506 - RSV Vaccine, Toxic Algae Blooms, When You’ve Lost Your “Why”

From the Centers for Disease Control and Prevention (CDC)
1) RSV Vaccine in Older Adults?

In May of this year, the US Food and Drug Administration licensed two vaccines against the respiratory syncytial virus (RSV), and in June, the Advisory Committee on Immunization Practices (ACIP) examined the evidence for this vaccine to create a recommendation. RSV vaccination can be provided to adults 60 years and older to prevent RSV-associated lower respiratory tract infection (LRTI) after a shared-decision making process.

RSV is famous mostly for causing bronchiolitis in infants. It was unmasked, during our emergence from the COVID pandemic, as one of the “triple threat” viruses circulating among adults last winter (COVID, flu and RSV). It is responsible for between 60 and 160,000 hospitalizations in older adults and 6-10,000 deaths in that age group per year. Factors that increase the risk of RSV-associated hospitalization include almost any chronic disease (especially respiratory), immune compromise, frailty, and living in a nursing facility.

The ACIP reviewed one phase 3 trial each for the Pfizer vaccine (Abrysvo) and the GlaxoSmithKline vaccine (Arexvy) as well as safety data from the previous phase 1 and 2 studies. The major outcomes studied for each vaccine were RSV-associated LRTI and “medically attended” RSV-associated LRTI (RSV infection associated with either an inpatient stay or an outpatient visit). There was not yet sufficient power (the trials are ongoing) to examine hospitalization due to RSV. The effectiveness of each vaccine in preventing any RSV-associated LRTI over 2 seasons averaged to 74.5%  (95% CI 60.0 to 84.5) for the GSK vaccine and 84.4% (95% CI 59.6% to 95.2%) for the Pfizer vaccine. For medically attended, RSV-associated LRTI averaged over 2 seasons, the effectiveness was 77.5% (95% CI 57.9% to 89.0%) for GSK and 81.0% (95% CI 43.5% to 95.2%) for Pfizer. The GSK vaccine had similar serious adverse events (SAE) as the placebo group but caused more “severe reactogenicity events” (intense local reactions, fevers, etc.), and some uncontrolled data from Japan revealed three instances of “inflammatory neurologic events” (like Guillain-Barre syndrome). The Pfizer vaccine did not differ from placebo in either SAE or severe reactogenicity events but did have three inflammatory neurologic events (compared with zero in the placebo group) occur during the studies.

The ACIP’s recommendation is for only a single dose of the vaccine in higher risk individuals after shared decision making. There is no recommendation as yet for any repeat doses. The vaccine may be given with other vaccines, but there is only data for co-administration with influenza vaccine.

John’s Comments: 

Despite the ongoing marketing campaigns by the pharmaceutical companies for this vaccine, I’m not sure it’s a slam-dunk decision.  First, the outcomes studied were “RSV-associated lower respiratory tract infections” (medically attended or not).  This is a specific complication from RSV, not all RSV, so we must keep our expectations in check for the clinical impact of this vaccine.  Second, the safety data is overall encouraging, but each vaccine seemed to decline in effectiveness in the second year, which could ultimately tip the balance between benefit and harm. Third, the data from these vaccines is still pretty immature, and don’t include solid patient-oriented outcomes like hospitalization, respiratory failure, quality of life, etc. I’ll discuss this vaccine with my more chronically ill patients 60 years and over as an option, but because it’s not routinely recommended, I’ll encourage them to check their insurance coverage first.

Reference:

·         Melgar M. Use of Respiratory Syncytial Virus Vaccines in Older Adults: Recommendations of the Advisory Committee on Immunization Practices — United States, 2023. MMWR Morb Mortal Wkly Rep. 2023;72. Link

From the NIH, CDC, and Personal Experience
2) The Growing Threat of Toxic Algae Blooms

Algae are microscopic organisms that live in aquatic environments and use photosynthesis to produce energy from sunlight, just like plants.  They can be found salt water, fresh water, and brackish water (a mix of salt and fresh water) and play an important role in the food chain. 

While most algae are not harmful, there are a few types that produce toxins.  Toxin production can be stimulated by environmental factors such as light, temperature, salinity, pH, and nutrient levels.  Certain environmental conditions, such as warmer water temperatures, still water, and excessive nutrients from fertilizers or sewage waste brought by runoff can trigger a harmful algae bloom (HAB).  HABs occur when toxin-producing algae grow excessively in a certain location.  The excessive algal growth becomes visible to the naked eye and can be green, blue-green, red, or brown, depending on the type of algae. 

Algal toxins released into the surrounding water or air by HABs can seriously harm people, animals, fish, and other parts of the ecosystem.  The most common impact on humans from ingestion is gastrointestinal disease but can also include hepatic damage and neurological effects.  Human exposures to aerosolized toxic can impact respiratory function and skin contact can result in dermatitis.  There are also multiple human poisoning syndromes associated with the consumption of molluscan and crustacean shellfish, fish, and other marine animals that have accumulated algal toxins.  Other effects include mortalities of fish and wildlife, ecosystem disruption, hypoxia and anoxia from high biomass blooms, and noxious impacts associated with the accumulation and decay of massive micro and macroalgal blooms.  Importantly, cooking contaminated seafood or boiling contaminated water does not destroy the toxins.

In 2021, 16 states self-reported HABs to the CDC.  These occurred most commonly in the summer, with Pennsylvania and Wisconsin reporting the most incidents.  Worldwide, HABs are increasing in both size and frequency.  Organisms include: 

Mark’s Comments:

Toxic algae blooms became a reality for both John and I when we had multiple areas of Cyanobacteria bloom at a popular local lake in June, closing those areas to swimming for weeks.  Interestingly, Cyanobacteria, which were formerly known as blue-green algae, are photosynthetic microscopic organisms that are technically bacteria.  They differ from other bacteria in that they contain photosynthetic pigments similar to those found in algae and plants.

While the oceanic “red tides” are perhaps the most well-known HABs, fresh water HABs are more common than is generally realized, though on a smaller scale.  As warmer weather continues to cause water temperatures to increase, HABs will likely become more common throughout the US.  It will be important for we clinicians to be aware of them and keep exposure to HAB toxins in our differential for patients presenting with GI, dermatologic, or neurological symptoms during the peak months.

References:

·         National Institute of Environmental Health Sciences (NIH-NIEHS).  Algae Blooms.  Last Reviewed 14 July 2023.  Link

·         CDC. Summary Report – One Health Harmful Algal Bloom System (OHHABS), United States, 2021. Atlanta, Georgia: U.S. Department of Health and Human Services, CDC, 2023. Link

·         Anderson D, et al.  Marine harmful algal blooms (HABs) in the United States: history, current status and future trends. Harmful Algae. 2021 February ; 102: 101975. doi:10.1016/j.hal.2021.101975.  Link

From PeerRxMed ( www.PeerRxMed.org )

3)  What to Do When You’ve Lost Your Why

“He who has a why to live for can bear almost any how.”   Friedrich Nietzsche

A recent statement by a physician colleague regarding his work caught my attention.  “I know why I went into medicine, but I’m not as clear as to why I keep doing it.”   From what I’m hearing, he’s not alone. 

We’re all quite practiced in telling our story as to “why I wanted to do this” ( … love science, help people, etc.).  We wrote about it and shared it repeatedly as we ascended the professional education ladder.  But the question “Why do I keep doing this?” – well that’s a different question entirely, and it caused me to pause.   

In reflecting, I was reminded of the story of “The Stonecutters” that I have shared in many leadership workshops, the origins of which are uncertain.  It goes like this: 

“The story is told of 3 stone cutters building a cathedral in the Middle Ages.  The village Noble visits one day to check on their work.   

He approaches the first and asks, “What are you doing?”  Angrily, the stone cutter turns and replies, “Idiot!  Use your eyes!  They bring me a rock, I cut it into a block, they take it away, and they bring me another rock.  I’ve been doing this since I was old enough to work, and I’m going to be doing it until the day I die.” 

Quickly, the Noble withdraws and goes to the next man, asking him the same question.  This stone cutter smiles and tells him, “I’m earning a living for my beloved family.  With my wages I have built a home, we have food on our table, and the children are growing strong.” 

Moving on, the Noble approaches a third man with the same question.  Pausing, this stone cutter gives him a look of deep fulfillment and tells him, “I am building a great cathedral, a holy lighthouse where the people of our village who are lost in the dark can find their strength and remember their way.  And it will stand for a thousand years!” 

Wow!  Same work, yet an entirely different life experience.  When I’m honest with myself, particularly given the present daily challenges of medical practice, on any given day I might be all 3 of these stone cutters at different times.  Too often I am in “survival mode,” just getting through the day the best I can.  That’s not necessarily a bad thing given some other alternatives, but I know that I’m called to more in this work – and this life.  And I know that when I anchor to purpose and meaning, work is more fulfilling for me and more highly impactful for others …. my “stones are cut” with better precision, with greater care.

So, remember that each day, whether consciously or unconsciously, we’re demonstrating our “why” by how we show up.  For many, the person who is showing up may be due for an upgrade, particularly if you’re having too many days like that first stone cutter – or our colleague quoted above.   In the coming weeks, consider intentionally choosing to anchor daily to a “why” that is compelling for you and allow it to define your day.  And if  you’ve “lost your why” professionally, don’t settle for just going through the motions.  Reach out to a friend, colleague (your PeerRxMed partner!), therapist or coach to help you gain clarity.  Considering the nature of the work we do, the stakes are much too high to do otherwise. 

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Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org