1 00:00:00,000 --> 00:00:12,680 Thanks for joining us again at the Canadian Breakpoint, a Canadian infectious diseases 2 00:00:12,680 --> 00:00:16,360 podcast by Canadian infectious diseases physicians. 3 00:00:16,360 --> 00:00:21,800 I'm Summer Stewart, back again with Dr. Rupeena Purewal, pediatric infectious diseases physician 4 00:00:21,800 --> 00:00:22,800 from Saskatoon. 5 00:00:22,800 --> 00:00:29,120 In this episode, we invite Dr. Zain Chagla, associate professor at McMaster University, 6 00:00:29,120 --> 00:00:33,720 co medical director of infection control at St. Joseph's Healthcare in Hamilton, and a 7 00:00:33,720 --> 00:00:39,200 consultant in infection control at Woodstock General Hospital to discuss the upcoming respiratory 8 00:00:39,200 --> 00:00:41,600 season and the RSV vaccine. 9 00:00:41,600 --> 00:00:42,600 Dr. Purewal. 10 00:00:42,600 --> 00:00:47,680 All right, welcome everyone to another episode of our podcast, the Canadian Breakpoint. 11 00:00:47,680 --> 00:00:52,080 Today we have a very special guest and many of you may actually know him. 12 00:00:52,080 --> 00:00:54,040 It's Dr. Zain Shagla. 13 00:00:54,040 --> 00:00:58,640 We'll be speaking about the respiratory season with us today and a lot of new information 14 00:00:58,640 --> 00:01:00,360 on RSV. 15 00:01:00,360 --> 00:01:04,080 So without further ado, let me introduce Dr. Shagla. 16 00:01:04,080 --> 00:01:11,040 Dr. Shagla is an associate professor at McMaster University and an infectious diseases consultant. 17 00:01:11,040 --> 00:01:16,240 He is the medical director of infection control, head of infectious diseases service, and the 18 00:01:16,240 --> 00:01:23,120 interim senior medical director of clinical operations at St. Joseph's Healthcare Hamilton. 19 00:01:23,120 --> 00:01:28,320 He's a member of the Institute for Infectious Diseases Research at McMaster University and 20 00:01:28,320 --> 00:01:30,760 a council member of AMI Canada. 21 00:01:30,760 --> 00:01:37,360 Dr. Shagla holds a BSc and MD from Queen's University, an internal medicine residency 22 00:01:37,360 --> 00:01:42,120 from Western University, an infectious diseases fellowship at McMaster University, and a master's 23 00:01:42,120 --> 00:01:47,680 of science infectious diseases, and a diploma in tropical medicine from the London School 24 00:01:47,680 --> 00:01:50,240 of Hygiene and Tropical Medicine. 25 00:01:50,240 --> 00:01:53,560 So it's fantastic with all those credentials. 26 00:01:53,560 --> 00:01:59,640 I'm super excited to speak with you today, Dr. Shagla, for a really important topic. 27 00:01:59,640 --> 00:02:06,840 We're kind of entering the respiratory season that we have been expecting for a few months 28 00:02:06,840 --> 00:02:12,840 now and I think all of us experts have been talking about this and a bit dreaded respiratory 29 00:02:12,840 --> 00:02:13,840 season. 30 00:02:13,840 --> 00:02:18,640 So, but we also have a lot of new information for this respiratory season. 31 00:02:18,640 --> 00:02:21,320 So that's kind of what we're going to focus on today. 32 00:02:21,320 --> 00:02:25,760 Why don't we start a little bit about what is this season looking like? 33 00:02:25,760 --> 00:02:28,040 What population is most affected? 34 00:02:28,040 --> 00:02:34,120 And really for our listeners who, you know, are general practitioners, nurses, nurse practitioners 35 00:02:34,120 --> 00:02:37,820 have family members that are probably going to ask them a dozen questions. 36 00:02:37,820 --> 00:02:43,000 And so why don't we give our listeners a bit of an overview of what we might be dealing 37 00:02:43,000 --> 00:02:45,040 with this respiratory season? 38 00:02:45,040 --> 00:02:46,600 Yeah, absolutely. 39 00:02:46,600 --> 00:02:48,040 And first off, thanks for having me. 40 00:02:48,040 --> 00:02:50,920 I hope we can go by first names here for the sake of it. 41 00:02:50,920 --> 00:02:53,360 It's a whole lot more fun. 42 00:02:53,360 --> 00:02:56,760 So, you know, no one wants respiratory season to come. 43 00:02:56,760 --> 00:03:00,000 I think that's, you know, if we could get rid of it, we would get rid of it. 44 00:03:00,000 --> 00:03:04,960 But at the same time, especially in a climate with four seasons. 45 00:03:04,960 --> 00:03:08,800 So you know, I wish we didn't have a respiratory season, but we did. 46 00:03:08,800 --> 00:03:15,960 And it's eventuality of every year that this is a tough season, tough season for individuals, 47 00:03:15,960 --> 00:03:20,640 for families, for people who have vulnerable people in their house, for people with kids. 48 00:03:20,640 --> 00:03:25,880 It's tough for, you know, society, workplaces, lots of absenteeism. 49 00:03:25,880 --> 00:03:27,840 And it's tough for health care. 50 00:03:27,840 --> 00:03:33,640 And that, you know, in that context that there are just a lot of patients, not only with 51 00:03:33,640 --> 00:03:38,880 respiratory disease itself, but flare ups of their underlying disease states, often 52 00:03:38,880 --> 00:03:41,120 from respiratory infections. 53 00:03:41,120 --> 00:03:44,600 And so, you know, it's even pre pandemic, it was a problem. 54 00:03:44,600 --> 00:03:49,480 And it was always a time when health care workers knew that things would be stretched. 55 00:03:49,480 --> 00:03:54,960 And come 2023, 2024, we've added another virus to the mix, even in the best of seasons. 56 00:03:54,960 --> 00:03:56,520 It wasn't a great time. 57 00:03:56,520 --> 00:04:00,760 And now we've added another virus that's here as a contributor to all of this. 58 00:04:00,760 --> 00:04:05,800 So you know, I think we will see obviously a respiratory season. 59 00:04:05,800 --> 00:04:10,840 Last year, we probably had one of our worst respiratory seasons on record. 60 00:04:10,840 --> 00:04:14,960 This year, there's a lot of speculation about what's exactly going to happen. 61 00:04:14,960 --> 00:04:20,000 But you know, recognizing even in the best case scenario, where we come in with a regular 62 00:04:20,000 --> 00:04:25,320 influenza season, a regular RSV season and add COVID-19 in the mix, it's still going 63 00:04:25,320 --> 00:04:26,320 to be pretty tight. 64 00:04:26,320 --> 00:04:30,040 And it's still going to be pretty hard for some health care systems to compensate for 65 00:04:30,040 --> 00:04:31,040 it. 66 00:04:31,040 --> 00:04:32,040 Yeah, definitely. 67 00:04:32,040 --> 00:04:37,960 And you know, kind of when we talk about this new virus, RSV in a population that we don't 68 00:04:37,960 --> 00:04:43,440 normally, you know, prior, I would say pre pandemic, but it probably is just prior to 69 00:04:43,440 --> 00:04:50,800 the last few years in general, you know, we would see RSV in pediatric populations quite 70 00:04:50,800 --> 00:04:51,800 frequently. 71 00:04:51,800 --> 00:04:58,360 And that was my kind of area for months and months, you know, this fall to spring, but 72 00:04:58,360 --> 00:05:03,280 not only that, like the patterns have changed in our pediatric populations too, for some 73 00:05:03,280 --> 00:05:08,080 of these viruses where we're seeing less of the seasonal and this kind of constant viral 74 00:05:08,080 --> 00:05:13,320 activity, which we've been picking up with a lot of our surveillance programs. 75 00:05:13,320 --> 00:05:18,640 So you mentioned, I mean, obviously there's vulnerable populations. 76 00:05:18,640 --> 00:05:23,600 So I think age groups, like I know for RSV classically, it's at less than six months 77 00:05:23,600 --> 00:05:27,540 old, that's really getting affected to getting into hospitals. 78 00:05:27,540 --> 00:05:33,960 And then in, I think adults, that would be the elderly population more so. 79 00:05:33,960 --> 00:05:36,100 So RSV in adults. 80 00:05:36,100 --> 00:05:40,680 So it's interesting, you know, I think last year was the season where everyone learned 81 00:05:40,680 --> 00:05:42,040 about RSV, right? 82 00:05:42,040 --> 00:05:46,640 Everyone over the last five years is getting infectious diseases and virology lessons left 83 00:05:46,640 --> 00:05:53,320 and right, and RSV became chapter two after COVID-19. 84 00:05:53,320 --> 00:05:56,760 And it was the pediatric system, obviously, that introduced it. 85 00:05:56,760 --> 00:06:01,200 You know, RSV has been an issue in adults for a long time. 86 00:06:01,200 --> 00:06:06,320 It's interesting because I think healthcare providers see it, you know, certainly as an 87 00:06:06,320 --> 00:06:12,520 internist and as a resident, as an ID physician, you see it often enough, but I think there's 88 00:06:12,520 --> 00:06:19,660 just been a lot of apathy towards it in the adult population, recognizing it's, you know, 89 00:06:19,660 --> 00:06:22,840 one of the respiratory viruses that makes people sick. 90 00:06:22,840 --> 00:06:25,460 We had zero tools to offer for it. 91 00:06:25,460 --> 00:06:30,920 It strikes down the same individuals that have issues with other respiratory viruses, 92 00:06:30,920 --> 00:06:35,440 you know, and there was a lot of focus on influenza because it was the one that had 93 00:06:35,440 --> 00:06:40,520 solutions in terms of vaccine campaigns, potentially therapeutics and other pieces. 94 00:06:40,520 --> 00:06:45,840 You know, if you look at RSV across the sector, you know, in many different studies, the impacts 95 00:06:45,840 --> 00:06:49,720 are actually pretty similar in the adult population to influenza. 96 00:06:49,720 --> 00:06:55,880 So you know, in the adult sector, for example, for long-term care costs, RSV, in the US, 97 00:06:55,880 --> 00:07:01,000 there's Medicare data suggesting it's actually pretty similar to influenza in terms of hospital 98 00:07:01,000 --> 00:07:05,320 care and specific care to long-term care patients. 99 00:07:05,320 --> 00:07:11,600 There's data from Alberta actually in terms of healthcare costs for adults with RSV and 100 00:07:11,600 --> 00:07:12,600 it's sizable. 101 00:07:12,600 --> 00:07:17,200 Like an RSV hospitalization costs about $12,000 to the system. 102 00:07:17,200 --> 00:07:23,600 It's about $40,000 at a year, which is actually pretty similar to influenza. 103 00:07:23,600 --> 00:07:26,200 Total budgets are actually not that far off in that sense. 104 00:07:26,200 --> 00:07:31,080 And if you look at patients, even what happens to them in hospital when they get RSV and 105 00:07:31,080 --> 00:07:37,560 you know, the rates of things like bacterial pneumonia, cardiac complications, death are 106 00:07:37,560 --> 00:07:38,760 actually pretty similar. 107 00:07:38,760 --> 00:07:43,120 So you know, I think it's one of these diseases that did affect adults. 108 00:07:43,120 --> 00:07:47,120 I think we didn't talk about it much because there wasn't really much we could offer, but 109 00:07:47,120 --> 00:07:53,520 I think, you know, leveraging on A, the global education that was given last year around 110 00:07:53,520 --> 00:07:59,060 RSV and the impacts, especially when it raced back into a population after being naive to 111 00:07:59,060 --> 00:08:05,440 it for a few years and B, the fact that we have actual now vaccines for RSV, which is 112 00:08:05,440 --> 00:08:10,040 a huge medical advance, you know, it's something that really should be brought to the forefront 113 00:08:10,040 --> 00:08:15,720 to talk about as a potential vaccine-mitigatable disease in that sense. 114 00:08:15,720 --> 00:08:16,720 Yeah, exactly. 115 00:08:16,720 --> 00:08:21,400 And I think you made a very important point here is that usually we don't talk about a 116 00:08:21,400 --> 00:08:24,520 lot of these things because we don't have solutions. 117 00:08:24,520 --> 00:08:29,720 But fortunately entering into a respiratory season where we're anticipating a lot of RSV, 118 00:08:29,720 --> 00:08:35,760 a lot of influenza, a lot of COVID, you know, all over respiratory viruses in general. 119 00:08:35,760 --> 00:08:42,480 I think this year, you know, seeing that we do have some new updates for people to counsel, 120 00:08:42,480 --> 00:08:47,680 not just to say lift your sleeves and let's get influenza and COVID vaccines, but for 121 00:08:47,680 --> 00:08:52,640 some of our populations, we actually have a new RSV vaccine. 122 00:08:52,640 --> 00:08:55,440 And so why don't we discuss a little bit, because I know there's going to be a lot of 123 00:08:55,440 --> 00:09:03,840 questions for family doctors and other upfront general practitioners and healthcare professionals 124 00:09:03,840 --> 00:09:09,040 where they're probably going to get questions around indications, contraindications. 125 00:09:09,040 --> 00:09:14,520 So why don't we dive into a little bit about the RSV vaccine and really when was it approved 126 00:09:14,520 --> 00:09:18,120 and all of the wealth of information that you can give us today. 127 00:09:18,120 --> 00:09:19,160 Yeah, absolutely. 128 00:09:19,160 --> 00:09:23,560 So, you know, the RSV vaccine story is a huge success over the last few years. 129 00:09:23,560 --> 00:09:29,400 And we talked about, I think about the burden of RSV in adults being not trivial. 130 00:09:29,400 --> 00:09:32,800 And so the big question is why don't we have, why didn't we have an RSV vaccine until now? 131 00:09:32,800 --> 00:09:36,680 We've had influenza vaccine, we saw in the pandemic, we could develop a COVID-19 vaccine 132 00:09:36,680 --> 00:09:37,800 very quickly. 133 00:09:37,800 --> 00:09:38,800 Why isn't there an RSV vaccine? 134 00:09:38,800 --> 00:09:44,000 And the answer was, there was, there were trial targets of RSV vaccines back in the 135 00:09:44,000 --> 00:09:45,800 60s and 70s. 136 00:09:45,800 --> 00:09:51,000 The issue is, you know, the epitopes and the antigen were not well developed. 137 00:09:51,000 --> 00:09:57,120 And RSV has a fusion protein, which is kind of what binds the virus, similar to spike 138 00:09:57,120 --> 00:10:01,400 protein, what binds the virus to the target cells within the respiratory tract. 139 00:10:01,400 --> 00:10:05,800 That fusion protein was thought to be very well conserved between both RSV and B, the 140 00:10:05,800 --> 00:10:07,160 two subtypes. 141 00:10:07,160 --> 00:10:09,280 So really good immunogenic target. 142 00:10:09,280 --> 00:10:16,280 The issue was, is that when RSV is in its natural state, the fusion protein goes into 143 00:10:16,280 --> 00:10:17,360 a post-fusion confirmation. 144 00:10:17,360 --> 00:10:23,280 So this, this, you know, more oblong looking protein, which helps with its function, but 145 00:10:23,280 --> 00:10:25,920 it is not very immunogenic. 146 00:10:25,920 --> 00:10:30,560 And then the binding sites for neutralizing antibodies are actually quite covered up. 147 00:10:30,560 --> 00:10:32,160 This actually creates two problems. 148 00:10:32,160 --> 00:10:36,120 One is that you don't get a good vaccine response. 149 00:10:36,120 --> 00:10:43,400 But secondly, you may develop antibodies which are not sterilizing, don't have effects on 150 00:10:43,400 --> 00:10:44,400 the virus. 151 00:10:44,400 --> 00:10:48,640 And then when exposed to the virus, you're already primed to make that immune response 152 00:10:48,640 --> 00:10:49,640 with those antibodies. 153 00:10:49,640 --> 00:10:53,720 And in fact, you know, some of those early vaccine trials not only showed that these 154 00:10:53,720 --> 00:11:00,320 vaccines weren't effective using the post-fusion protein and lysed viral components, but they 155 00:11:00,320 --> 00:11:05,880 actually may have been deleterious in the context of increasing susceptibility to severe 156 00:11:05,880 --> 00:11:08,120 COVID, severe RSV in that context. 157 00:11:08,120 --> 00:11:12,920 And so they were largely abandoned and there was a lot of work done over the last few decades 158 00:11:12,920 --> 00:11:15,720 to kind of figure out, okay, where is the immune target? 159 00:11:15,720 --> 00:11:17,600 What can we find that stable? 160 00:11:17,600 --> 00:11:21,400 And how does that relate to, you know, eventual development of a vaccine? 161 00:11:21,400 --> 00:11:28,200 The last 10, 15 years, there's been this recognition that the pre-fusion state, so before the fusion 162 00:11:28,200 --> 00:11:34,380 protein binds to the cell, is not the stable state for the protein, but actually does open 163 00:11:34,380 --> 00:11:38,860 up some very potent neutralizing antibody binding sites. 164 00:11:38,860 --> 00:11:41,200 So that was piece number one to the puzzle. 165 00:11:41,200 --> 00:11:45,200 And then piece number two is really work over the last few years is how to actually keep 166 00:11:45,200 --> 00:11:47,320 the protein in that stable confirmation. 167 00:11:47,320 --> 00:11:49,960 So let's keep it in that pre-fusion state. 168 00:11:49,960 --> 00:11:55,640 And once that was really developed, we saw three companies, in fact, multiple companies, 169 00:11:55,640 --> 00:12:00,760 develop RSV vaccines based on that construct, two of them using a protein-based method with 170 00:12:00,760 --> 00:12:07,080 an adjuvant and one using an mRNA method, but really using that pre-fusion protein and 171 00:12:07,080 --> 00:12:11,320 that immune response for the pre-fusion protein to then develop vaccines. 172 00:12:11,320 --> 00:12:15,800 And so GSK developed the RxV vaccine, which is the one approved in Canada. 173 00:12:15,800 --> 00:12:19,320 Pfizer developed a vaccine not approved in Canada yet, but going through HealthCan approval, 174 00:12:19,320 --> 00:12:23,440 and Moderna developed a vaccine again, going through HealthCan approval currently. 175 00:12:23,440 --> 00:12:29,760 So these work essentially with that pre-fusion protein and an adjuvant. 176 00:12:29,760 --> 00:12:34,560 So adjuvant is a molecule that's used to really trigger potent immune responses. 177 00:12:34,560 --> 00:12:36,320 They're part of most protein-based vaccines. 178 00:12:36,320 --> 00:12:39,200 And the adjuvant is actually pretty similar to one that we have on the market. 179 00:12:39,200 --> 00:12:42,080 It's actually the same as one that's in the Shingrix vaccine. 180 00:12:42,080 --> 00:12:47,000 So this AS01 adjuvant, which is for the Shingles vaccine, a very, very potent vaccine. 181 00:12:47,000 --> 00:12:49,160 It gives very, very good immune responses. 182 00:12:49,160 --> 00:12:53,360 And so using that technology in this vaccine. 183 00:12:53,360 --> 00:12:57,440 They took the, and I'll talk about the GSK vaccine mainly because it's the one that's 184 00:12:57,440 --> 00:12:59,300 approved on the Canadian market. 185 00:12:59,300 --> 00:13:02,400 So they took about 12,500 individuals. 186 00:13:02,400 --> 00:13:06,760 They gave them this vaccine versus placebo, and they looked at lower respiratory tract 187 00:13:06,760 --> 00:13:07,760 disease. 188 00:13:07,760 --> 00:13:11,800 They did this trial actually during the pandemic, which is remarkable considering there wasn't 189 00:13:11,800 --> 00:13:17,400 a lot of respiratory virus spread, but they saw about an 80% reduction in lower respiratory 190 00:13:17,400 --> 00:13:22,520 tract disease with RSV, about a 90% reduction in severe lower respiratory tract disease, 191 00:13:22,520 --> 00:13:27,380 and even about a 70% reduction in acute respiratory symptoms. 192 00:13:27,380 --> 00:13:31,280 So just like a sore throat, minor symptoms, but having RSV with minor symptoms. 193 00:13:31,280 --> 00:13:32,840 So really big benefits. 194 00:13:32,840 --> 00:13:38,360 This was a population that was over 60, and it was a population where about 30, 40% of 195 00:13:38,360 --> 00:13:43,740 them had comorbid diseases like cardiac disease, lung disease, diabetes, obesity, and a few 196 00:13:43,740 --> 00:13:48,080 of them that were actually not frail, but what we consider pretty frail. 197 00:13:48,080 --> 00:13:53,200 So people that had functional issues and may have been even higher risk for severe disease 198 00:13:53,200 --> 00:13:54,200 in that sense. 199 00:13:54,200 --> 00:14:00,560 So really, really good data, and that's really what led to the approval of this vaccine and 200 00:14:00,560 --> 00:14:05,360 now the availability of this vaccine actually across the country for populations over the 201 00:14:05,360 --> 00:14:06,360 age of 60. 202 00:14:06,360 --> 00:14:07,360 Well, it's fantastic. 203 00:14:07,360 --> 00:14:08,360 Yeah. 204 00:14:08,360 --> 00:14:12,640 I mean, those efficacy rates are very high and definitely the population, you know, it's 205 00:14:12,640 --> 00:14:16,680 always the strength of the study when the population that's tested is that high risk 206 00:14:16,680 --> 00:14:17,680 population. 207 00:14:17,680 --> 00:14:21,920 So because that's what we're talking about with those comorbidities and the respiratory 208 00:14:21,920 --> 00:14:25,860 season, because those are the patients that we would see that would enter the hospital 209 00:14:25,860 --> 00:14:30,880 and have very severe morbidity and mortality from RSV. 210 00:14:30,880 --> 00:14:36,040 So Zane, in terms of all of this research is out there, is it a one dose? 211 00:14:36,040 --> 00:14:37,120 Is it two doses? 212 00:14:37,120 --> 00:14:43,520 So what's kind of the administration requirements and can this be given at a physician's office? 213 00:14:43,520 --> 00:14:44,520 Yeah. 214 00:14:44,520 --> 00:14:47,280 So for the first question, it's a really good question. 215 00:14:47,280 --> 00:14:52,000 And, you know, when we think about COVID-19 vaccines, you know, we weren't sure about 216 00:14:52,000 --> 00:14:54,840 the dosing, the virus continues to evolve. 217 00:14:54,840 --> 00:14:58,200 And the other part of COVID-19 vaccines is a lot of people that got COVID-19 vaccines 218 00:14:58,200 --> 00:15:00,120 have never seen COVID-19 before, right? 219 00:15:00,120 --> 00:15:03,840 So this is really priming the initial immune response. 220 00:15:03,840 --> 00:15:07,880 Influenza vaccines, they often have to be tweaked to deal with the antigenic drift. 221 00:15:07,880 --> 00:15:12,040 So kind of different subtypes of influenza circulating globally and try to match appropriately. 222 00:15:12,040 --> 00:15:14,220 RSV vaccine is a little bit different. 223 00:15:14,220 --> 00:15:18,280 So number one, this is an infection, especially in the six year old population, which people 224 00:15:18,280 --> 00:15:21,920 have probably seen five to 10 times during their lifetime. 225 00:15:21,920 --> 00:15:23,760 They have some preexisting immunity. 226 00:15:23,760 --> 00:15:28,040 It's clearly not enough to keep them out of hospital and keep them from getting sick. 227 00:15:28,040 --> 00:15:30,200 But there is some preexisting immunity. 228 00:15:30,200 --> 00:15:36,360 And number two is a virus that is relatively antigenically stable. 229 00:15:36,360 --> 00:15:39,440 So not seeing that much of the drift in that sense. 230 00:15:39,440 --> 00:15:45,400 There's RSV, A and B and the GSK trial showed that similar effects in both, but relatively 231 00:15:45,400 --> 00:15:49,560 you're not seeing the viral evolution we see with influenza and COVID-19. 232 00:15:49,560 --> 00:15:55,920 So all of the trials have incorporated not only the initial one shot versus no shot one 233 00:15:55,920 --> 00:16:01,840 year clinical data, but are actually ongoing looking at what year two looks like for these 234 00:16:01,840 --> 00:16:05,160 people, what year three looks like for these people. 235 00:16:05,160 --> 00:16:10,320 And in the GSK trial, they actually gave a subset of people who got the shot in year 236 00:16:10,320 --> 00:16:14,680 one, a shot in year two versus not getting a shot in year two. 237 00:16:14,680 --> 00:16:20,520 So really now we have a little bit of year two data and interim data analysis that looks 238 00:16:20,520 --> 00:16:28,240 at two shots versus one shot versus zero shots in year two of the respiratory season. 239 00:16:28,240 --> 00:16:31,320 And the bottom line is efficacy is still pretty preserved. 240 00:16:31,320 --> 00:16:36,400 It's about 77, 78% for medically attended or respiratory tract infection. 241 00:16:36,400 --> 00:16:39,560 And two shots right now looks as good as one shot. 242 00:16:39,560 --> 00:16:45,880 So that 78% number is similar, essentially not different between two shots and one shot. 243 00:16:45,880 --> 00:16:51,640 So for the moment, this vaccine is currently only recommended as a single dose because 244 00:16:51,640 --> 00:16:56,720 we do now have two seasons data suggesting that a single dose has the effects for two 245 00:16:56,720 --> 00:16:59,440 seasons that multiple doses would have as well. 246 00:16:59,440 --> 00:17:05,000 And so that's really a good piece that we may have a vaccine that, similar to others, 247 00:17:05,000 --> 00:17:10,200 where it's more of a staggered strategy of immunization, not a yearly strategy. 248 00:17:10,200 --> 00:17:14,400 And so when people go and roll up their sleeves, they can get some assurance that the protection 249 00:17:14,400 --> 00:17:19,480 isn't just going to be for every season I need to update it, but maybe actually for 250 00:17:19,480 --> 00:17:21,920 a decent amount of time afterwards. 251 00:17:21,920 --> 00:17:24,800 The second part to your question was who can administer it? 252 00:17:24,800 --> 00:17:26,340 So this is a new vaccine. 253 00:17:26,340 --> 00:17:29,480 And so that creates a little bit of logistical challenges across the board. 254 00:17:29,480 --> 00:17:34,800 It isn't very different than, say, Shingles vaccine or hepatitis B vaccine in the context 255 00:17:34,800 --> 00:17:37,400 of what it's constituted with. 256 00:17:37,400 --> 00:17:42,600 So in certain provinces, like the Western provinces, pharmacists have the ability to 257 00:17:42,600 --> 00:17:46,640 administer either with or without a physician's order, depending on the province and the scope 258 00:17:46,640 --> 00:17:48,080 of practice. 259 00:17:48,080 --> 00:17:54,280 In places like Ontario, it's really just physician discretion right now, but there is a lot of 260 00:17:54,280 --> 00:17:58,240 work ongoing to make sure that that's a bit more open and matches. 261 00:17:58,240 --> 00:18:02,720 Because again, I presume a pharmacist in British Columbia is pretty similar to a pharmacist 262 00:18:02,720 --> 00:18:07,320 in Ontario in terms of their ability to deal with a vaccine. 263 00:18:07,320 --> 00:18:11,580 And so there is a lot of work that's being done to really try to make sure that it's 264 00:18:11,580 --> 00:18:15,640 more accessible to people, recognizing the challenges in primary care. 265 00:18:15,640 --> 00:18:21,000 This is still a vaccine outside of one province that's publicly funded it for long-term care 266 00:18:21,000 --> 00:18:22,240 in Ontario. 267 00:18:22,240 --> 00:18:27,180 This is still a vaccine that's also privately paid because there's not really a nasty recommendation 268 00:18:27,180 --> 00:18:32,840 for it yet, which is often a trigger to then look at cost effectiveness and public versus 269 00:18:32,840 --> 00:18:35,440 private payers. 270 00:18:35,440 --> 00:18:39,840 So Ontario has invested in long-term care facilities, recognizing that there's probably significant 271 00:18:39,840 --> 00:18:41,280 benefit there. 272 00:18:41,280 --> 00:18:43,880 But outside of that, it's privately funded. 273 00:18:43,880 --> 00:18:48,020 It may be funded through private insurance plans, but that also creates a logistical 274 00:18:48,020 --> 00:18:51,700 challenge because now you actually have to buy the product and administer it. 275 00:18:51,700 --> 00:18:56,920 So again, hopefully more advocacy around getting it in pharmacies and more spots that can do 276 00:18:56,920 --> 00:19:00,120 it appropriately that put less barriers at that patient level. 277 00:19:00,120 --> 00:19:04,720 And generally, do we know if like, let's say patients are asking about costs, do we know 278 00:19:04,720 --> 00:19:07,120 roughly maybe it's a little bit different? 279 00:19:07,120 --> 00:19:09,800 Yeah, the manufacturer cost is 230 Canadian. 280 00:19:09,800 --> 00:19:13,180 In the US, it's $280 American. 281 00:19:13,180 --> 00:19:17,700 So there is a discount being north of the border. 282 00:19:17,700 --> 00:19:19,480 That is not necessarily the cost to patient. 283 00:19:19,480 --> 00:19:24,000 There's obviously costs the pharmacy has to take for bringing it in, injection costs, 284 00:19:24,000 --> 00:19:25,000 et cetera. 285 00:19:25,000 --> 00:19:29,200 But that's the baseline cost plus probably a little bit on the pharmacy end or the provider 286 00:19:29,200 --> 00:19:31,040 end in that standpoint. 287 00:19:31,040 --> 00:19:35,240 And then just like any new rollout for vaccines, I know there's always questions in regards 288 00:19:35,240 --> 00:19:36,400 to safety. 289 00:19:36,400 --> 00:19:40,840 So what, you know, we talked about the efficacy, we talked about the administration of this 290 00:19:40,840 --> 00:19:47,200 vaccine in those similar trials, I would assume, especially at the second year for sure, but 291 00:19:47,200 --> 00:19:49,980 initially as well, safety was looked at. 292 00:19:49,980 --> 00:19:53,800 So what can we tell our some of our listeners about that? 293 00:19:53,800 --> 00:19:54,800 Yeah, absolutely. 294 00:19:54,800 --> 00:20:00,300 So the GSK vaccine, the Eurexia vaccine, you know, it has a Shingrix adjuvant. 295 00:20:00,300 --> 00:20:05,320 For those who have taken Shingrix or administered Shingrix, it gives people a sore arm and a 296 00:20:05,320 --> 00:20:06,320 lot of swelling. 297 00:20:06,320 --> 00:20:10,880 And so that was seen in the clinical trials, a lot of, you know, compared to placebo swelling, 298 00:20:10,880 --> 00:20:17,600 fever, malaise, nausea, injection site redness, you know, those were higher in the group that 299 00:20:17,600 --> 00:20:20,920 got the RSV vaccine versus the group that got placebo. 300 00:20:20,920 --> 00:20:24,160 That's not necessarily a harm, but it's just a recognizable side effect of that adjuvant 301 00:20:24,160 --> 00:20:25,840 being very, very immunogenic. 302 00:20:25,840 --> 00:20:29,040 Unfortunately, it leaves people with a bit of immunogenic side effects. 303 00:20:29,040 --> 00:20:31,920 Most of these SAEs were dealt with in 40 to 72 hours. 304 00:20:31,920 --> 00:20:36,960 Sorry, these AEs, sorry, were dealt with in 40 to 72 hours. 305 00:20:36,960 --> 00:20:42,560 In terms of SAEs, serious adverse events in the registration clinical trial, there was 306 00:20:42,560 --> 00:20:44,840 none higher than placebo. 307 00:20:44,840 --> 00:20:51,680 On the product monograph, there are two descriptions of Guillain-Barre-like cases associated with 308 00:20:51,680 --> 00:20:53,180 the vaccine. 309 00:20:53,180 --> 00:20:57,080 One was associated with co-administration with the influenza vaccine. 310 00:20:57,080 --> 00:21:01,120 So it's not clear exactly what the source was. 311 00:21:01,120 --> 00:21:06,600 And there's one that probably is temporally related to the vaccine in a separate clinical 312 00:21:06,600 --> 00:21:09,120 trial, wasn't actually in this clinical trial. 313 00:21:09,120 --> 00:21:11,880 So there is that indication. 314 00:21:11,880 --> 00:21:14,960 And certainly part of post-marketing surveillance is looking for it. 315 00:21:14,960 --> 00:21:21,160 But at the same time, outside of that, and these Guillain-Barre events are also difficult 316 00:21:21,160 --> 00:21:25,800 to adjudicate just because they're spontaneous events in a baseline risk in the population 317 00:21:25,800 --> 00:21:28,600 and a risk associated with respiratory tract infections too. 318 00:21:28,600 --> 00:21:33,720 We have actually data around, for example, natural influenza and Guillain-Barre syndrome, 319 00:21:33,720 --> 00:21:39,040 which is about 1 in 100,000, that risk and benefit discussion in that context. 320 00:21:39,040 --> 00:21:42,840 And hopefully, as again, more global administration happens, we get more global data if this is 321 00:21:42,840 --> 00:21:45,080 a real trend and what the prevalence is. 322 00:21:45,080 --> 00:21:50,160 But really, outside of that issue, there really isn't major SAEs that were noted. 323 00:21:50,160 --> 00:21:57,160 And again, other than the side sore arm, which for some people could be considered, it feels 324 00:21:57,160 --> 00:21:59,720 lousy, but at least means it's working in that sense. 325 00:21:59,720 --> 00:22:00,720 Right? 326 00:22:00,720 --> 00:22:01,720 Yeah. 327 00:22:01,720 --> 00:22:02,720 Right. 328 00:22:02,720 --> 00:22:07,880 So I know in pediatrics, we always talk about co-administration of vaccines because our 329 00:22:07,880 --> 00:22:10,800 vaccine schedules are so detailed and intricate. 330 00:22:10,800 --> 00:22:13,160 There's multiple vaccines that are given. 331 00:22:13,160 --> 00:22:18,200 So in this adult population over 60, I know that a lot of people are now getting that 332 00:22:18,200 --> 00:22:22,520 text message where influenza vaccines are rolling out. 333 00:22:22,520 --> 00:22:27,720 We know that there is a new COVID vaccine covering the Armicon variant that was released 334 00:22:27,720 --> 00:22:28,720 by Moderna. 335 00:22:28,720 --> 00:22:36,280 So in terms of with RSV and in the study, like you mentioned that some of the co-administration 336 00:22:36,280 --> 00:22:43,160 with RSV and influenza led to, let's say an incident like Yomber, so did they discuss 337 00:22:43,160 --> 00:22:48,240 co-administration of all the other vaccines that maybe even shingles, I guess, because 338 00:22:48,240 --> 00:22:51,800 a lot of that population would also be exposed to such a vaccine? 339 00:22:51,800 --> 00:22:52,800 Yeah, absolutely. 340 00:22:52,800 --> 00:22:59,560 So the trial that had the single case with co-administration, there was actually a trial 341 00:22:59,560 --> 00:23:05,720 that looked at co-administration with both high dose quadrivalent vaccine for influenza 342 00:23:05,720 --> 00:23:08,600 and adjuvanted influenza vaccine. 343 00:23:08,600 --> 00:23:18,040 At least outside of H3N2 titers with, I believe, the adjuvanted vaccine, there was non-inferiority 344 00:23:18,040 --> 00:23:24,680 in terms of individuals who got influenza alone versus influenza plus the RSV vaccine. 345 00:23:24,680 --> 00:23:28,280 And safety wise, there was no concerns other than the single case and even then it was 346 00:23:28,280 --> 00:23:31,240 hard to say where it was adjudicated. 347 00:23:31,240 --> 00:23:34,400 So at least we have some co-administration data. 348 00:23:34,400 --> 00:23:39,440 Even that lower level of H3N2 antibodies, it's not clear what that clinically still 349 00:23:39,440 --> 00:23:45,160 developed antibodies that were slightly lower than pre-specified margin. 350 00:23:45,160 --> 00:23:48,520 Does that mean there's less protection or does that mean the protection is the same? 351 00:23:48,520 --> 00:23:50,560 If you were exposed, it's not really clear. 352 00:23:50,560 --> 00:23:54,640 The ACIP in the US, which is probably the guideline organization we rely on, just kind 353 00:23:54,640 --> 00:23:59,840 of said consider co-administration if it's easier for the patient, the risks and benefits, 354 00:23:59,840 --> 00:24:06,640 losing patients, et cetera, and consider if there's factors that may want people to space 355 00:24:06,640 --> 00:24:12,120 things out, they're a bit more predisposed to side effects, they're worried about side 356 00:24:12,120 --> 00:24:14,680 effects, then space them out. 357 00:24:14,680 --> 00:24:18,760 And if you have good patient follow-up, then that's not an unreasonable issue. 358 00:24:18,760 --> 00:24:21,880 And obviously consider where you are in the respiratory season. 359 00:24:21,880 --> 00:24:26,480 If we're talking about doing this in May, probably fine to space things out. 360 00:24:26,480 --> 00:24:30,960 If RSV is surging, then you might want to have some second thoughts about spacing things 361 00:24:30,960 --> 00:24:35,120 out if you're going to lose the patient in that couple of weeks. 362 00:24:35,120 --> 00:24:41,640 The other vaccines like herpes zoster, pneumococcal, COVID-19 vaccines, there's no data and there 363 00:24:41,640 --> 00:24:45,240 wasn't co-administration data in clinical trials. 364 00:24:45,240 --> 00:24:49,960 I would say there are some organizations, the Ontario Advisory Council on Immunization, 365 00:24:49,960 --> 00:24:56,360 for example, that said maybe for the first little while, give a couple of weeks between 366 00:24:56,360 --> 00:25:01,240 vaccines, not for any safety issue, but just for the fact that you could actually attribute 367 00:25:01,240 --> 00:25:05,020 if there is an adverse event where what vaccine it's associated with. 368 00:25:05,020 --> 00:25:10,120 But at the same time that the ACIP had really come out with a recommendation to say, think 369 00:25:10,120 --> 00:25:15,720 about your patient, their demographics, their risks, their benefits of getting co-administration 370 00:25:15,720 --> 00:25:19,240 versus non-benefits of getting co-administration and make a discussion. 371 00:25:19,240 --> 00:25:21,260 There's not a yes or no. 372 00:25:21,260 --> 00:25:25,640 You can certainly co-administer if you want, but really consider that patient. 373 00:25:25,640 --> 00:25:28,240 The only other thing I would say is if you're going to use adjuvanted vaccines like the 374 00:25:28,240 --> 00:25:32,560 adjuvanted influenza vaccine or the adjuvanted herpes zoster vaccine, give it in separate 375 00:25:32,560 --> 00:25:37,120 arms to that patient so that you don't have a huge amount of adjuvant in one side. 376 00:25:37,120 --> 00:25:40,920 Not dangerous, but they're going to have a lot of pain on that side if you keep pushing 377 00:25:40,920 --> 00:25:41,920 it in that sense. 378 00:25:41,920 --> 00:25:42,920 Yeah. 379 00:25:42,920 --> 00:25:46,040 And then I guess seeing we should probably let our listeners know that with RSC this 380 00:25:46,040 --> 00:25:48,760 vaccine is inactivated. 381 00:25:48,760 --> 00:25:50,240 And so that would be important. 382 00:25:50,240 --> 00:25:53,680 I know that's always a question when vaccines roll out. 383 00:25:53,680 --> 00:26:00,560 And so like influenza, obviously we have active and inactive formulations, but specifically 384 00:26:00,560 --> 00:26:02,600 unless I'm wrong. 385 00:26:02,600 --> 00:26:05,760 So this is a protein based vaccine. 386 00:26:05,760 --> 00:26:11,960 And so for immunocompromised populations and their families, there's no issues with potential 387 00:26:11,960 --> 00:26:15,360 spread or again, being immunocompromised. 388 00:26:15,360 --> 00:26:20,080 And we do know RSC is a big issue in immunocompromised patients and is actually a population of concern. 389 00:26:20,080 --> 00:26:24,880 So especially if they're over 60, that is a population of really, really consider vaccination. 390 00:26:24,880 --> 00:26:29,640 We have good data from herpes zoster that this adjuvant really does a good job at triggering 391 00:26:29,640 --> 00:26:30,640 immune responses. 392 00:26:30,640 --> 00:26:36,960 And in bone marrow transplant individuals, there's no contraindication in immunocompromised 393 00:26:36,960 --> 00:26:37,960 person. 394 00:26:37,960 --> 00:26:40,640 And in fact, probably a good amount of benefit in that context. 395 00:26:40,640 --> 00:26:43,520 I think it's also fantastic that it's a one shot, right? 396 00:26:43,520 --> 00:26:50,420 So I mean, probably the benefits of being conjugated and also that if we get it early 397 00:26:50,420 --> 00:26:54,080 on in the season, then it will last you the season. 398 00:26:54,080 --> 00:26:58,640 And who knows what the respiratory season, how long the respiratory season will be? 399 00:26:58,640 --> 00:27:05,840 Because I know in pediatrics, for instance, we saw this early fall, late spring was our 400 00:27:05,840 --> 00:27:06,960 RSV season. 401 00:27:06,960 --> 00:27:12,220 And then now it's just turning into kind of that less seasonal pattern. 402 00:27:12,220 --> 00:27:16,960 So I think it's reassuring to people as well that this isn't something that's only going 403 00:27:16,960 --> 00:27:23,720 to last you four or five months, but the hope is that it lasts you the entire season and 404 00:27:23,720 --> 00:27:24,720 longer. 405 00:27:24,720 --> 00:27:25,720 Yeah, absolutely. 406 00:27:25,720 --> 00:27:29,080 And you know, in those discussions around costs, like we know cost is an issue. 407 00:27:29,080 --> 00:27:33,600 People have cost containment issues and the need to afford medications. 408 00:27:33,600 --> 00:27:38,040 You know, think about it as amortizing it over at least two years, maybe even longer. 409 00:27:38,040 --> 00:27:41,160 And so, you know, this is not just a cost upfront today. 410 00:27:41,160 --> 00:27:44,880 It's probably a cost for two years or three years, depending on the data that we see coming 411 00:27:44,880 --> 00:27:45,880 out. 412 00:27:45,880 --> 00:27:50,120 You know, there may be that frame of mind that this is more of a long term intervention 413 00:27:50,120 --> 00:27:51,120 than a short term intervention. 414 00:27:51,120 --> 00:27:57,320 I know there's a lot of discussion around RSC in general, even in the pediatric population. 415 00:27:57,320 --> 00:27:59,760 So like we talked about the disease burden. 416 00:27:59,760 --> 00:28:05,720 So in the past, we've really, I mean, even now we don't have like an RSC specific vaccine 417 00:28:05,720 --> 00:28:08,040 in pediatric patients. 418 00:28:08,040 --> 00:28:13,640 There is some discussions around rollouts in pregnant women and other high risk populations. 419 00:28:13,640 --> 00:28:18,480 Like we've already fortunate to see that at least one came out in elderly population with 420 00:28:18,480 --> 00:28:19,480 comorbidities. 421 00:28:19,480 --> 00:28:25,200 But just so our listeners know, like there isn't a pediatric formulation of this yet. 422 00:28:25,200 --> 00:28:30,080 We, they will be hearing a little bit more about some of the monoclonal antibodies. 423 00:28:30,080 --> 00:28:35,380 Historically, we've had Pellivizumab on the market for a long, long time, as long as I 424 00:28:35,380 --> 00:28:39,280 can remember practicing and learning about it. 425 00:28:39,280 --> 00:28:47,500 And so I think there will be some newer data coming out from PHAC for sure in a few short 426 00:28:47,500 --> 00:28:53,200 months here in terms of Nercivumab, which I think a lot of our listeners probably tuned 427 00:28:53,200 --> 00:28:59,080 into some of the information and probably will be hearing from their RSC programs locally. 428 00:28:59,080 --> 00:29:03,360 It is obviously jurisdiction, inter-jurisdictional differences. 429 00:29:03,360 --> 00:29:09,980 We know that with all vaccines and healthcare in general, and you know, once like Health 430 00:29:09,980 --> 00:29:12,880 Canada definitely has approved this. 431 00:29:12,880 --> 00:29:18,840 And so with the rollout of Nercivumab, we don't know exactly which populations to target. 432 00:29:18,840 --> 00:29:26,240 I know the US has definitely given us more information in terms of a wide group patients, 433 00:29:26,240 --> 00:29:32,040 but just for our listeners to be aware that some of that data isn't as particular, you 434 00:29:32,040 --> 00:29:34,760 know, rolled out yet for Canada, but should be on the way. 435 00:29:34,760 --> 00:29:38,880 But just to discuss a little bit about what we're seeing with RSV. 436 00:29:38,880 --> 00:29:44,520 So obviously through some of our impact surveillance data, similarly to what other groups have 437 00:29:44,520 --> 00:29:49,400 seen in other populations, like you mentioned in the adult population as well, is that we 438 00:29:49,400 --> 00:29:56,440 didn't actually have a season for RSV back in 2020 to 2021, which was a bit strange for 439 00:29:56,440 --> 00:30:03,160 us in pediatrics because prior to that and then after that, we've seen peak numbers of 440 00:30:03,160 --> 00:30:08,200 RSV and really affects kind of the young comorbidities definitely. 441 00:30:08,200 --> 00:30:13,960 So if anybody has chronic or congenital heart conditions, chronic lung disease, and that's 442 00:30:13,960 --> 00:30:16,480 kind of our same population. 443 00:30:16,480 --> 00:30:23,040 Now we haven't seen much of a difference in terms of the actual morbidity that's changed. 444 00:30:23,040 --> 00:30:27,560 So that's been very similar, but we have seen a rise in our hospitalizations. 445 00:30:27,560 --> 00:30:34,040 And so that's gone up significantly and still affecting less than six months old, primarily. 446 00:30:34,040 --> 00:30:38,720 And so I think that's still, whenever we talk about extremes of age, I think that's very 447 00:30:38,720 --> 00:30:40,040 common in medicine, right? 448 00:30:40,040 --> 00:30:45,440 So extremes of age, less than six months, I mean, even probably up to a year, we worry 449 00:30:45,440 --> 00:30:49,880 about that with RSV and then 60 and older is kind of what we're talking about in the 450 00:30:49,880 --> 00:30:51,120 elderly population. 451 00:30:51,120 --> 00:30:55,480 So I think some of these things are towards preventative, right? 452 00:30:55,480 --> 00:30:57,560 That's what our actions are towards. 453 00:30:57,560 --> 00:31:00,800 And that's what Nercifimab and even Pellivizumab in the past. 454 00:31:00,800 --> 00:31:05,120 So I think some of the differences, I won't go into all the details of that today for 455 00:31:05,120 --> 00:31:06,120 time's sake. 456 00:31:06,120 --> 00:31:11,080 And, but definitely once PHAC gives us some more information, I think we'll probably do 457 00:31:11,080 --> 00:31:18,480 another episode on Nercifimab because I think it's worthy of its own episode for sure. 458 00:31:18,480 --> 00:31:19,920 It's a difficult file, right? 459 00:31:19,920 --> 00:31:27,120 Because vaccinations are kind of pretty straightforward in terms of, you give it, that's it. 460 00:31:27,120 --> 00:31:29,360 There's a cost associated, there's a burden associated. 461 00:31:29,360 --> 00:31:33,680 And the demand drives the vaccination in terms of the disease state. 462 00:31:33,680 --> 00:31:34,680 This is a tricky file, right? 463 00:31:34,680 --> 00:31:38,600 Because there's a cost effectiveness component in terms of the number of hospitalizations 464 00:31:38,600 --> 00:31:39,600 averted. 465 00:31:39,600 --> 00:31:45,560 There's lots of ways that we measure cost effectiveness in terms of quality adjusted 466 00:31:45,560 --> 00:31:46,800 life years and that type of thing. 467 00:31:46,800 --> 00:31:50,800 And so this is where some of these discussions are happening. 468 00:31:50,800 --> 00:31:55,320 This is where the one decision could be made in the US, one decision could be made in Canada 469 00:31:55,320 --> 00:31:57,320 that are polar opposites. 470 00:31:57,320 --> 00:32:00,600 And again, it's not as simple as saying yes or no. 471 00:32:00,600 --> 00:32:06,080 The drug's approved, it's just how do we roll this out effectively to the most individuals 472 00:32:06,080 --> 00:32:09,840 that are at risk and get the biggest value for it in that sense, right? 473 00:32:09,840 --> 00:32:10,840 Yeah. 474 00:32:10,840 --> 00:32:15,000 And just like you mentioned, Zane, we're entering into programs that are already established, 475 00:32:15,000 --> 00:32:16,000 right? 476 00:32:16,000 --> 00:32:19,040 So we already have these RSV programs and multiple centers. 477 00:32:19,040 --> 00:32:22,800 And so kind of figuring out the logistics of the change as well. 478 00:32:22,800 --> 00:32:27,040 And I think it rolled out in a time where RSV is just around the corner too. 479 00:32:27,040 --> 00:32:31,700 So but definitely new information, a lot of updates. 480 00:32:31,700 --> 00:32:37,600 And so all of this along with other preventative measures that we've seen being implemented 481 00:32:37,600 --> 00:32:41,320 in the last few years, I think we're on the right track. 482 00:32:41,320 --> 00:32:44,680 That's probably the most fortunate take back from this. 483 00:32:44,680 --> 00:32:50,240 Even though it's a dreaded respiratory season, we have more options. 484 00:32:50,240 --> 00:32:55,280 So with this upcoming respiratory season, what's our future? 485 00:32:55,280 --> 00:32:57,800 Do we think that we're seeing an uptick in general? 486 00:32:57,800 --> 00:32:59,280 Are we already seeing this uptick? 487 00:32:59,280 --> 00:33:00,280 Yeah. 488 00:33:00,280 --> 00:33:03,320 I mean, I think COVID-19 obviously is one that it's hard to predict, right? 489 00:33:03,320 --> 00:33:08,520 If you could tell what could happen, you'd probably make a lot of money and be able to 490 00:33:08,520 --> 00:33:09,520 go through it. 491 00:33:09,520 --> 00:33:12,240 But at the same time, we do see COVID transmission. 492 00:33:12,240 --> 00:33:16,600 It is translating into some degree of hospitalizations and unfortunately is translating into nosocomial 493 00:33:16,600 --> 00:33:17,800 activity. 494 00:33:17,800 --> 00:33:23,480 But in the same context, there has been a rapid, rapid decline in severe complications 495 00:33:23,480 --> 00:33:28,240 with COVID-19 and that's really due to COVID-19 and therapeutics. 496 00:33:28,240 --> 00:33:33,600 Influenza is probably, as we saw in some of the other Southern jurisdictions, is probably 497 00:33:33,600 --> 00:33:36,760 going to have more of a typical seasonal pattern. 498 00:33:36,760 --> 00:33:39,200 Maybe a bit of a higher peak, it's not clear. 499 00:33:39,200 --> 00:33:43,560 A little bit more reassuring from last year, it doesn't seem to have taken off just yet. 500 00:33:43,560 --> 00:33:44,680 It's kind of at the beginning. 501 00:33:44,680 --> 00:33:48,640 So it's probably a little bit more hopefully predictable. 502 00:33:48,640 --> 00:33:54,080 RSV, again, I think we're starting to see the uptick a little bit earlier, not as bad 503 00:33:54,080 --> 00:33:57,360 again as last season's uptick, but starting. 504 00:33:57,360 --> 00:34:02,120 All the other respiratory viruses obviously come around to adenovirus and rhinovirus, 505 00:34:02,120 --> 00:34:07,520 that's typically earlier in the year, parainfluenza, human beddenumovirus in the spring, all that. 506 00:34:07,520 --> 00:34:15,360 I think the one thing that is probably new-ish and one of the directions on improving vaccinations 507 00:34:15,360 --> 00:34:21,600 is also a significant recognition of the chronic disease states that get exacerbated by underlying 508 00:34:21,600 --> 00:34:22,600 viral diseases. 509 00:34:22,600 --> 00:34:27,400 I'll give one example of coronary artery disease or cardiovascular disease. 510 00:34:27,400 --> 00:34:30,280 It's always been known, I mean, we see it in the winter, right? 511 00:34:30,280 --> 00:34:35,680 That heart attacks go up and people often complain of a viral illness before their MI. 512 00:34:35,680 --> 00:34:40,920 These are pure MIs, chest pain MIs, not I have a cough and I have no troponin, this 513 00:34:40,920 --> 00:34:47,240 is people who have plaque disruption and need an intervention. 514 00:34:47,240 --> 00:34:51,760 There's been a lot of data across the country, Jeff Kwong's group here in Ontario has really 515 00:34:51,760 --> 00:34:57,600 studied this quite a bit and saw, for example, the rate of incident MI after influenza is 516 00:34:57,600 --> 00:35:03,120 six times higher in the seven days post-influenza diagnosis than it is before having influenza 517 00:35:03,120 --> 00:35:06,560 or even seven days after having influenza. 518 00:35:06,560 --> 00:35:08,280 That's an important concept. 519 00:35:08,280 --> 00:35:15,160 We actually have our first randomized clinical trial of influenza vaccine in cardiac prevention 520 00:35:15,160 --> 00:35:16,840 and it's pretty landmark trial. 521 00:35:16,840 --> 00:35:21,160 It's actually one that isn't discussed much, but this was by Mark Loeb, who's a colleague 522 00:35:21,160 --> 00:35:22,160 of mine here. 523 00:35:22,160 --> 00:35:28,240 They went to some low-income countries where influenza vaccine was not standard of care. 524 00:35:28,240 --> 00:35:32,840 So it was really kind of an altruistic trial to get some people influenza vaccine. 525 00:35:32,840 --> 00:35:38,400 They gave influenza vaccine versus placebo to individuals who had cardiac risk. 526 00:35:38,400 --> 00:35:45,640 They looked in the influenza season and they saw about a 19% relative risk reduction in 527 00:35:45,640 --> 00:35:52,680 incident fatal or non-fatal myocardial infarction or stroke as a composite outcome in individuals 528 00:35:52,680 --> 00:35:54,640 who got an influenza vaccine versus not. 529 00:35:54,640 --> 00:35:59,360 This isn't that they get influenza, this isn't that they get pneumonia, did they end up hospitalized? 530 00:35:59,360 --> 00:36:03,920 It's literally, did they have a heart attack or a stroke and they saw a decline. 531 00:36:03,920 --> 00:36:05,800 So that's an important intervention, right? 532 00:36:05,800 --> 00:36:12,820 For those primary care specialists who deal with high-risk cardiac patients, we have agonizing 533 00:36:12,820 --> 00:36:22,000 discussions about antiplatelet agents, anticoagulation, statin, glycemic control, hypertension control. 534 00:36:22,000 --> 00:36:26,600 We rarely have discussions of, hey, are you up to date with your immunizations? 535 00:36:26,600 --> 00:36:30,440 But I think that paradigm has shifted to say, actually, I need to talk to you if you're 536 00:36:30,440 --> 00:36:35,160 up to date on your immunizations because that's just important as the antiplatelet discussion 537 00:36:35,160 --> 00:36:40,280 we need to have or the statin discussion or the hypertension discussion we need to have. 538 00:36:40,280 --> 00:36:45,560 So really groundbreaking, but a concept that I think has been going on for a while, but 539 00:36:45,560 --> 00:36:49,900 recognizing again that there is a probably chronic disease burden from viral infections 540 00:36:49,900 --> 00:36:54,240 that needs much more intervention from those in that sense. 541 00:36:54,240 --> 00:36:59,760 So really emphasizing preventative measures alongside other preventative risk-modifying 542 00:36:59,760 --> 00:37:02,120 disease methods that they're using. 543 00:37:02,120 --> 00:37:07,520 So I think for some of our cardiologists listening out there, I think that's good to implement 544 00:37:07,520 --> 00:37:14,280 into our day-to-day counseling because I think it's important to have that whole framework, 545 00:37:14,280 --> 00:37:15,280 right? 546 00:37:15,280 --> 00:37:19,600 So we have to cover all aspects and presenting some of this data to your patients. 547 00:37:19,600 --> 00:37:24,760 I think that's really important because I think a lot of information, there's a lot 548 00:37:24,760 --> 00:37:30,160 of information out there, but really having some of that evidence-based and trial information, 549 00:37:30,160 --> 00:37:34,080 I think is very helpful for patients to understand. 550 00:37:34,080 --> 00:37:37,720 It's not just that we're preventing you from getting a common cold, but there's actually 551 00:37:37,720 --> 00:37:38,720 other benefits. 552 00:37:38,720 --> 00:37:39,720 Absolutely. 553 00:37:39,720 --> 00:37:40,720 And it's a group discussion, right? 554 00:37:40,720 --> 00:37:43,400 So all healthcare providers need to be involved with immunization. 555 00:37:43,400 --> 00:37:44,520 It's not just primary care. 556 00:37:44,520 --> 00:37:45,520 It's not just pharmacy. 557 00:37:45,520 --> 00:37:47,280 It's not just infectious diseases. 558 00:37:47,280 --> 00:37:49,720 It's everyone has a role to play. 559 00:37:49,720 --> 00:37:54,880 Again, a cardiologist has just as much skin in the game to make sure that person's immunized 560 00:37:54,880 --> 00:37:57,440 as the primary care physician. 561 00:37:57,440 --> 00:37:58,440 Yeah. 562 00:37:58,440 --> 00:37:59,440 And I think just making it routine. 563 00:37:59,440 --> 00:38:05,440 And I know there's a lot of discussion around, there's obviously vaccine hesitancy, but there's 564 00:38:05,440 --> 00:38:07,420 also vaccine fatigue, right? 565 00:38:07,420 --> 00:38:15,000 So we are seeing people from the last few years, all we talk about is vaccines, vaccines, 566 00:38:15,000 --> 00:38:21,120 vaccines, and I can imagine for patients and for their families and for people who are 567 00:38:21,120 --> 00:38:24,960 trying to raise their families, it's challenging, right? 568 00:38:24,960 --> 00:38:26,160 There's always something new. 569 00:38:26,160 --> 00:38:29,800 There's always something that we're talking about, but I think this is just the spread 570 00:38:29,800 --> 00:38:33,120 of information is very different nowadays than it was before. 571 00:38:33,120 --> 00:38:37,920 And so I think just counseling your patients is really important, reminding them that we're 572 00:38:37,920 --> 00:38:44,720 not going to talk about this all the time, not in July and August, but right now as we're 573 00:38:44,720 --> 00:38:48,160 having peak respiratory season, that's why you're hearing more about this. 574 00:38:48,160 --> 00:38:51,480 And so really taking on those preventive measures. 575 00:38:51,480 --> 00:38:53,120 That's fantastic, Zane. 576 00:38:53,120 --> 00:38:58,800 I'm really excited about this RSV vaccine because I want to see some of the post-marketing 577 00:38:58,800 --> 00:38:59,800 surveillance. 578 00:38:59,800 --> 00:39:05,040 I think it'll be interesting to see some of the data through there. 579 00:39:05,040 --> 00:39:06,920 So what's the future currently? 580 00:39:06,920 --> 00:39:13,560 Are there enrollments for trials that physicians should be thinking about? 581 00:39:13,560 --> 00:39:16,920 Is there a future combined vaccines that are coming out? 582 00:39:16,920 --> 00:39:21,800 And maybe we can prep our patients for anything that's on your end. 583 00:39:21,800 --> 00:39:25,200 So definitely the combined vaccine is a big issue. 584 00:39:25,200 --> 00:39:29,920 And certainly there's a lot of work being done, COVID-19, RSV and influenza, bundling 585 00:39:29,920 --> 00:39:34,280 them, not only having them separate, but bundling them up, recognizing it's a challenge. 586 00:39:34,280 --> 00:39:38,300 The data cuts from year two and year three of these studies are also going to start coming 587 00:39:38,300 --> 00:39:44,120 out so we can probably get a bit more sense of what long-term efficacy of these vaccines 588 00:39:44,120 --> 00:39:45,120 are. 589 00:39:45,120 --> 00:39:46,720 There is a lot of work being done. 590 00:39:46,720 --> 00:39:50,280 And again, we'll probably see real-world implementation data. 591 00:39:50,280 --> 00:39:54,560 And similar to the journey of the herpes zoster vaccine, we start seeing what happens in real-world 592 00:39:54,560 --> 00:39:55,560 populations, right? 593 00:39:55,560 --> 00:39:59,880 So long-term care populations, majorly immunocompromised populations. 594 00:39:59,880 --> 00:40:05,880 I think the data will be good, but I think, again, it gives more push for, A, public funding 595 00:40:05,880 --> 00:40:09,520 models, but B, really the benefits of these vaccines. 596 00:40:09,520 --> 00:40:10,520 Yeah. 597 00:40:10,520 --> 00:40:15,040 So a lot to look forward to, but let's all be safe this respiratory season. 598 00:40:15,040 --> 00:40:18,280 So I think we have some preventative options. 599 00:40:18,280 --> 00:40:20,240 The vaccines have started to roll out. 600 00:40:20,240 --> 00:40:25,480 So reach out to your local pharmacists and pharmacies and physicians if you need more 601 00:40:25,480 --> 00:40:27,040 information. 602 00:40:27,040 --> 00:40:30,840 And so I think really important is along with prevention. 603 00:40:30,840 --> 00:40:32,560 We do this in pediatrics all the time. 604 00:40:32,560 --> 00:40:38,440 I counsel everybody about hand washing and if you're sick, stay home, masking, that type 605 00:40:38,440 --> 00:40:39,440 of thing. 606 00:40:39,440 --> 00:40:44,600 So we know that all of these preventative measures along with vaccines are effective. 607 00:40:44,600 --> 00:40:49,880 And so is there any last few words you want our listeners to know about? 608 00:40:49,880 --> 00:40:50,880 Yeah. 609 00:40:50,880 --> 00:40:55,120 No, it's just, look, we live in a, it's a terrible time that we have to deal with respiratory 610 00:40:55,120 --> 00:40:56,880 season, but think about it. 611 00:40:56,880 --> 00:40:58,840 This year is very different than 2018. 612 00:40:58,840 --> 00:41:01,200 We have multiple vaccines, we have therapeutics. 613 00:41:01,200 --> 00:41:05,160 We have lots of different ways to make sure people are safer during respiratory season. 614 00:41:05,160 --> 00:41:08,960 You know, it's time, you know, I think providers are really willing to have those discussions 615 00:41:08,960 --> 00:41:09,960 with patients. 616 00:41:09,960 --> 00:41:14,360 And so, you know, have that discussion with your provider because again, it's important. 617 00:41:14,360 --> 00:41:18,240 And again, it's really the scientific progress, which has been great. 618 00:41:18,240 --> 00:41:19,240 Exactly. 619 00:41:19,240 --> 00:41:23,640 And I think we're very fortunate that all of this is rolling out at a very good speed. 620 00:41:23,640 --> 00:41:28,240 So definitely timely for the respiratory season as well. 621 00:41:28,240 --> 00:41:29,240 That's fantastic. 622 00:41:29,240 --> 00:41:33,600 So before we go, I just want to let everybody know that this podcast is only for informational 623 00:41:33,600 --> 00:41:39,760 purposes and not to endorse a product or a vaccine product or any information. 624 00:41:39,760 --> 00:41:45,040 Pleasure to have you on our podcast today and, you know, talk about such a pressing 625 00:41:45,040 --> 00:41:49,520 issue that's, you know, just around the corner for most of us. 626 00:41:49,520 --> 00:41:54,520 And so I think with all of this advice and information that you've given us today, I 627 00:41:54,520 --> 00:42:00,400 think we're setting ourselves up for a successful, although dreaded respiratory season. 628 00:42:00,400 --> 00:42:01,400 Thanks for having me. 629 00:42:01,400 --> 00:42:02,400 Thanks, Sain. 630 00:42:02,400 --> 00:42:05,640 Thank you, Dr. Purwall and Dr. Shagla. 631 00:42:05,640 --> 00:42:07,080 Have a topic suggestion? 632 00:42:07,080 --> 00:42:13,640 Email us at thecanadianbreakpoint at gmail.com and follow us on ex, formerly Twitter, at 633 00:42:13,640 --> 00:42:14,640 CA Breakpoint. 634 00:42:14,640 --> 00:42:28,000 See you again soon at the Canadian Breakpoint.