Kids Could Be Worst Off In Winter Illness Surge – Expert Q&A

Cases of RSV and Influenza B are on the rise this winter
– both illnesses which predominately affect our youngest and
most vulnerable.

Meanwhile, the FDA in the US is
recommending infants
get a monoclonal antibody vaccine to ward off RSV
infection. The government here has also recently released a
five-year
roadmap on tackling rheumatic fever and rheumatic heart
disease.

The SMC asked
experts about winter
illnesses.

Dr
Sarah Jefferies, Public Health Physician, Health
Intelligence and Surveillance Group, ESR,
comments:

Are there any winter bugs that are
unusually prevalent for this time of
year?

“Nationally, we have seen a steady increase of
influenza-like illness consultations in the community since
April, in line with average seasonal trends for this time of
year. Some parts of the country have shown higher activity
than usual, including Counties Manukau, Waitemata and the
Hawkes Bay districts. More serious viruses such as influenza
B, influenza A (H1N1) and respiratory syncytial virus (RSV)
are circulating in the community, as well as common cold
viruses like rhinovirus.

“This is the first time
influenza B has circulated significantly in New Zealand
since 2019. Influenza B tends to hit young children the
worst and its return to New Zealand is a good reminder that
the flu vaccine is now free for children aged 6 months to 12
years old.

“Certain groups of people are at more risk
of severe complications of flu, such as pneumonia, which is
why the annual flu vaccine is also free for pregnant women,
Māori and Pacific people over 55 years, older people and
those with certain medical conditions. The Ministry of
Health is a good source of information for further advice
on preventing the spread of influenza, and self-care.
The flu vaccine is our key line of defence and provides
protection against all four seasonal influenza viruses:
A(H1N1), A(H3N2), B/Victoria and B/Yamagata.

“We are
currently seeing increasing rates of RSV-related
hospitalisations in children aged 1-4 years old in the
Auckland region. RSV also tends to affect young children
most severely. RSV caused a lot of serious illness in June
2021 as a result of the COVID-19 restrictions in place in
2020 reducing the circulation of RSV and therefore reducing
levels of community immune protection. The Ministry of
Health has advice
about RSV.

“Influenza B and influenza A(H1N1) are
also causing severe illness across a range of age groups in
the Auckland region in recent weeks. COVID-19 related severe
acute respiratory infection (SARI) hospitalisations detected
through this surveillance system are slightly higher than
this time last year but nowhere near the peak of the first
Omicron wave in March 2022.

“Normally influenza is
most active in July-August, but we have seen that this
year’s flu season started earlier than usual. Flu-positive
SARI hospitalisations in Auckland first surpassed the
seasonal baseline in April. Both severe illness activity and
community illness activity have remained low overall but
have been steadily increasing in the past
month.”

No conflict of interest.

Dr
Joanne Hewitt, Science Leader, Health and Environment, ESR,
comments:

What is the latest on Covid-19 wastewater
surveillance?

“ESR continue to monitor COVID-19
trends and variants through the analysis of wastewater
across Aotearoa New Zealand. Currently, just over 60 sites
are regularly tested for SARS-CoV-2 RNA as part of COVID-19
surveillance. This data supports other COVID-19 surveillance
activities including reported COVID-19 case numbers, and
hospitalisations. An increasing trend in levels may give an
early warning of increases in cases. Wastewater testing is
also independent of RAT/PCR testing and reporting by
individuals so is unbiased.

“Nationally, SARS-CoV-2
RNA levels in wastewater have been relatively low and steady
from February 2023 but noting there are some regional and
site differences over that time. As of 9 June 2023,
wastewater data does not indicate an increasing number of
COVID-19 infections at the national level.”

No
conflict of interest.

Associate Professor Joanna
Kirman, Immunologist, University of Otago,
comments:

US health authorities are
recommending infants get a monoclonal antibody vaccine for
RSV. Is this something Aotearoa should
consider?

“Nirsevimab is a preventative
treatment (known as passive immunisation) and works
differently from our usual vaccines. It gives the antibodies
directly to the individual, rather than asking the body to
make its own antibodies. So, it is generally quite
short-acting lasting weeks or months – whereas many
vaccines last for years or decades and are a lot cheaper to
make.

“We have something similar to Nirsevimab in NZ
– it is called Palivizumab
and needs to be administered in multiple doses during the
RSV season rather than just one dose, which is the benefit
that the newer medicine, Nirsevimab offers.

“I should
add both passive immunisation treatments are offered to
“high risk” infants – those at risk for severe disease
(eg pre-term infants, infants with chronic lung disease etc)
rather than the general population.”

No conflict of
interest.

Dr Rawiri Keenan (Te
Atiawa/Taranaki), Adjunct Senior Fellow, Medical Research
Centre, Te Huataki, University of Waikato; Senior Research
Fellow, Dept of Primary Care and General Practice,
University of Otago Wellington,
comments:

How might we avoid the worst of
winter illness this year?

“The winter we have been
worried about with COVID, RSV and Influenza is well and
truly here.

“The school holidays are coming up, and
not too soon enough in many ways. If we look previous data
on COVID numbers, the holidays generally give a small drop
off as children are no longer crammed into classrooms with
inadequate ventilation and minimal masking. That said there
are still two weeks, then next term as well, and COVID is
not the only thing going around.

“Currently it’s
specifically influenza that seems to be really doing the
rounds. Influenza compared to the common cold, has much more
widespread symptoms (fever, headache, body aches and tummy
upset) and lasts closer to or longer than a
week.

“Masking indoors and crowded spaces helps with
the prevention of many bugs, not just COVID so I would
totally recommend people keep this up (or restart). Having
had the flu (and even better if you haven’t) getting the
flu vaccine is still really important and worth getting (as
are COVID boosters where eligible).

“Of course the big
topic is childhood immunisation for measles, whooping cough
etc. Our numbers nationally here are poor (hence the
increased media coverage recently) but specifically they are
really low for our Māori and Pacific communities/tamariki.
I’d just really encourage anyone considering it to find a
trusted health professional and ask those questions
regarding these really important vaccines.

“We know
that due to staffing issues (chronic shortages, but also
more acute ones due to the same winter bugs affecting staff
and their whānau) getting appointments can be tricky, but
childhood immunisations are free, as are those for COVID,
and many people are eligible for a free flu vaccine too. Any
other ‘bills’ with a clinic or pharmacy etc does not
affect your eligibility for any of these funded vaccines.
Many of these same vaccines are also now uncoupled from
needing to be at your registered GP clinic, you can do this
through the bookmyvaccine.com
website, so check it out if that’s something you prefer as
well.”

No conflict of interest
declared.

Associate Professor Amanda
Kvalsvig, Department of Public Health, University of Otago
Wellington, comments:

How can we avoid the
worst of winter illness this year?

“Every year when
the weather turns cold Aotearoa New Zealand sees a huge
surge in respiratory infections. The large numbers put
pressure on a GPs and hospitals but even when people
aren’t unwell enough to need healthcare, highly disruptive
impacts ripple through communities when infection levels go
up. As as every working parent knows, it’s challenging to
meet work expectations when children are constantly coming
down with coughs and colds brought home from school and
daycare. For many families, not being able to work means no
income, generating huge worry for families that are
struggling. We shouldn’t accept this situation happening
every single year now that we have the knowledge and tools
to change it.

“The pandemic has shown us just how
preventable many of these infections can be when the right
protections are in place. Respiratory infections spread
through the air, which is a major reason why the numbers
jump up in winter: people are indoors, crowded together, and
breathing other people’s air. Recent studies are showing
that ventilation and air filtration are vital infrastructure
for public health because they’re effective protection
against multiple pathogens. The CDC in the United States has
also recently updated its rules to set a target of five
air changes per hour for rooms and buildings. Once we
get indoor air quality right we should start to see benefits
right away.

“In terms of where to start there are some
key settings where infection transmission really matters.
Schools and early childhood settings need to be made safe
because they’re highly connected within their communities,
enabling infections to pass from school to home to daycare
and back. Another key setting is healthcare: everyone,
including people who are immune compromised, needs to be
able to access healthcare safely right through winter. These
settings need to be resourced to excellent standards of
safety to protect New Zealanders’ right to education and
health.

“Another important strategy is financial
support and an organisational culture of enabling sick leave
to ensure that people can stay home when they’re unwell.
Time to rest is important for recovery, and staying home
avoids the risk of spreading infections on public transport
and in workplaces. Self-testing is a very promising
innovation that we’ve experienced with Covid, and it would
be good to see New Zealanders gaining access to newer
testing kits that can test for Covid, influenza, and RSV.
Rapid tests are a great way to help people make good
decisions on the day about whether to join a large
gathering.

“With these protections in place and new
vaccines on the way for RSV, we’ll be in an excellent
position to reduce the current massive load of winter
infections down towards the low levels we see in summer.
This would be truly transformative change and I suspect that
once we experience it, we’ll never want to go back.
Additionally, we know that if our respiratory health
infrastructure is working efficiently and well through
winter, we’re well-prepared to face the next
pandemic.”

No conflict of interest
declared.

Dr Tara Officer, Lecturer in
Applied Health Sciences, Victoria University of Wellington;
and Registered Pharmacist, comments:

How
could telehealth help us cope with the winter illness
surge?

“During the winter season, primary care
services face surges in demand, particularly given concerns
about rapidly increasing influenza rates.

“To address
this challenge, telehealth offers an excellent opportunity
to manage many conditions effectively. However, healthcare
providers need to be proficient in delivering care through
this medium, and patients must feel at ease using
it.

“To ensure safe and effective consultations, it is
essential to establish guidelines for telehealth
consultations, and healthcare service providers should
document patient preference for appointment type carefully.
Failure to provide adequate infrastructure and training for
all primary care staff, including receptionists who control
access to services, may lead to a disparity in the quality
of care provided to patients via telehealth, causing them to
miss out on the care they require in the way that best meets
their needs.

“Without appropriate support, telehealth
may potentially create issues between patients and their
preferred primary care providers, which is a growing concern
given the anticipated increase in demand for
services.”

Note: other experts previously commented
on telehealth,
or phone and online health support. The
government announced extra support for this as part of a
winter health package to come into effect next
week on 23 June.

No conflict of
interest declared.

Dr Janine Paynter,
Senior Research Fellow, General Practice and Primary
Healthcare, University of Auckland,
comments:

What do you make of the relatively
high rates of RSV throughout Aotearoa this
winter?

“Oh no, this isn’t good news. The sooner we
have a vaccine option or the new monoclonal antibody
treatment the better!”

The FDA in the US is
recommending infants get a monoclonal antibody vaccine. Is
this something Aotearoa should
consider?

“Yes, NZ should definitely be
looking into this as a priority. Modelling work in Canada
and another study focussing on low and middle income
countries shows it is cost effective. Some modelling work in
the US indicates that the cost effectiveness can be variable
depending on who is being vaccinated and when, e.g. it might
not be cost effective if giving to older healthy babies in
the non-RSV season.”

What do you make of the
relatively high rates of Influenza B throughout Aotearoa
this winter?

“This year the eligibility
for a free flu vaccine (which includes influenza B) has
been extended and is available for all children aged up to
12 years and older Māori and Pacific (55-64 years old) New
Zealanders in addition to those already eligible. I
encourage parents and whānau to get themselves and their
children vaccinated if they haven’t
already.”

Conflict of interest statement: “I work
on a research project that has been funded by GSK. I have
been on an advisory board for Novavax and paid for my
time.”

Associate Professor Dianne
Sika-Paotonu, Immunologist, Associate Dean (Pacific), Head
of University of Otago Wellington Pacific Office, and
Associate Professor, Dean’s Department, University of
Otago Wellington, comments:

How might the
most vulnerable in Aotearoa fare through the winter illness
season?

“Our health and associated support systems in
Aotearoa New Zealand are continuing to experience pressure.
These systems were already overloaded prior to the start of
the Covid-19 pandemic, and now into the winter months and
with Covid-19 still causing problems and this year’s
seasonal illnesses, there is added stress and
strain.

“The actual true Covid-19 case numbers in
Aotearoa New Zealand are still likely to be higher than
those figures currently being reported.

“For Covid-19,
antivirals still need to reach those who require them
quickly, and the sooner the better – within 5 days of
symptoms, in order to prevent severe illness and
hospitalisation – and try to help our hospitals and
support systems, primary and community care.

“In
addition, the bivalent Covid-19 boosters are still available
for those aged 30+ years and those at high risk, and contain
mRNA coding for the original virus strain– giving broad
protection against Covid-19, plus an mRNA code common
between the Omicron variant BA.4 and BA.5 lineages– giving
better protection against Omicron
specifically.

“Regular (non-Covid-19) childhood
vaccine schedules for children tamariki and tamaiki in
Aotearoa New Zealand have also been significantly affected
by the Covid-19 pandemic. As a result, there remains risks
of outbreaks for measles and other serious illnesses that
could be prevented through immunisation.

“This
situation leaves some of our most young unprotected from
serious conditions. We need to keep our little ones safe and
protected and remember that all vaccinations for our
children, tamariki and tamaiki are important –
particularly at this time.

“The Covid-19 pandemic has
exacerbated pre-existing and significant inequities for
communities and groups here in Aotearoa New Zealand and this
includes for Māori and Pacific peoples, and for children,
tamariki and tamaiki – highlighting the need for more
Equity based approaches.

“Equity based approaches take
into account the specific and different needs of respective
communities in seeking to address inequities effectively and
efficiently by reducing barriers and building trust with
people along the way.

“We saw examples of Equity based
approaches in action during the Covid-19 vaccination roll
out when Māori and Pacific-led, community driven, properly
resourced, targeted and tailored vaccination efforts that
involved and included Pacific leaders and health
professionals, helped drive up vaccination levels for Māori
and Pacific peoples here in Aotearoa New
Zealand.

“Addressing current inequities in health and
society are also important steps in working towards being
prepared for potential future health challenges and
outbreaks.”

No conflict of interest
declared.

Dr Natalie Anderson, Senior
Lecturer, University of Auckland; and currently-practising
Registered Nurse, comments:

How can we avoid
the worst of winter illness this year?

“Get
vaccinated. Stay home if you’re sick. Wear a mask.
Optimise ventilation wherever people gather.

“These
actions saved New Zealanders (and our healthcare system)
from the catastrophic and deadly COVID outbreaks and
associated trauma, and loss experienced by other countries
2020-2021.

“The same simple individual actions for the
benefit of the collective can minimise the harms of
influenza and RSV. How quickly many seem to have
forgotten.”

No conflict of interest
declared.

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