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ASA Monitor Today

The go-to spot for busy clinicians to get the necessary answers on issues important to anesthesiologists.


January 26  |  January 12


3 Questions on… RSV

January 26

Child laying in hospital bed with oxygen mask onWho is most at risk for RSV?
RSV is one of the most prominent causes of lower respiratory tract infections, affecting nearly all children before the age of 2 (asamonitor.pub/3weGHbC). While RSV can cause infections among all age groups, the most severe infections typically occur in infants and young children. For most adults and older children, RSV infection does not pose a threat. However, severe infections are now increasing in the elderly and adults with comorbidities.

Can you elaborate on the role of “immunity debt”?
Some pediatricians have attributed the surge to “immunity debt.” Non-pharmaceutical interventions like masking and social distancing implemented in 2020 and 2021 to mitigate the transmission of Covid-19 prevented the typical exposure to pathogens. As a result, children did not develop immunity to the typical panoply of childhood infectious diseases. Instead, respiratory infections which typically would have occurred throughout 2020 and 2021 appeared as a destructive wave in 2022.

This concept of “immunity debt” was raised in a 2021 publication authored by a French Pediatric Infectious Disease Group, who observed that the “reduction of infectious contacts secondary to hygiene measures imposed by the pandemic may have led to a decreased immune training in children and possibly to a greater susceptibility to infections in children” (Infect Dis Now. 2021;51:418-23). Presciently they noted “low viral and bacterial exposures due to NPIs (non-pharmaceutical interventions) imposed by the Covid-19 pandemic raise concerns as we may witness strong pediatric epidemic rebounds once personal protection measures are lifted.”

The implementation of widespread masking and handwashing during the pandemic allowed for a comparison of the RSV disease activity during the pre-pandemic seasons to those during the pandemic. Typically, RSV disease activity peaks around December. During the pandemic, there was a dearth of RSV infection except for a surge during the summer of 2021 when non-pharmaceutical interventions were relaxed. As noted by Bardsley and colleagues, “the absence of RSV activity in England during the winter of 2020–21 and then atypical activity in summer 2021 was unprecedented in the modern epidemiological era, and was most likely due to the introduction and subsequent relaxation of public health non-pharmaceutical interventions to mitigate the spread of Covid-19” (Lancet Infect Dis. 2022:S1473-3099(22)00525-4). An accompanying commentary noted that “immunity debt” might be an unintended consequence of non-pharmaceutical interventions (Lancet Infect Dis. 2022:S1473-3099(22)00544-8).

This concept of immunity debt is controversial. A robust rebuttal was published by the McGill University (Canada) Office of Science and Society (asamonitor.pub/3iKMRNK). The author, Mr. Jarry, criticized the French Pediatric Infectious Disease Group for “boldly asserting the existence of an immunity debt in children” and “opening the floodgates.” As Mr. Jarry notes, following the publication by the French Pediatric Infectious Disease Group, immunity debt “was being quoted in other papers and in media reports, and now we are led to believe that our immune system is just like a muscle: stop working it out and it will atrophy.”

The primary criticism of immunity debt is that “…children during the pandemic were not kept in sterile bubbles. They were in contact with microorganisms from the food that they ate, the soil that they played with, and the adults in their lives.” Mr. Jarry attributes the rise in pediatric RSV and other infections to non-immune factors. “It’s not just RSV that is putting kids in the hospital but respiratory enteroviruses, influenza, and parainfluenza as well. These are viruses that many children were not exposed to {during the Covid lockdowns} … and there is now a lot of catching up to do.”

What does the future hold with regard to RSV?
As has happened with Covid-19 over the past 3 years, the surge in RSV is driving research into vaccines and novel therapeutics. We will be better prepared next time. The good news is that new variants of RSV do not appear to be emerging, based on genomic sequencing data (asamonitor.pub/3XAgksl). This is very different from SARS-CoV-2, which mutates faster than we can develop monoclonal antibodies. The low mutation rate for RSV suggests that the RSV surge seen over the past few months is not likely to recur for some time.

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3 Questions on… Infectious Diseases

January 12

ASA Monitor Today consults with APSF Patient Safety Priorities Advisory Group - Infectious Diseases. Read their answers to pertinent questions about infection prevention and control. The complete article can be found here.

  1. Experts are saying that Covid will not be the world’s last pandemic. What is the goal for any emerging virus?

    We should have learned from the Covid-19 pandemic that emerging viruses like monkeypox, Ebola, and polio join endemic viruses like respiratory syncytial virus and influenza as real threats to our patients and the health care team. Our interest in stopping the transmission of these viruses, along with pathogenic bacteria like Enterococcus, Staphylococcus aureus, Klebsiella, Acinetobacter, Pseudomonas, and Enterobacter spp., make this the perfect time for anesthesia professionals to refocus our attention on reducing patient harm through infection prevention. We can refocus the energy we have already learned to spend on Covid-19 mitigation into a holistic approach to pathogen reduction.t.

  2. What does the literature say about basic infection control precautions in anesthesia?

    There is no question that we, current and historical leaders in patient safety, can generate substantial reductions in bacterial transmission and, in turn, surgical site infections (SSIs). In fact, based on a recent randomized controlled trial and large postimplementation analysis, we can reduce surgical site infections by over 80% (JAMA Netw Open 2020;3:e201934; J Clin Anesth 2022;77:110632). This is of tremendous importance, as SSIs increase the risk of death for our patients by greater than two-fold and substantially increase health care costs (Surg Infect (Larchmt) 2012;13:307-11; Infect Control Hosp Epidemiol 1999;20:725-30). These same measures have also been shown to eliminate residual intraoperative environmental contamination with SARS-CoV-2.

  3. Which infection control measures should be prioritized?

    The committee recommends feedback optimization of:

    • patient decolonization
    • improvement in provider hand hygiene
    • disinfection before each administration of an intravenous medication
    • environmental cleaning done by the anesthesia provider to address the post-induction peak in environmental contamination.

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