intro: Welcome to Pediatric Voices, Duke Children's podcast about kids' healthcare. Now, here's our host, Dr. Richard Chung.

Richard J. Chung, MD (Host): Hello, and welcome to Pediatric Voices, expert insights about timely topics in children's health, brought to you by Duke Children's Hospital and the Department of Pediatrics at the Duke University Medical Center. My name is Dr. Richard Chung, a physician at Duke Children's and a co-host of this show.

Today, we'll explore several hot topics in the world of infectious diseases. This winter, there are multiple viruses circulating, including COVID-19, respiratory syncytial virus, and influenza, which can impact children, as well as an evolving landscape of immunizations available to prevent infection. To help us understand these issues better, I'll be speaking with Dr. Ganga Moorthy. Dr. Moorthy is an Assistant Professor in pediatric Infectious Diseases at Duke University Medical Center and an Assistant Research Professor at the Duke Global Health Institute. She serves as the Medical Director for Pediatric Antimicrobial Stewardship in the Duke Center for Antimicrobial Stewardship and Infection Prevention. Welcome to Pediatric Voices, Ganga.

Ganga Moorthy, MD: Hi, Richard. Thank you for having me.

Host: Yeah, I really appreciate you making time in your busy schedule for these critical topics. You know, before we jump into all things viral infections, let's actually start with you, Ganga. Tell us, how did you get interested in children's health and becoming a pediatrician?

Ganga Moorthy, MD: Yeah, that's a really interesting question. I grew up in rural Oklahoma without access to a pediatrician and I spent my summers visiting our family in India. And I think I saw the importance of childhood healthcare and the ability for people to intervene early in life to affect long-term change. My mom is a Montessori preschool teacher, and my dad is a professor of Microbiology, so I sort of took the best of both of their careers and created my own. And when I arrived in medical school, I had really awesome pediatric mentors, and really enjoyed the ability to care for a patient and their family, and as I said, impact their long-term potential and their health through preventative and acute care, and to be able to create change through community-based partnerships and legislative advocacy and research.

Host: Excellent. I love that you sort of hybridized the teacher and the microbial scientist into a pediatric infectious disease doctor. You know, I think certainly pediatricians are scientists at heart, but we're also teachers very much so in terms of teaching the kids and youth that we care for, their families as well as each other. And so, yeah, that's a really great origin story as we like to call them.

So, Ganga, before we kind of jump into some of the immunizations and changes in that landscape and then some other more kind of technical issues around infection, what in general are we seeing in terms of viruses and such in our community? We had Dr. Emily Greenwald, one of our emergency room doctors, on the podcast very recently and she was sharing that certainly from their perspective, they're seeing a lot viruses as they typically do at this time of the year. But what have you heard from an infectious disease standpoint? What does this winter look like so far?

Ganga Moorthy, MD: Sure. So, you know, we're recording this at the beginning of January, and we're seeing an expected post-holiday spike in viral infections. This is not unexpected after the holidays with people gathering together and where the season typically follows. Here in the United States, and particularly in the South, there are fears of a COVID-19, RSV, and flu triple-demic, where all three viruses are surging around the same time. We saw this last year as well. And before we started this viral season, we had expected a triple-demic just given what we know about viral epidemiology.

Right now, influenza and COVID-19 are peaking in our community. Influenza is probably going to decrease before COVID does. We've stopped many of our COVID tracking measures that we've been using in recent years, particularly during the peak of the pandemic. Now, one thing that we're following is wastewater data and that helps us understand community transmission. Right now, the wastewater levels are very high, but this is a complicated measure that may not accurately track the number of cases. But we can say that there is a lot of COVID circulating in our communities through people shedding viruses. It's difficult predict when these peaks will happen. We think that COVID transmission may peak in the next two weeks, and influenza will likely peak in around the same time as well. RSV is still around, but activity is declining. Hospitalizations are decreasing. And we think that severe disease in children has likely peaked in the south and adults should follow soon.

Host: Got it. Thank you so much. That was a really helpful and very nuanced kind of perspective on what's actively going on and it's really helpful to understand where we are in this respiratory virus season.

We'll come back to kind of infection later on and specifically what families can be doing to try to prevent or at least mitigate the impacts on their own kids. But leading into that, there's been some changes in the landscape of immunization. You know, one of the big kind of news stories over the fall was actually the approval of an RSV immunization. Can you tell us a little bit more about what that was and what impact it has had so far?

Ganga Moorthy, MD: As you mentioned, there is a new RSV immunization available for infants. In previous years, we've had an immunization for infants. But it was really targeted towards infants who had medical complexity, and that immunization was called Synagis. The new RSV immunization is called nirsevimab, and it goes by the trade name of Bayfortis and is produced by Sanofi. It was recommended by the CDC and approved by the FDA late last summer, and began to be available around October across most of the United States. And what's really exciting about nirsevimab is that the data suggests that it could be helpful in a much broader group of infants, and has been approved for use in many more infants.

So, as I said, it became available in October and it's a seasonal immunization. And why it's called an immunization and not a vaccine is that it is actually a monoclonal antibody. And so, it is a passive immunization. We give babies antibodies against RSV directly. And the data suggests that it is about 80% effective in protecting infants from medically attended RSV. And so, what that means is that it is 80% effective against protecting your child from needing to see a doctor for RSV. It has been approved for two groups. The first is for every infant who is less than nine months of age during the months of October to March, which is typically when an RSV season occurs. And the second group are older infants who are nine to 18 months of age who have certain health conditions that would continue to place them at high risk for RSV disease if they got it later on in life.

Unfortunately, this RSV season, there was not enough supply of nirsevimab to meet the needs of the community and to be able to immunize every eligible child. And so, hospitals and clinics across the country have had to restrict use to certain groups of infants based on certain risk factors or predisposing factors, and they've been doing that based on the amount of product that they were able to acquire this season. The good news is that more infants were able to access RSV immunizations this year, and health systems and clinics are working with Sanofi to better meet the need next fall.

Host: Perfect. And so, RSV is such a critical piece of kind of the viral landscape. And we as pediatricians certainly know that. I think families often may not be quite aware of what RSV is and what role that plays, but this is such a substantial piece. And therefore, this advancement and hopefully with increased access into the future will really shift the landscape in terms of wintertime viruses and such. So, that's really great to hear about.

Another change sort of this fall was actually the new COVID vaccine as well. Can you share a little bit more about that? And maybe, stepping back, where are we with COVID-19? You know, I think I certainly was hoping throughout the pandemic that it would just kind of come and go and be a figment of our long lost imagination, but it sounds like COVID is here to stay at some level. Is that true or how should we be thinking about that?

Ganga Moorthy, MD: I too wish that COVID was a figment of our history, but COVID is here to stay. So, COVID is caused by a virus called SARS-CoV-2. And like all viruses, it changes over time. And it does that so it continues to stay alive and to infect hosts. As we expected with viruses, SARS-CoV-2 is changing, so that it may be more transmissible, but less deadly. And that is important because it keeps its host alive so it can continue to spread.

Similar to the flu, we see slight variations in the virus every year since 2020. And so, that means that we have to update our vaccines to better target the virus year to year. As I said, COVID is here to stay for the foreseeable future. We're likely to have a new vaccine every year that's formulated to target what the circulating strain looks like around that time. We'll have to see what happens in terms of seasonality of the virus. Right now, we're seeing that spikes are happening every few months. But it may become something that follows a clear seasonal pattern, similar to like what we see with RSV and influenza.

Host: And just to kind of follow the thread of COVID-19 just a little further, you know, one question we're getting a lot in clinic is just, you know, is it necessary, right, to get every next COVID vaccine that's coming up? You mentioned that there could be some evolution in the virus, maybe to increase transmissibility, but perhaps decrease the severity of illness or the risk of death from COVID-19. And to the extent that maybe many people in our community have had actual infection or at least prior vaccination previously, how do you usually think about it used yourself personally? And then, how do you talk to others about, you know, should I get every single COVID vaccine that comes down the pike?

Ganga Moorthy, MD: Yeah. That's a complicated question. And I think it may look different for everybody. I think what I would say that is different about COVID-19 from other seasonal viral infections is that we do know that COVID-19 infection and particularly recurrent infection can cause some long-term adverse effects in some people. That can look different for a lot of people. I think many people have heard of long COVID, which we're still fully understanding. It can also cause hearing loss, taste changes, that sort of thing that can be short-term or long-term, but is not ideal for most people.

So, I would say that while the virus is likely becoming less lethal and more transmissible, it is important to protect yourself and your family because we don't really fully understand what the long-term effects of COVID infection are. It also is important to help protect those around you who may be more susceptible to severe disease, because they're not able to be vaccinated, because they have immunocompromising conditions, or other reasons why they may get more sick, even if the virus is less deadly.

Host: Really great point. So even if, you know, the virus may be to some extent less likely to land you into the hospital or cause a severe outcome like death, there are still a range of other potential consequences that are hard to predict and certainly would be worth preventing if we can in the first place. And then, your point about the impacts on others around you and just protecting those who may be particularly vulnerable to severe outcomes from COVID-19. So yeah, thank you for kind of clarifying that particular piece.

Now, certainly, the tried and true flu vaccine is also a part of this landscape as well. You know, questions we get are, is it really important to get the flu vaccine each year? What if it's January, February, or even into March, right, and there's still flu vaccine stock perhaps in the clinic? Should people be getting it regularly? You know, how would you generally counsel people?

Ganga Moorthy, MD: So, influenza, similar to COVID, changes year to year. And we've been tracking this for many, many years and have a good way to see what kind of virus is circulating and what we expect it to look like here in North America. There are small changes year to year, and it is important to get the latest vaccine to make sure you're protecting yourself and others against the current strain.

One thing that, that I often answer for families is a lot of people feel like they've gotten the flu after they've gotten the flu shot and that doesn't actually help them. And I think one important piece is that the virus that's in the flu shot is dead. And so, you can't get the flu from the vaccine. You might have side effects or adverse effects like a mild fever or body aches or muscle pains. And those are signs that your body's acknowledging that it sees this dead virus and it's making antibodies to it. Sometimes people have just had a timing fluke where they have been exposed to the flu, they got their flu shot, and then they got the flu a few days later. But that is really just from your exposure to the community, not necessarily from the vaccine. And I would just tell families that those side effects are unpleasant, but it's much, much milder than actually having the flu with a real infection.

And while the flu can be, and is most likely a self-limited infection in most people, we are seeing children who were admitted to the hospital after the flu for issues with muscle breakdown, with bacterial pneumonia, sinus infections, and occasionally more invasive and severe infections. And so, it's not too late to get your flu shot. Just last week, about 20,000 people were hospitalized for the flu, including children, and we've seen seven deaths nationally from pediatric influenza. We're currently on track for about a typical flu season. Our flu vaccines are a good match this year. And while we are nearing the peak of flu in the south, the virus will stick around at lower levels through March or April. And so, it is helpful to get your shot as soon as possible.

Host: Great. So, a good reminder that certainly flu or sort of classical influenza illness is not pleasant and should be prevented. But then, there are also these less common but quite severe potential outcomes from influenza as well. And so, you heard it here from Dr. Moorthy, it is not too late to get your flu vaccine. You've also heard that you cannot get flu from the flu vaccine. I tell people all the time, but I'm not sure that they believe me. So Dr. Moorthy is an infectious disease specialist, and so she would know.

I guess one other piece on the flu vaccine, I was told previously, Ganga, that there is benefit to getting it every single year, meaning that the flu vaccine that I got a year ago, or even two years ago, has kind of longer lasting benefits. So, it's not just that like each vaccine is beneficial just for that particular season. Is that true?

Ganga Moorthy, MD: That is true. Dr. Tony Moody would be able to explain this much more eloquently than me, but your body has sort of a muscle memory and in a way that it's an immune memory that each vaccine helps build your immune system's ability to fight the flu virus year to year and stacking vaccines definitely compounds that.

Host: Really helpful. One more question on immunization, and then we'll kind of shift gears just slightly. In the news just this week, actually, is a measles outbreak, I believe, in the Philadelphia region. Can you talk a little bit about this? Why are we seeing sort of these viruses or these illnesses that people may have long forgotten, just because vaccines historically have done their job, but why are we seeing them crop up? And what are you thinking as an infectious disease specialist about these sorts of outbreaks?

Ganga Moorthy, MD: So, as you mentioned, there's been an outbreak of measles in Philadelphia among children who were either unvaccinated or undervaccinated. Measles is a highly transmissible disease and it spreads really quickly among people who don't have immunity. It's also a disease that requires a high level of community immunity to create a wall for those people who are not immune.

We know that during the COVID-19 pandemic, many children didn't have access to routine vaccines for a multitude of reasons. And in the last several years, rates of pediatric vaccines have decreased substantially across the country. This is probably due to a combination of kids still getting caught up on their immunizations as well as a rise in families choosing not to immunize their children.

As I said, measles in particular needs a really high level of community immunity to protect children who are either too young to be immunized or those who are immunocompromised. And I kind of think of it like a brick wall. So when we have holes in it, people who are susceptible at risk can get infected. And with measles, even just a few holes can lead to outbreaks, as opposed to other viruses where you can have many more bricks missing.

In the last 20 years, vaccines, as you said, have prevented many illnesses in children. And I do worry that if kids aren't getting their routine vaccines, we'll see continued outbreaks of preventable diseases that we haven't seen in a long time. But they can cause severe illness and death in young children. Pediatric vaccines are safe and effective. And I know that families choose not to immunize their children for a multitude of reasons. But I would encourage those who are vaccine-hesitant to have an open and honest conversation with their pediatrician about their concerns, and think about what it would mean for their family and for their community if their child were to get one of these diseases.

Host: Yeah. Thank you for talking about that. I think it's such a complex issue. And certainly, from my perspective in our clinical work, we talk with families quite regularly about vaccine decisions. And while I would say the majority of families certainly are quite accepting of our recommendation and follows the sort of typical schedule of vaccination, some have a bit more sort of difficulty wrestling with some of those issues. And certainly, as a pediatrician, I respect that certainly, right? Because at the end of the day, the parent is the caretaker, right? They're the decision-maker for their child and family. And there's a great reverence that we have for that.

I think for my part, it's more to set them up to succeed, right? To do that really important job of making that decision so that they're making it with the best information at hand without any kind of twisted information or misinformation or a lack of information. So, I think when I see a family declining vaccination and it's not, you know, because they processed everything as thoroughly as they might want, but rather they were kind of given something that wasn't quite precise in terms of information. That's when I feel sort of sad about it and wish that we could do better for them. And so, it's really helpful to kind of hear how you think about this. I guess the other piece is just to recognize that underimmunized or unimmunized kids could be because of vaccine declination, but it also could be because they couldn't access it, right? Because of, like you said, with the pandemic and other structural barriers to accessing routine care, some kids are behind and undervaccinated.

Ganga Moorthy, MD: Definitely, I think there's work that we can all do to help improve immunization in our communities and some of that, as you said, is due to structural barriers and making sure that kids do have access to their immunizations and to their pediatricians.

Host: So if listeners are kind of wrestling with vaccination decisions, don't sort of sit on your uncertainty. Reach out to your pediatrician, other caring professionals and talk it through. I think anyone in the child health profession would love to kind of work with you and walk with you through some of these decisions so that your child is as healthy as they can be.

 Ganga, let's kind of shift gears back to these kind of viral infections that are swirling all around us. Besides vaccines, besides immunization, what are other tips that you as an infectious disease doctor would offer to prevent viral illness among kids?

Ganga Moorthy, MD: That is a very complicated and hard question, Richard. What we know is that it can be really hard to keep kids well during the fall and winter. There is a study that is one of my favorite studies. It was done at the University of Utah in 2015 and it's called Big Love and what they looked at were large families and families of different sizes and they found that people who live in households without children were infected with a virus on average three to four weeks during the year. If a household had one kid, that number jumped to 18 weeks. And if you had exposure to six kids, there was a virus in the household for up to 45 weeks of the year. So pretty much, you're exposed to a virus.

One thing that's interesting about this study is that only half of those who tested positive for a virus actually had typical symptoms of a virus. So, things like cough, fever, stuffy nose. And that can be really helpful, I think, for both families and their healthcare providers when they do think about how their child is ill all the time. One thing to also note in this study is that kids who are less than five had one virus in their nose for about 50% of the year, which is twice as often as older kids or adults, and they are also more likely to have symptoms. So, I say all this to acknowledge that families are right. Your kid is sick all of the time, but I want to provide some reassurance that this is par for the course. It gets better as your child gets older. And most often, this is a viral illness, and it's not something more serious.

To answer your question of what you can do other than staying up-to-date with your recommended immunizations, families should try to wash your hands as frequently as possible. I know that can be really challenging with little kids, but even using hand sanitizer before you do things like eat or touch your face is super helpful. I'd encourage families to think about wearing a mask in a highly trafficked or crowded area, especially if you have a child or someone else at home who is immunocompromised or has some other medical conditions that might make them more vulnerable to an illness. And if you can, to stay home when you or your child is sick to avoid getting other people sick. Those are all ways that families can try to protect themselves this winter.

Host: Got it. So, did I hear you correctly? The Big Love Study? Is that what it was called?

Ganga Moorthy, MD: Yes.

Host: Okay. So, the Big Love Study tells you that the virus is always around at some level, but there are ways to try to prevent and maybe mitigate the severity of impact. Is that right?

Ganga Moorthy, MD: Yes. And that kids are just vectors of disease, but at least they're cute.

Host: Well, you know, one other question I actually have on that, so let's say your kid is in daycare or early school age and they come back and clearly have a virus in their nostril and some symptoms emerging. As parents, as family members, do you just kind of like wave the white flag and assume that everybody's going to get it at some level in the household? Or is there really scientific rationale to try to quarantine that kid or otherwise prevent spread throughout the household?

Ganga Moorthy, MD: I think that it is possible to avoid other people getting sick. We've seen that in COVID, there are good ways of mitigating infection with things like quarantining and wearing masks. I think that can be a little bit more challenging when you're trying to avoid infection from someone who's small and may not be able to follow some of those social distancing measures. But I think one thing to keep in mind is that as you get older, you see viruses over time and your body builds up immunity to it. So while your child may be seeing that virus for the first time at daycare, you've probably seen it before, which means that you may not get sick, because your body has a level of protection against it.

Host: Really great point. And then, you mentioned kind of potentially masking actually in certain strategic settings, if it's a crowded setting, in the public perhaps. What type of masking are you suggesting in that setting? I know in COVID-19, certainly many, hopefully most, if not all of us, are now familiar with the idea of masking and kind of different options in that space. Is there a particular recommendation at this point in terms of just kind of general safety precaution when you're out and about?

Ganga Moorthy, MD: So, I think in terms of what kind of mask, any kind of mask, whether that's fabric or a medical grade mask is better than no mask if you are trying to protect yourself from respiratory droplets. Certainly, things like medical grade masks or KN95s or N95s offer a level of protection that's higher than a cloth mask.

I think that families and people have different levels of risk tolerance and different decision-making factors that lead to when or why they would mask. Personally, I mask when I go into grocery stores or into crowded areas during the fall and the winter, because I know those are areas where people could be sick and you could be exposed to the virus. And sometimes if you're spending a long period of time next to somebody that you may not know, that's another opportunity to mask, for example, on a flight, or in an airplane, or in an airport. Those are all ways that you could protect yourself and your family.

Host: Excellent. Thank you, Ganga. I'm throwing all sorts of curveballs and sliders at you, but you're really doing great. And thank you for answering all of my questions, actually. I do have one question about your role in antimicrobial stewardship, actually. So, another very common, perhaps often hot button question that we get in the office is about antibiotics. You know, your kid is having a fever, has all sorts of respiratory symptoms. And certainly, the parent side of me understands the allure of the antibiotic because it feels like something you're doing, and it seems like a non-zero percent chance it could help, right? Just in case. And so, can you walk us through how you would talk about that question? You know, "Can I have an antibiotic for my kid just in case there is a bacterial issue going on?" Does it really hurt to just kind of cover for bacteria?

Ganga Moorthy, MD: That's a great question. So as we talked about and see in the data from the Big Love study, children most commonly have a virus, which antibiotics don't treat, but they can have bacterial infections that can develop either alongside of a viral illness, after a viral illness, or just independently without a viral illness.

And the most common kinds of infections that we see in kids are things like ear infections, pneumonias, or urinary tract infections. When you ask, is there harm in antibiotics, there is, and that looks a couple of ways. And so, my job as an antimicrobial Stewardship Director is to help be a good steward of antibiotics, but that is the job of both families and clinicians.

As you said, sometimes we are tempted to give an antibiotic just in case, especially when families have come to see us many times, and we're all worried about their kid. But this does come with risks. Antibiotics can be useful when they're indicated, if they're targeted, and if we use the right dose and duration. But they can also cause adverse effects, things like diarrhea, upset stomach, rashes. And if used inappropriately, they lead to antimicrobial resistance. We know that a lot of antibiotic prescriptions are inappropriate, and that could be the wrong drug, the wrong dose, the wrong duration, or if they're being given for a viral infection, or an illness that would have just improved with time. Antibiotics could be indicated, and pediatricians and healthcare providers can see signs of bacterial illness on their exam, and sometimes they'll also get labs, which help us determine whether something is a virus or a bacteria.

And things like the length of illness can also give people ideas of whether or not an antibiotic is necessary. There are some things that are myths about whether something is a virus or bacteria. One in particular is the color of snot. That is not a great marker of bacteria versus virus. But I understand and I feel for families. I know that it can be really frustrating when you have a kid that's been sick for a really long time. And as you said, an antibiotic is a tangible thing that you could give a child. But it may not actually help and it could cause harm. I would just caution families that it is not without risk and it can lead to adverse effects.

Host: Yeah, that's really helpful to know, just kind of that it's not all plus, right? It's not all just a win to kind of add something on. There's potential risks for the individual. And then also impacts from your perspective, certainly from a stewardess standpoint, impacts on all of us and the broader landscape of antibiotics and future potential resistant pathogens and such.

And so, yeah, it's not a simple decision or an easy add on, something worth talking through with your pediatrician or other healthcare professional when you're evaluating things. So, thank you for that. Ganga, I really, really appreciate you taking time today out of your busy schedule to share some really important insights and tips regarding immunization, viral infections, the Big Love Study, and now antimicrobial stewardship.

I've learned a lot and I know you've offered a lot of practical tips for our families and other listeners, to really bring to bear. Let's sort of round this out and finish off back with you, Ganga. I'm curious, your day to day work, what inspires you most? After the pandemic, you and other infectious disease doctors were working overtime for a few years. And you're still working because of all the infections we're talking about today. But what inspires you? What kind of keeps you going day to day and brings you back?

Ganga Moorthy, MD: I think I had mentioned when we started that, you know, my mom's a teacher of children and my dad's a professor of microbiology, but the first job I ever wanted was to be a detective. And I think that being an ID doctor, I have found my perfect job because I get to be a detective and I get to solve complicated problems and think very thoughtfully about complex situations.

But what inspires me day to day is a couple things. I have a really cool job. I get to work here at Duke and do antimicrobial stewardship and see patients. And I get to also do research both here in the U.S. and also abroad. And I work predominantly in Tanzania. And what I've seen across the world is that children are really resilient. And the people who care for children, whether that's families or clinicians or everybody else that goes into raising and caring for children are really creative and very passionate. And so, seeing that inspires me to continue to do my work, and it's really wonderful to see how that looks in different contexts and in different cultures.

Host: Awesome. Wonderful to hear. And I resonate with everything you've articulated. Thank you again, Ganga, for joining us on Pediatric Voices.

Pediatric Voices is produced by the team at Doctor podcasting. The show has been developed by my co host, Dr. Angelo Milazzo and me. Thanks to Dr. Ann Reed and the administrative team at Duke Children's, particularly Debbie Taylor and Courtney Sparrow for their support.

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