument for doing both. That is the reason why an individualized decision and knowing your patients is important, because you know what's going to work out best for the person in front of you. Is it one time that you have the only opportunity to give them protection for all these illnesses, or do you trust that that person will get the vaccines over time, in the way that you recommend? That is where you really have to focus on the person in front of you, but you could go either way. It is what is the best decision for the person who you're talking to?

Dr. Gordon:

Well, thank you. That is a nice segue into something that is now in our lexicon in vaccines, and that is vaccine hesitancy versus vaccine resistance. So, I look at vaccine hesitancy as somebody who's not sure. They have not made their decision, but obviously weighs some evidence. Versus those that are vaccine hesitant that you’re not going to get to yes or the decision is set in stone, which is relatively minor of the patients that I see.

However, I want to look at how clinicians are supposed to message RSV, it is something called shared decision-making model. Can you explain that in terms of how you put that into practice in terms of using persuasion or discussing with the patients about the RSV vaccine in particular.

Dr. Factora:

Yes, that can be a really challenging discussion to have with your patients, and the key thing is to really think about the person who's in front of you. What I often will ask when a person doesn’t want to have a vaccine is, "what's the reason why, what’s the reason why you're concerned?" and you want to address that concern directly with the evidence that you have available and the reasons why that person may not actually want to get vaccinated. It may be a knowledge deficit. It may be a particular fear of a side effect.

They may not be concerned about its effectiveness, might not be convinced of it. But you have to address that first, before really moving forward. When you individualize the decision, and you want to try to convince, because we cannot force a person to get a vaccine. But when you want to try to convince them that this is really going to help you, you want to find something that would motivate that individual to say, "Yes, this really is appropriate for me."

Again, I do not just look at the number that's next to a person. Although you can say that as you get older if you get RSV, you are more likely to have severe illness. The other thing that you want to add to that is, you may not die from it but, you are more likely to get into a hospital situation if you get sick from this. And it may not just be the age but the medical problems that a person has. If a person has underlying COPD or heart failure and the other comorbidities that are associated with poor outcomes for RSV, you can say, " You know, you're going to be at risk for serious outcomes."

So, we want to make sure that you are protected. This is the reason the vaccine is effective. But then you can also think about, let's say that you end up in the hospital and you have patients that have been hospitalized before. Often, they're accompanied by family members that remember what they were like in the hospital, and they may be able to recall an episode of delirium that they had in the hospital that they may or may not have been able to recover from, or the rehab stay that occurred after hospitalization where a person really didn't do well and didn't recover completely.

So, they understand what hospitalization means for their family member, and that is something that often they will want to try to avoid. That is one more bit of information that can help you convince a person that you want to use this vaccine to protect you because these are the consequences of hospitalization that you may encounter again. Delirium and incomplete recovery from delirium, physical deconditioning, and more loss of mobility. Then you can historically look back and say, "This is what happened to you last time. You were walking independently last time in the hospital and now, you are using a cane, or now you are using a walker. You were able to drive and manage your finances and medications independently before you're hospitalized last time. Now, you need help for these things."

That loss of independence often is a motivating factor for people to be proactive in preventing that from happening again because, again, this is important for that individual. I think it's a harder argument for someone who's totally healthy, who has no comorbidities. There is no convincing evidence to tell them that they're going to get benefit. That really is a harder discussion to have. But as doctors, as clinicians, we know what the data shows, and that person can still derive benefit. So, you can slowly chip away at that wall over time with continued discussion, just like I have with my patients who have been reluctant to take the COVID vaccine or the flu vaccine before historically.

I will bring it up again, every year, we're going to have the discussion. You know, I will see them again in three months. We can talk again; it is never too late. The flu season, there is always a time that is too late. But with RSV, we don't really know that yet. So, you can go back and revisit the vaccine again in the future and take the opportunity to see if they are willing to try. It is just like you would bring up any other primary care prevention, colon cancer screening, other vaccines.

It becomes an annual ritual, and you bring it up. They may have had a come to Jesus moment at some point where they have heard about a friend or a family member that got RSV and they were in the hospital, or they had severe side effects. Now, they don't want this to happen to them. Often, that is a motivating factor for a lot of people that they know someone who was affected by an illness and now they don't want to have that happen. You don't know what happens between the last visit with them and the next visit. They may have changed their mind.

So you want to give them that opportunity to reconsider. You will still have the data to help you out, and you bring it up again and hope next time you're successful. Then you would have done your job as a doctor.

Dr. Gordon:

Ronan, I like that approach. I personally learned so much, obviously, through the COVID pandemic in terms of vaccine education. And I think your approach is one that I try to model after, and that is be curious as opposed to judgmental. In listening there are studies to show that physicians maybe wait an average of 10 seconds before jumping in. But really listening and obviously trying to be respectful and then, as you said, trying to throw in some counterpoints. As I told some of my patients, "Look, I'm not advising you on changing the oil, but I do know something about infectious diseases," that's my hopefully bailiwick.

I like your other point about it could be a bridge to decision. It may not be this time, but think about that, it's not irreversible, the decision that you make or don't make today. The power of persuasion is a very good one that a lot of docs, we aren't necessarily good at. Other thing is  a family unit, as you mentioned, because you might be protecting the family. As we say in healthcare, if you're not going to do it for yourself, do it for whomever else is in the family. You might have more vulnerable people or small children.

And as you know as well as I do, there are many studies that show, for instance, pneumococcal vaccination of the children can help protect the grandparents and vice versa. So, there's that kind of milieu in the environment that we live in.

Dr. Factora:

Yes, I think that is an excellent point. Especially if you have family members and caregivers around, who understand that if they have a family member who is vulnerable, if they get vaccinated, they are protecting them too. That was also something that came up during the COVID pandemic, is that individuals who cannot be vaccinated for any reasons, the people around them can protect them by getting vaccinated themselves. We see that also in nursing facilities and congregate living facilities, where the staff, who come in and out very frequently, are often exposed to other persons who may be ill. They often are required to be vaccinated, so they can protect the people they provide care for as well.

So that herd immunity so to speak is so important, in which case, you are not just thinking about yourself. You are thinking about the other people around you that you are protecting. That is an important consideration and may be a motivating factor for the family members who are there in attendance with your older persons to decide to get vaccinated themselves if that person refuses or, for whatever reason, cannot be vaccinated. So, it becomes more altruistic at that point. It is less about a selfish motivation.

Dr. Gordon:

Well, thank you for that. As we wrap up here, were there are other things that came out of the pandemic that help your population? When I'm thinking about is an elderly patient, the transportation or the coming to the clinic, so can you tell me what your perspectives have been in terms of using telehealth or distance health? In terms of touching your patients but obviously decreasing some inefficient or unnecessary transportation aspects?

Dr. Factora:

Right. That is one of the great evolutions in medical care during the pandemic. When we were isolated, we still had to take care of our patients who had medical problems, but they were at home and couldn't see us in person. And so, we have used these virtual visits as a wat to connect, even briefly, and even spontaneously to individuals who have medical concerns, urgent issues. And I think that we have evolved to the point where it becomes easy.

Even for family members, older persons who have challenges with technology, often, there's younger persons who are very facile with technology. So, it is not really a barrier anymore. So the opportunities to communicate these recommendations to your patients are not necessarily blocked by the absence of one-on-one or face-to-face person contact. If you have the ability to actually see a person on the screen, you can communicate your opinion to them. Even a phone call, as a virtual visit can still be effective because you can talk to the patient, you can talk to the family. As long as you are able to communicate your thoughts and ideas and have a discussion, it is not a barrier.

But even beyond that, vaccines are readily available. You don’t just have to go to the doctor's office for this anymore. Any drug store has these vaccines available. You have access to them. They will be covered by your insurance. Often, family members can plan when they can provide transportation to bring them conveniently during the weekend or after hours. It does not have to be during the business day anymore. and you can time it so that if you are afraid to be around a lot of other people, you know when it's going to be less busy in a drug store. You can go and not be worried about being exposed to other individuals if you really are concerned about picking something else up.

I know that was also a concern for a lot of my patients in going to public places. Would I be exposed to COVID? Am I going to get sick from COVID just by going there to get this vaccine? Who are the other people that are going to be sick there? Those are legitimate concerns. But you can time it so that it works out better for your schedule, for your concerns. Everything can be individualized. I think the availability of technology and the availability of so many sources for the vaccine just makes access so much easier.

Dr. Gordon:

When I listen to you, there’s a philosophy that I hear on the book written by Atul Gawande about his experience with his father on being mortal and just what is important to the patient, the patient-centered principles that you've articulated now. I wonder, is there any other books or things that you are reading that you might recommend for the audience to get better ideas in terms of the joys of taking care of the elderly in those experiences?

Dr. Factora:

Referring to Atul Gawande book, which was a great example. More than anything else that helps to highlight the individualized nature of getting older. How as a healthcare system, we really have to change from cookie-cutter to really talking about a person as an individual. And thinking about the needs of that individual, the uniqueness of that individual when it comes to any medical decisions.

You have to make everything individualized. But then beyond that, really talking about a person along with their caregivers and family. It is not just about the patient. When I see patients in my clinic, there's the caregivers that are there too. You have the family members that are affected when a person is ill. When a person gets sick, these people are going to take care of them. So, we just don't have to worry about the impact of the disease on that person that we're talking about in vaccination.

We have to think about how that is going to impact the family members that are still working. The other members of the family that are there that may still be at risk for other illnesses, the level of care that they are going to need down the line. How is it going to affect their finances and their employment? So, these are questions that go beyond just medicine. We are talking about the impact of an illness on the life of the whole family. So, those are all considerations, when you're suggesting something that is meant to protect the individual, there are long-ranging implications even beyond that person, that can affect the family. That is how you want to view a person who is older. It is the family unit you are thinking about, who else is living with that person that the decision will affect, and not just the individual.

Dr. Gordon:

Well, that is a great way to close. Again, gratitude for my colleague, Dr. Ronan Factora, for giving us a great overview of geriatric care and the role of the RSV vaccine. Again, my name is Steve Gordon, department chair of Infectious Disease. Thank you for joining us, and I wish everyone very well. Thank you so much.

Dr. Dweik:

Thank you for listening to this episode of the Respiratory Exchange podcast. For more stories and information from the Cleveland Clinic Respiratory Institute, you can follow me on Twitter @RaedDweikMD.