RSV and Flu Season in Cayman: Protecting Your Child

While for many in Cayman, the latter part of the year marks an increase in hurricane watching, the art of dodging puddles on school drop offs and a holiday season full of events and parties, for a paediatricians and healthcare providers, it also marks our RSV season and an increase in pediatric hospital admissions for respiratory illness, from wheezing to pneumonia. And it has been just that, with four young children needing hospital admissions for RSV this past week.

There has been increased interest in RSV recently as the UK and USA began offering routine RSV vaccination to pregnant women in their third trimester. There is also a new single dose monoclonal antibody for infants to provide protection against severe RSV. Let us take a look together at RSV and how we can protect our littlest ones from severe RSV infection here in Cayman.

What is RSV and the RSV season?

RSV stands for Respiratory Syncytial Virus (RSV) and on this side of the world the RSV season runs from October to March and peaks in December. RSV is a common virus causing cold symptoms, cough and bronchiolitis in infants with approximately 90 percent of children contracting RSV at least once in their first two years of life. For most older children and adults this respiratory virus will be a very mild illness. However there are some members of our community who are at much higher risk to severe RSV infection. Those most at risk are babies under the age of 6 months, those born prematurely, babies, children and adults with a weakened immune system or long term lung or heart problems, and adults over 75 years of age.

How does one catch RSV?

RSV is spread via respiratory droplets when those infected cough or sneeze. The virus can be spread directly to someone in close contact or be transmitted from surfaces or toys where the virus can survive for about 4 to 7 hours. The incubation period, which is the time from when the person becomes infected with the virus to developing symptoms, is about 3- 5 days.

A person with RSV can be contagious anywhere from 3-8 days, and may be infectious a day or so before they develop any obvious symptoms. In the UK, there are approximately 20 000 admissions for bronchiolitis due to RSV per year. According to Centers for Disease Control and Prevention (CDC) data, RSV is the leading cause of newborn and infant hospitalisation in the USA and there are up to 80 000 hospitalisations and 100 to 300 deaths per year in children under 5 years of age. This is a significant burden of disease on children and on the health care system over the winter months.

What are the symptoms of RSV?

RSV symptoms can vary, for most it will be common cold like symptoms starting with a runny or blocked nose, sneezing, tiredness and cough. In children under the age of two, the virus can cause the small airways in the lungs, known as the bronchioles, to swell, narrow and become full of mucus. This condition is known as Bronchiolitis. Bronchiolitis symptoms include persistent coughing, wheezing, and difficulty with breathing. Babies will often be irritable and have difficulty with feeding and sleeping. Fever may be low grade while a high fever may indicate a bacterial pneumonia along with the RSV. In the long term, RSV infection can also lead to an increased risk of childhood wheezing episodes. RSV symptoms usually get worse after the first few days of cold symptoms, start to improve again after about a week and can last up to 10-14 days.

How is RSV treated?

To date there is no specific treatment for RSV. Treatment is usually supportive, helping babies manage their nasal congestion with saline drops, giving smaller and more frequent oral feeds and using anti fever/pain medicine if needed. Infants and children with difficulty breathing and low oxygen levels or poor feeding need admission to hospital. More severe cases may need additional respiratory support, or even admission to intensive care. Antibiotics are given if there is evidence of bacterial pneumonia or infection. Hospital admission may last from a few days to two weeks or more.

How can I stop my baby getting RSV?

So how can we protect the most vulnerable little ones in our community to stay well and out of hospital over the RSV season? Up until very recently in Cayman, infants under two years of age with identified risk factors for severe RSV infection, were offered monthly injections of a very expensive monoclonal antibody called Palivizumab (Synagis) during the RSV season. Monoclonal antibodies are laboratory made proteins that mimic the immune system, providing antibodies that are ready to fight RSV infection. There is now a newer monoclonal antibody available here in Cayman, Nirsevimab, for infants born with risk factors for severe RSV infection. This is a single injection given once from the first week of life up to the age of 24 months. It is not available on island for otherwise well infants.

In the UK maternal vaccination for RSV (Abrysvo) is now routinely offered all year round to pregnant women from 28 weeks to 36 weeks gestation. In the USA the vaccine is offered through the RSV season from September to January to pregnant women 32 to 36 weeks gestation. The RSV vaccine is a recombinant vaccine, which means that it does not contain any live or changed version of the virus, but rather an extracted protein from the virus. By vaccinating with this specific protein, the mother’s immune system is boosted creating more antibodies which help protect against RSV infection. These antibodies can then cross through the placenta and into baby, so at birth baby is born with RSV antibodies ready to recognise and fight infection. This is known as passive immunity and can help reduce the risk of severe RSV infection and its complications by 70 percent in the first six months of life. It also helps protect mum from RSV infection and further reduces exposure of RSV to baby. RSV antibodies can also be passed through breast milk to the baby. With each subsequent pregnancy, RSV vaccination will be recommended to the mother to boost her antibodies and therefore her baby’s before birth.

The RSV vaccine has a good safety record and has been approved for use in the UK, Europe and USA, and to date more than 100 000 women in the USA have had the vaccination. During the vaccine trial, it was seen that slightly more babies were born premature in the vaccine group compared with the control group ( pregnant women who did not have the vaccination). This very small difference is thought due to chance with no link shown between the timing of the vaccination and giving birth. Vaccine safety will continue to be monitored and overall it is still safer for you and your baby to have the vaccine than to risk baby getting an RSV infection.

Is RSV vaccination available for pregnant women in Cayman?

Unfortunately RSV vaccination is not yet available here on island for expectant mothers. In the interim, the most vulnerable infant group will receive Nirsevimab to protect against severe infection and there are some simple preventative measures that can be followed to help reduce the spread of RSV. Teach your child to sneeze or cough into their elbow or a tissue rather than using their hands and practice good hand hygiene. Keep frequently touched surfaces including toys clean. Keep your child with cold symptoms, cough or fever home from day care or play dates until their symptoms subside. Avoid sharing drink bottles or utensils amongst family members.

If you have a newborn baby at home make sure visitors are free from colds. For those with a toddler and baby at home, hand washing is very important and encourage your toddler to kiss or touch the feet of baby rather than kiss baby’s head. Keeping your house smoke free is very important as RSV infection is much more severe in infants exposed to second hand smoke.

Although RSV vaccination is not currently an option, if you are pregnant please discuss both whooping cough and flu vaccination with your OBGYN. These vaccines are both readily available on island and recommended. The whooping cough or pertussis vaccination (Tdap) is given all year round to pregnant women from 28 weeks, and provides passive immunity against whooping cough for baby, until baby is old enough to commence their own vaccination against whooping cough starting from 2 months of age. The flu vaccine is recommended at any stage of pregnancy to protect pregnant mothers from Influenza and is available during the winter flu season.

I think my baby has RSV, what do I do next?

If you are concerned your baby may have RSV it is important to see your paediatrician, especially if your baby is less than three months old or has a high fever, is feeding poorly or unable to sleep, or shows signs of increased breathing effort. This may be noted as a fast breathing rate, a prolonged noise on breathing out (wheeze), head bobbing, nostril flaring, tugging in the lower centre of the neck or using the belly to breath.

How do you test for RSV?

When a child or infant presents with suspected RSV to Integra we are able to do a quick nasal swab for bedside testing (similar to a lateral flow) to confirm the diagnosis within 15 minutes. If RSV is confirmed, we will give both verbal and written information about RSV and what to watch for at home (red flags or safety netting) along with a supportive care plan. If there are concerns your baby or child is more unwell or needs additional support, we will arrange admission to the paediatric ward at George Town hospital where we will continue to monitor and care for your child until they are safely ready for home.

My baby has a cold and cough, what should I do?

For infants and babies with cold symptoms, nasal saline drops can help clear the nose, using one to two drops in each nostril. It is important to make sure babies who are breast or bottle feeding have clear noses before feeding to allow them to breath while sucking. Bogies or boogers may be suctioned out of the nostril using a bulb suction or nasal aspirator. Over the counter medication Tylenol or Calpol (acetaminophen) may be used if your child is miserable or has a fever. Please do not use any over the counter cough mixtures unless directed by your paediatrician and do no offer honey to any infant under the age of one to sooth the cough. Offer smaller amounts of fluid more often and monitor wet diapers or urine output. If baby is feeding poorly, is having less wet diapers or you are worried about your baby’s breathing see your paediatrician. Any infant less than three months of age with fever more than 38 degrees Celsius or 100.4 Fahrenheit is considered high risk and must be seen by a doctor immediately. Always listen to your “mothers gut”, if you are worried about your baby or child, please see your pediatrician.

For further information regarding RSV, Bronchiolitis and RSV vaccination for mothers, please click on the links below:

https://vimeo.com/708709904/7c5ce8bc96

https://www.what0-18.nhs.uk/professionals/gp-primary-care-staff/safety-netting-documents-parents/bronchiolitis