Burden of disease - The economic and societal impact of acute respiratory viruses

Aida Bakri: 0:00

Welcome to ESWI Airborne. This podcast series on the burden of disease is made possible thanks to the kind support of AstraZeneca, BioNTech, GSK and Roche.

Clare Taylor: 0:34

Welcome everyone to ESWI Airborne. This is your host, Clare Taylor speaking, and today we're talking all about acute respiratory viruses like COVID, RSV and seasonal flu, what the economic impact is and, most importantly, what this means for people. A tiny reminder, this episode is one of a three-part special on the burden of disease of acute respiratory viruses brought to you by ESWI, the European Scientific Working Group on Influenza. Now we have a real super group here with us today and I'd like to introduce them. First up we have ESWI board member Colin Russell. Good to see you again, Colin.

Colin Russell: 1:08

Great to be here, Clare.

Colin has a super title: Professor of Applied Evolutionary Biology at the Amsterdam University Medical Centre, and regular listeners to ESWI Airborne may remember Colin describing how he uses mathematical modelling to predict virus evolution. If you haven't heard it yet, check it out. It's well worth a listen. Next up we have Elizabeth Kuiper, also with a super title: Associate Director and Head of the Social Europe and Wellbeing Programme at the European Policy Centre, a well-established think tank here in Brussels. Welcome to ESWI Airborne, Elizabeth.

Elizabeth Kuiper: 1:46

Thanks so much for having me.

And, finally, a man with an award-winning history of innovation for social change George Valiotis, the Executive Director of the European Health Management Association. Hello, George.

George Valiotis: 2:00

Hi Clare, it's a pleasure to join you today.

Well, thank you so much to all of you for being here. Colin, maybe I'll start with you, because you are, after all, a great man for the numbers. Now, RSV, in particular, was in the headlines during the past winter, but when we're talking about acute respiratory viruses, typically, how many people will be taken ill in a given season?

Well, to start, I think that I have to be a little careful about being a great man for the numbers, but I will say some numbers now. Now, when we talk about acute respiratory viruses in general, we're talking about millions of infections, hundreds of thousands of hospitalisations and hundreds of thousands of deaths. When we speak about RSV specifically, RSV is understudied compared to a lot of other respiratory viruses. This is changing, but we're still in the process of really trying to uncover that burden. So there are great studies out there by people like John Padgett, who's associated with ESWI, and Harish Nair as well, and if you're really interested in this, I suggest looking that up. But the sort of headline numbers are that in children under the age of six years, there are roughly 33 million infections per year. This results in hundreds of thousands of hospitalisations and approximately 100,000 deaths every year. Now I always find the more striking statistic there that for children under the age of six months, one in 25 deaths, roughly speaking, is associated with RSV infection, and to me that's genuinely shocking. Now, on the other end of the spectrum, we have the burden of disease in the elderly and other at-risk groups, and this is something where, for diseases like influenza, we have a much better handle on what that burden looks like. But for RSV it's comparatively understudied. Studies that have been done show that there are certainly millions of infections, hundreds of thousands of hospitalisation and at least tens of thousands of deaths. But that burden in particular is primarily calculated from high-income countries and the burden in low and middle-income settings is barely understood at all.

Well, they are really some very shocking numbers. George, is this territory familiar to you? What's your take?

Yeah, absolutely, the numbers are really concerning and I think for me, more concerning is that RSV represents an infection that people are almost used to, they don't think about and so on a social level, we don't prioritise it in terms of policy resources and healthcare resources. Where we do see it addressed in hospitals and primary care is in routine settings and in responding to families who need care. But certainly what we saw. So we did a study at the European Health Management Association trying to understand what the burden of RSV is in the health system. We looked at both the primary healthcare setting and also at hospitals. And what we found was that there was a significant burden, especially around the peak RSV season. So people describe that as being around November, December, January, but it can vary, give or take a couple of months, and certainly we saw a massive use of bed resources in primary care for babies. We also saw the same in emergency care for babies. So our focus was really on babies, but we do know that older people are also affected. And the reason we did this study is there is, as Colin referenced, there's really limited data to understand what the actual impact is, so we wanted to at least figure out, since we don't have any epidemiological data on the overall European studies, the overall European prevalence. What you can find is local data around what hospitals might be keeping, but that's about it. And often RSV is not diagnosed effectively or misdiagnosed for other respiratory infections, so we really don't have a proper understanding of its impact. So that's why we took this approach of asking actual physicians, people working in primary care, nurses, doctors working in emergency care, in pediatric wards around how they saw RSV, what resources it consumed and how it impacted families. And certainly what we found was significant. You can check out the study on our website, ehma. org, where we've got this white paper on the impact of RSV but certainly we saw that it has a major impact.

Elizabeth, what can you contribute to this about how these more at-risk groups, the very young, babies and older people, are affected?

Well, I think it was very clear from what both Colin and George mentioned in terms of the data that indeed a lot of people don't realise that diseases of the respiratory system are one of the main causes of death in the EU and, as you say, it's very striking that indeed, especially children and elderly people are affected by it even more. And I think it's very clear from the data that indeed, almost every child is affected by RSV by the age of two. And I think later during this conversation we're going to speak also about causes like air pollution, where indeed you see that because of the fact that children are shorter than adults, RSV has a very different impact on them. And I think, also, coming back to elderly people, we all learned during the pandemic that older people have waning immunity and increased frailty, so people in nursing homes or long-term care facilities are particularly at risk, and especially, I think, for RSV. This is indeed a very understudied area where we need more data to have more specific approaches in place to tackle this.

Okay, that's great, thank you. Now, obviously this is a serious effect at the kind of individual and family level, but what can we say about some of the wider consequences or knock-on effects for the health system, George?

So the knock-on effects tend to be that, if you require, we saw this in COVID. So it's the same thing in COVID, where you are putting all of your resources into one particular thing and it means then you have less beds, you have less appointment spaces for other people that might need care. And the reason it's concerning for RSV is it's preventable. So a preventable disease is what is consuming a lot of resources. Now, if it wasn't preventable, we would have to realign resources. But because it's preventable, what happens is every year we can predict that there'll be a peak around the season of RSV, so we can reallocate resources. However, the healthcare system has very limited resources. We've all been seeing that as what's come out of COVID. So we're relying on a lot of overtime from staff. What we're seeing and what people reported in our study was a lot of burnout, a lot of fatigue. It's a real problem for the overall wellbeing of the workforce because there simply isn't the resources to countermeasure that.

And Elizabeth, what consequences do you see for systemic consequences?

Well, it's really the wider health systems resilience I think that is at risk. Because indeed we have seen with a pandemic also the consequences for the health workforce, staff shortages within hospitals and healthcare centers due to infection and, I think, at large, the COVID-19 pandemic revealed deep-rooted inequalities in European healthcare systems, where indeed the peak rise in RSV infections and hospitalisations occurs between October and March. So there is acute pressure on primary care providers that we have to deal with and I think, broadly speaking, I think there's also specific communities that are disproportionately affected. For example, if we think about people with lower socioeconomic backgrounds also, for example, Roma people, travelers, people that are, when it comes to housing conditions, in overcrowded or multi-generational accommodations, where there may be a higher risk factor for respiratory infections, or people in low paid occupations, where indeed there are unhealthy working conditions. So this is not just a public health concern, it's also, I think, a much broader societal concern.

Indeed and not a burden that is shared equally, let's say, among different groups in society. In terms of what we know about how fast viruses move, Colin, you're certainly the man for this. But the group that we're talking about here RSV, Covid, the flu, do they move through the population at different rates? How do they compare?

That's difficult to answer with any authority, in large part because it depends on exactly what setting we're talking about. But one of the key things about RSV is that it spreads remarkably efficiently. Just like Covid, just like flu, it spreads very fast and, particularly amongst young children, it spreads incredibly quickly. And this is one of the things that really does contribute to the overall burden of disease, which is that it is so remarkably good at spreading.

And how can we slow the rate of spread?

Well, right now, there are basic things that we can do that we learned all too well during the pandemic. Things like social distancing and face masks. They work, they really do and, granted, it's not 100% reduction, but it does work to slow things down. And in terms of reducing burden, that's really what we're talking about. Just slowing things down. Now in the next few years there are exciting things on the horizon in terms of new vaccines that are in late stages of clinical trials right now, such that they could be rolled out in the following few years, and that will help to bring things down further. But even before those vaccines are available, we can just do sensible things like staying a little bit further apart or, if we can't stay far apart, putting on masks, and it will help to reduce spread.

And I was interested in what George had to say about sort of predictability, peak season and so on, like in a given setting, are certain patterns now of spread predictable for you?

The short answer to that is no. The longer answer is that there is a disappointing reality to what we can predict, which is that this year, just like last year and the year before that, there will be an RSV outbreak and it will likely be severe and it will likely be a substantial burden on public health resources and on individuals and families across Europe and across the world. But beyond that, there isn't a lot that we can predict.

Elizabeth, what kind of policies are suited to prevention?

Well, we already spoke about influenza vaccinations, where I think it can be argued that many of the deaths and some of the costs because again, this is not just a public health concern but also there's an economic angle and side to it so indeed all of this associated with influenza epidemics can be avoided through a wider uptake of influenza vaccinations. I think a really important point is also the importance of improving data collection and surveillance, because we need to have these in order to develop more granular policies. If you think, for example just to mention one example, about the fact that a higher proportion of males than female die because of RSV, and that may have to do with the fact that there may be different smoking habits or, let's say, occupational risk, where also extractive industries such as coal mining sometimes affect more men than women, we need to have these data to develop more targeted policies. But also, if you think about the intersection between health, animal and planetary health, which we now call One Health, it's also really important to look at something like air pollution. Because air pollution is the largest environmental health risk in Europe. And there again, we need to realise that we need to take a holistic approach where all of this comes together. Because, again, we spoke about children and elderly people. Children are shorter than adults, so they're closer to the ground, if you think it more practically, and therefore the exhaust pipes of vehicle impact them differently. Also, young children breathe faster, meaning that they take in more air. So therefore, you can see that a topic like air pollution is not just something that we need to tackle as part of the green agenda, but also as a public health concern.

Thanks very much for that, Elizabeth. And I see, Colin, that you're enthusiastically nodding at the mention of data and surveillance.

I think my enthusiasm there comes from the disappointing reality that we don't have a good handle on the true burden of RSV. Because, compared to diseases like influenza or COVID, which are comparatively well studied, there has just been less attention given to RSV. And to that end, I think, particularly in older individuals, we are missing the true burden there. And so there, more systematic surveillance and more careful attention to the true infection status in the elderly is going to yield valuable information that I think is going to dramatically reshape our estimation of the risks and the burden posed by RSV.

That's great, thank you very much. George, when you're looking at this through the health management lens, what makes the most sense in terms of public health resource allocation?

What I found really interesting hearing from both Elizabeth and Colin and the need for better data and better understanding, like I agree entirely. Once you get into the health system, though, we just need immediate solutions. So, from the health system perspective, I'd say we know enough. We know that almost all children get RSV, we know that it is affecting children and adults and elderly people, and we know that we're having to deal with this burden every single year routinely. So we know we need immediate action. We've talked already today about existing prevention that we can use hand washing, better air ventilation and what we also know is that that is not enough in itself. So we really need better prevention options, things like immunisations. We need to give people immediate protection so that they don't have to worry about this burden, especially for people who are immunocompromised, people who simply cannot sustain being infected and actually getting through that safely. We need to provide them with a better solution. So, from the healthcare perspective, we want to see healthier people so that they're not coming to hospital and they're not going to primary care, and we can do that not just through routine prevention, but also we need to see an immunisation programme.

That sounds like a serious and underreported burden I would say. Here I suppose I think of the recent pandemic and how it changed all of our lives and health policy in Europe was really in focus and evidently quite fragmented. Elizabeth say, what's this talk of a European health union all about?

quite a big question, but I think, in light of this conversation, I think it's really the European answer to COVID, because Covid was already pretty early on during the pandemic I believe it was May 2020, that the French President Macron said that we needed une Europe de'une la Santé, so santé', a European Health Union. So, indeed, later that year, the European Commission President von der Leyen announced that indeed, she would want to work on the creation of European Health Union that would have different pillars. So one of the pillars obviously was a pandemic preparedness, because it was true and it was very clear, I think, for everyone back then that we needed more competences for the agencies at European levels, or the European Medicines Agency and the European Centre for Disease Control, but Control, but general, that we also were becoming better prepared for future pandemics. But, equally, one of the pillars of the European Health Union is the European Health Data Space, and it really comes back to what we said about the need for data collection. It's something where we need an infrastructure at European level to work on data, to use it for research. But equally, the European so-called pharmaceutical strategy is another pillar of the European Health Union. So, I think, for the sake of this conversation. It's, conversation, it's one hand, very positive again that there's much more attention to health at European level. On the other hand, I think the focus of the institutions, as well as member states, is still very much on pandemic preparedness. Because, you know the minute and I think that's oftentimes what happens in healthcare the minute healthcare, the crisis mode is over, we go back to that question of, well, is health a European issue after all? And all these heads of states that have to explain in their capitals that healthcare is something to do with your local hospital, perhaps in your region? No, it's also to do with something you know level, and I think, especially the fact that RSV is such an understudied subject. As we as where in need, member states can learn from each other. They can and should share best practices. Again, we It's very important that again broadening the mandate of the European Health Union include prevention,. Include better sharing of best practices in area of respiratory viruses, because we. Because European elections coming up no-transcript. so I think it is very important to to keep that on the agenda and t m w b d o t

Colin, have you heard of the European Health Union and do you think it could help in amassing those vast tracts of data that you love to crunch?

Indeed I have, and, just as Elizabeth was saying, more coordination amongst the EU member states for diseases, particularly for diseases that don't have any respect for political borders, almost inherently has to be a good thing. But I think that Elizabeth also alluded to one of the potential risks, which is that politicians have to go back to their respective countries and make the case for health over and over and over again. This is something that every country faces individually. But particularly when we get to the European level, there is a risk that bureaucracy will slow down our ability for something like the European Health Union to do anything meaningful. Provided that it is able to act efficiently and in the interests of health I think that that level of coordination is nothing but a good thing is nothing but a good thing, and that we can be better protected against the next pandemic but also potentially do a better job of combating known threats that we confront day to day with better coordination.

Well, let's hope for the best and follow that European Health Union developments carefully as it evolves. I think we've really well established the burden here and there's sort of like somewhat patchwork of responses at different level. But in terms of really what needs to happen next, George, what's your takeaway?

We need to immediately apply what we have already learned time and time again from Covid and every infection outbreak before then. Regarding RSV, we have a good enough understanding of the data to make healthcare decisions right now. We have prevention options, including ventilation and hand washing, and we know that there is a vaccination, and we need to see the implementation and engagement with all of those things right now.

Hear, hear. That was excellent message. Colin, what's your takeaway?

You know, as George was just saying, I'm somewhat shocked by the extent to which we have to learn the same lessons over and, over and over again. Nearly 100 years ago, we had the worst infectious disease outbreak in modern history. That was the 1918 Spanish flu pandemic. And if you look at the newspaper headlines from 1918, they look just like the ones that we saw during Covid, which is that face masks must be worn by everybody and wash your hands. And the simple thing, the simple fact is that these strategies work. They reduce the spread of disease and they are things that we can be applying right now. I also think that we need to look forward to the near future, when we are going to have vaccines and antiviral drugs as options for helping us to control the burden of RSV. And making best use of those tools is going to require that we have good data that clearly shows the burden of RSV, because, unfortunately, antiviral drugs and vaccines are going to cost money and we need to make sure that money is set aside for them, and that requires data.

This conversation has really made me newly aware of how acute the burden is and indeed, although perhaps nothing changes, let's keep pressing for positive change. Elizabeth, how about you? What's your last word?

Well, as you say, it's astonishing in a way that RSV remains so under-recognised, because, you know from the 50s we know about the negative impact and the importance of this virus. So it's really about raising public awareness, develop and implement clear prevention strategies. But, in general, I think it's also really about, again, a broader, moralistic approach. Again, One Health, where you look at the intersection between human, animal, planetary health and perhaps even you know, about the well-being economy, where we link all these topics together. And we at the European Policy Center are doing that. We are working on different projects, perhaps to indeed end with one project where we're working on the impact of air pollution. The purpose really is to draw attention to the topic and influence policymakers that have the power to protect people's health through policy. And again, knowing that in May 2024, so in almost one year we have European elections coming up and I think it will be really important for all of us working in this area to ensure that the topic remains high on the agenda and also that the next mandate of policymakers keep this very seriously.

And let's hope that this episode of ESWI Airborne contributes in its own small way to raising that awareness. That brings us to the end of today's episode. Colin, George, Elizabeth, thank you so much for taking the time out of your busy schedules to be with us today. Folks, thanks for tuning in and don't miss the other episodes in this three-part ESWI Airborne series. We're talking about long flu and long COVID and how to deal with lingering acute respiratory viruses, and we've also got a particularly dynamic episode on the burden of disease for older people. Don't miss it. Keep on listening and learning from the people working on the front lines of viruses, public health, policy development and, of course, members of the European Scientific Working Group on Influenza. Until next time, dear listeners, stay safe.

Aida Bakri: 24:47

ESWI Airborne is brought to you by ESWI, the European Scientific Working Group on influenza and other acute respiratory viruses. These episodes would not be possible without the team's efforts and we would like to extend special thanks to our ESWI secretariat, our technical and IT teams, our arts team and our host, Clare Taylor. The podcasts are recorded virtually and we thank our guests for their participation in this inspiring series. Talks are adapted to a global audience and are intended to be educational. For any specific medical questions you may have, these should be addressed to your local general practitioner. Many thanks to our sponsoring partners and thank you for listening.

Burden of disease - The economic and societal impact of acute respiratory viruses

ESWI Airborne: Burden of Disease

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ESWI Airborne: Burden of Disease