Burden of disease - A focus on acute respiratory viruses in older adults

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. Today's hot topic is the burden of disease of acute respiratory viruses, so we're talking about RSV (respiratory syncytial virus), SARS-CoV-2 and influenza, and about the impact for older adults. This episode is one of three in a special series on the burden of disease of such viruses brought to you by ESWI, the European Scientific Working Group on Influenza. I'm your host, Clare Taylor, and I am very happy to introduce our expert guests today. Stefania Maggi, ESWI board member, geriatrician and epidemiologist specialised in the epidemiology of ageing. Hello Stefania.

Stefania Maggi: 1:13

Hi Clare.

Jane Barratt, Secretary General of the International Federation on Ageing, and a woman with a deep and abiding interest in adult vaccination. Welcome, Jane.

Jane Barratt: 1:24

Good to be with you, Clare.

And finally, Kirsty Short, a virologist at the University of Queensland. Good to see you again, Kirsty.

Kirsty Short: 1:31

Good to be back.

What a super group of women we have here. Our regular listeners may remember Stefania and Kirsty from previous episodes of ESWI Airborne. Kirsty, you're a member of ESWI's Influenza Diabetes Community and contributed to the discussion on the burden of flu for people living with diabetes. And Stefania, I remember your insights on how to reduce the burden of disease in older adults. Now, Jane, as the newbie, you are especially welcome here. Along with your own considerable expertise, I was interested to note that the IFA, your organisation, the International Federation on Aging, represents the interests of over 75 million older people. A very impressive number. So, folks, I think we're very well set up to dive into this important topic, and I think we all understand how timely this is, given that acute respiratory viruses have been in the news in the recent times. Of course, SARS-CoV-2, since the world changed in 2020, and RSV and flu really hit the headlines in this past winter 2022-2023. So, I'd like to ask our distinguished guests to tell our listeners about the impact on older populations. Stefania, perhaps we could start with you.

Yes, sure, thank you. Well, I feel indeed that during the past year, many regions of the world had to face simultaneously the outbreaks of three virus infections, Covid-19, influenza and RSV. While, you know, most of healthy adults can deal with respiratory disease, with very small and little symptoms, for older individuals often affected by frailty and by co-morbidities, these diseases can really be serious and can lead to hospitalisation and also to death. Moreover, these infections, respiratory infections can really have a negative impact on coexisting diseases, causing an exacerbation of diseases such as COPD (chronic obstructive pulmonary disease) or asthma. And you know, for example, older people with comorbidity are four times more likely to be hospitalised and two times more likely to die because of these conditions. That's why it's a major impact on the older population and, with regard to COVID, I think that what we have learned about long COVID has really increased the awareness that infectious diseases, respiratory infectious diseases in older individuals, are not just acute episodes, self-limited in times, but might have a long-lasting impact on the health and on the functional status of older people.

Jane, do you want to come in there and give us your perspective?

Certainly, Clare.

I think it's really important to recognise that RSV is well recognised among the paediatric population, but it's not so well recognised in the community among older people. And, as Stefania said, you know, those with underlying co-morbidities. You know the chronic medical conditions that, you know, as we get older, there's a likelihood to have more and more, as Stefania said. I think one area that we don't really touch on is, you know, the RSV is the cause for many hospitalisations with moderate to severe influenza-like symptoms. And the global burden of the disease in this population is not well known at all. And we've seen from the pandemic that those that are in residential care facilities or those living in the community with services, you know, they are really particularly at risk. And it's not only the older people, it's the family network around them that is actually part of the care system. I think one last point that I'd like to make, and it really comes from a publication, a 2020 publication in JAMA (The Journal of the American Medical Association), and it was Jung Jun Chung and Takahashi. You know they did an extensive study of over two and a half thousand people across two RSV seasons and it really revealed that a great deal more work needs to be done in examining the long-term impacts on the health-related quality of life. And it's this quality of life that we need to be examining as well with these respiratory infections.

Okay, we've got a lot of unpacking to do during this episode. I think, just from the aspects that you touched on there, this quality of life is very important and the transmission. We really need to come back to that. Kirsty, what's your opening salvo in this great debate?

So I mean I'll just talk briefly because I think this was covered really nicely by my colleagues. But what we're seeing here in Australia is that COVID-19 has really become a disease of the elderly. So now nine out of 10 deaths are happening in individuals who are over 65. We know that their immune response to the COVID-19 vaccine, as well as other vaccines like influenza virus vaccine, is suboptimal. So there's really a lot from the vaccinology perspective, as well as the public health, that we can do to protect these individuals.

Kirsty, if we just stay with you for a moment, is this, well, a natural consequence, should we say, or are pandemics always worse for older people?

It depends on the pandemic. So I always tell my mother when she was complaining during the height of COVID-19 about why she had to stay at home and I was relatively risk-free, and I told her that she was living through the wrong pandemic. Because in 2009, for example, individuals who were older actually had some cross-protection against the virus, so they really didn't do as badly as they would in a seasonal influenza. Similarly in 1918, so the so-called Spanish influenza pandemic, what we know is that the death rates were particularly high amongst middle-aged individuals, so 25 to 35. So it really does depend on the pandemic and the virus. But I think we've always got to be very wary for vulnerable populations and, as Jane mentioned, even if age isn't a severe factor, we do have a lot of these other underlying co-morbidities in older populations and we know that these co-morbidities are risk factors for severe viral disease.

So, when it comes to looking at different ways that we can mitigate these risk factors, Jane just touched on transmission, but what do we know about respiratory virus transmission for older people?

I can answer from the SARS-CoV-2 perspective. We know from household transmission studies that older individuals are more likely to contract the virus, which obviously becomes particularly problematic because they're the individuals who go on and experience severe disease. So definitely, what we would call this sort of immunocompromising nature of age extends not just to the response to the virus but also the acquisition of the virus.

Yes, if I may add something, I think that the problem really in older people is the fact that they might have also atypical symptoms compared to the typical respiratory symptoms and therefore the diagnosis is more difficult and often is not really done. On top of that, even when respiratory symptoms are the typical ones, clinicians tend to think more to, for example, a flu instead of RSV and therefore we have a misdiagnosis. And, last but not least, often the diagnostic tests are not available and therefore the underdiagnosis of RSV in particular is really very, very frequent in the older population.

So, when it comes to look at the kind of official responses to this situation, what can we say about how governments, public health administrations and even civil society react? What has the response been like for at-risk populations, including older people in the pandemic, where it was kind of cocooning and shielding, but also with regard to routine immunisation?

I think, in terms of the pandemic, there was a lot that we could have improved on in terms of the protection of older individuals. So disproportionately around the world, we saw that care homes have very high mortality rate from SARS-CoV-2. We also have incidences in countries, so without naming certain countries, who released people back into care homes from hospital without doing SARS-CoV-2 testing, leading to sort of seeding of new outbreaks. So I think there's a lot that we can do, in particular in regards to aged care, in looking at how we can better protect these vulnerable individuals in a pandemic scenario.

Yes, I would also add that during the pandemic, there were major recommendations actually made by international agencies such as WHO and by national governments. They were all stressing the need to improve the surveillance. But unfortunately, we have major differences in terms of surveillance systems across countries and this, I think, from the public health point of view, is really a very important problem. There were strong recommendations about improving the vaccine coverage for flu and for COVID-19 in order to avoid the differential diagnosis and all the clinical troubles we might have with that. But the adherence to this recommendation across countries and even across the region within countries such as Italy, were really very, very different. And I think that the need to increase the awareness of the relevance and the importance of infectious disease in older population is still one of the very important points.

But why do we have this lag? You are talking about official bodies with responsibility for public health and putting forth the information and then this delay or this, you know, lag in policymaking to respond to the scientific evidence. Jane, do you want to talk about this?

Look, this is such a complex and important topic, but I want to put the pandemic conversation separate to routine immunisation. And I think during the pandemic, knowledge was evolving almost by the day and so it was really difficult for scientists and policymakers to be on the same page and communicating. That's one problem. But really, I think we really need to talk about whether older people have the same value proposition in society as younger people. You know it's something called ageism and we saw it in the pandemic in many, many countries where decisions had to be made because there was either a shortage of vaccine or an inability to get older people to be vaccinated, you know, physically, or it was infection control. And I think we really have to address this as part of our push for a life course implementation of immunisation. You know we've got institutional ageism, interpersonal ageism and self-identifying ageism. We even saw some older people saying: give it to my grandchildren before you give it to me, right, because my life is almost over. You know, one in two people, as reported by WHO, are ages towards older people, and so you know we really have to look at our policy development and disparities, just in targets for immunisation. But if I can put that aside and it's a big topic for one minute.

You know, there's a historical issue where ministerial portfolios don't talk to one another. They're not well integrated. So finance don't talk to public health, don't talk to aged care. Also, policies are often about political cycles and that's the reality of it. You know, austerity measures impact short-term economic decisions, and that's what we're seeing now. And policies are optimally underpinned by evidence, but most countries don't collect, nor do they have systems in place to track and gather age-disaggregated data. So it's a very complex issue. And that's before we even get to the problem of why don't older people go and be vaccinated. What are the barriers to them being vaccinated, even if it's free, it's accessible, et cetera. So I look at the modifiable barriers that we can deal with, but it's a big topic.

It certainly has. I feel like you've opened three cans of worms there Jane. Here we are. Policymakers certainly had my sympathy during the pandemic. Who would want to be one with, you know, the situation evolving day by day. And thank you very much for making that distinction for us, you know, between an emergency unfolding situation and routine immunisation. This is a really important point, as well as the excellent advocate that you are of highlighting the serious issue of ageism. And I remember those stories of, you know, no, the end of my life, give him the ventilator. You know, I remember these kind of popular stories in the media at the time. So how does an organisation like yours in the field of aging, how do you get involved in the area of immunisation? How do you act in this area?

We have an absolute responsibility. We have to stand up against Stefania and Kirsty and we have to work across sectors and across disciplines. If we don't have that, then we don't have a common agenda. And all three of us on this podcast today have a common agenda, but we come to it from different perspectives. You know, the IFA comes to it from three pillars: prevention, access, equity. And we do that because that frames the understanding of, is there the education? Is there the narrative? Can people access? Is there the health literacy? And then you've got the access piece, and that ranges from timely, affordable vaccines to just how do we actually get through the system to be vaccinated. And then equity, we really have to look at the social determinants of health. So it is fundamental to our work in bringing unlike together. So when we are advocating for changes at the WHO or at a national level, we'll bring the diabetologists along and the patient groups, because we're really focusing on an end outcome, which is improving the uptake rates of adult vaccination. So it's an easy place for us to be and it's an easy place for us to stand aligned alongside, you know, professionals like Stefania and Kirsty.

Prevention, access, equity. Have I got it? And Kirsty, if you can come in now from a virologist from where you're coming from and tell us about what's the state of play for vaccines, you know, for the different acute respiratory viruses.

Well, I think we're in a pretty exciting stage in terms of vaccines. We've got the first RSV vaccine through phase three clinical trials and, you know, the particular target of that is for the elderly. We've got flu vaccines that are tailored for the older population, so these high-dose vaccines. And then with SARS-CoV-2, we're in an interesting situation where we know that as you get older your immune response to the vaccine becomes a bit suboptimal. So we have these individuals prioritised for boosters. But what I'm hoping in the future is that we will start to see more tailored versions of these vaccines, much more like you tailor the flu vaccine for different populations, such that we can address some of these issues of waning immunity with age. I think the other really exciting thing about vaccination is the combination vaccines that are on the horizon. I can't wait to see the day where I rock up to the doctor and I get my COVID, flu and RSV vaccine all in one go. So I think we're in a really exciting position.

And if we can just stay with that, like, how far away are we from offering combined vaccines?

I think it depends, but certainly in some of the policy meetings that I've sat in on, in the Southern Hemisphere at least, is we're hopeful that perhaps by next winter so that would be July next year that there might be something available. Now, whether or not that will come to fruition I don't know, but already having such optimistic expectations, I think, is a good sign.

So perhaps by next winter in the Southern Hemisphere. And, Stefania, is this I mean okay, for what's actually happening now are at-risk populations such as older people and those with chronic conditions. Are they getting multiple vaccines at the same time? Is this a realistic prospect?

Well, for now, what we really aim is to never miss an opportunity and to take any chance to vaccinate people with even co-administration of, for example, covid vaccine and flu, because this has been demonstrated does not decrease the effectiveness of the vaccine and they are safe even if co-administrated. So we have to take advantage really of any contact the patients, the older patients, have with the system to administer more than one vaccine. And I think it is really realistic to think that we will have a combination of vaccines, such as curcimation, and they would be really precious because you know, it would be too much to ask older people to get in contact with the health system to get the RSV, covid and flu vaccines at different times. So really, but I think that the technologies are really advancing and making major, major progress, so it is realistic to think that very soon we will have them available.

This is much sooner than I thought. Yeah, this prospect I was waiting for Kirsty to say years away, but perhaps by next winter. Indeed, in the Southern Hemisphere. Jane, you've obviously got like a number of different fronts that you're advancing simultaneously, but what's the next step for you? I mean, what's that outlook from here on how we make progress on this issue?

Clare, I'm cautiously optimistic about the future. But we have to work at a vertical level as well as a horizontal level. Vertically we've got to, civil society has to work to help to join up into governmental agendas like the UN Decade of Healthy Ageing, the WHO Immunisation Agenda, the Global Report on Ageism and the work of the NCD Alliance. So, making those connections and the pull through of the importance of routine immunisation, I think fundamentally we should be calling for an increased investment in infrastructure and the percentage of GDP to be significantly increased towards health promotion and prevention and therein, immunisation. You know, at a country level, it's about targeting those modifiable barriers, understanding the policy gaps and looking at the low hanging fruit. You know there were policy changes within the pandemic that actually shifted the needle to improve uptake rate. How can we use those now in routine immunisation? And, of course, WHO will be coming out very soon with the big catch up, and that's about catching up on your routine immunisation and looking at the delayed response that we've had across the world.

My last point really is, this is a global issue. This is not high income versus low income. You know. We really have to use all of our levers and all of our intelligence to connect across the world. Because, you know, less developed countries, we have a lot to learn from the way that they actually build momentum at a community level and vice versa. You know, some of the surveillance systems and the technology advancements really help in terms of how do we explore the narrative and improve uptake rates.

That is the last word folks. Invest in public health, routine immunisation. This is a global issue and we do indeed live in one world. That's all we've got time for today, folks. Thanks to each of you, Jane, Stefania and Kirsty, for sharing your expert insights with us today. Thanks for tuning in and don't miss the other episodes in this three-part ESWI Airborne series. We'll be talking about long flu and long COVID and how to deal with lingering acute respiratory viruses, and we'll also be diving into the economic and societal impact and crunching the numbers on how people and businesses are affected. Get your information directly from the people working on the front lines of viruses, vaccinations, ageism, public health and more from the members of the European Scientific Working Group on Influenza. Until next time, dear listeners, stay safe.

Aida Bakri: 26:12

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 - A focus on acute respiratory viruses in older adults

ESWI Airborne: Burden of Disease

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ESWI Airborne: Burden of Disease