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There have been more than 180,000 cases of 

 detected via PCR or antigen testing in the US since the beginning of 2022, per data from the Centers for Disease Control and Prevention (CDC). Since September alone, cases have neared 140,000 going into early December—generally the time at which cases of the common pediatric virus actually increase.

The terms “unprecedented” and “epidemic” have been unfortunately combined to described the presence or risk of numerous viral outbreaks since 2020. Even this year, continued challenges with COVID-19 control combined with early influenza burdens and the monkeypox outbreak highlighted the strain of circulating viruses in distinct patient populations and the corresponding hospital and emergency departments treating them.

But few pose as concerning a threat as RSV, the common young-age respiratory virus without a vaccine and impacting children with truly unprecedented reach this year.

 recap interview, Steven Selbst, MD, pediatric emergency medicine physician at Nemours Children’s Hospital, discussed with sister publication 

 how the early onset of RSV has affected the flow and treatment of pediatric patients in hospitals.

“It’s unbelievable how many cases of RSV we’ve seen in the last few weeks since the end of the summer,” Selbst said. “I’ve been around for many seasons of RSV, but this is probably the worst we’ve had in terms of the number and severity cases.”

Many theories persist as to why RSV has been so particularly surgent in 2022; many experts point to COVID-19 as a co-driver. Selbst noted that children may have been previously less exposed to viruses and bacteria due to masking and social distancing during the pandemic, and thus may have weaker immune systems. Physicians have also been surprised by the timing of the RSV season, which is generally a winter-onset issue.

On the matter of prevention, Selbst has observed growing talk around RSV vaccine candidates—none of which are currently approved by the US Food and Drug Administration (FDA). He shared particular hope for Pfizer’s investigative vaccine, which in phase 3 data shared last month showed its efficacy in preventing RSV-borne respiratory tract illness in newborns when administered to pregnant moths. Unfortunately, the vaccine is a prospect for approval in 2023.

Selbst provided advice for his colleagues navigating the current epidemic, stressing the limited availability and capability of emergency departments during this wave.

“Our emergency departments are already overwhelmed across the country, and there isn’t much we’re going to be able to do for that baby who has a mild case,” he said. “There is no magic treatment for RSV; we recommend nasal suctioning and monitoring the baby, and certainly pediatricians can do that with their parents and family from home.”

Selbst also stressed stewardship for antibiotics, noting the national shortage on amoxicillin has been tied to the RSV epidemic—a correlation that confuses him. “Amoxicillin is not useful for RSV, so I would hope pediatricians are not overusing antibiotics during this epidemic,” he said.

Among infants ≤2 months old, he highly recommends parents and pediatricians look for signs of presenting and worsening disease: poor oxygen saturation, dehydration, low urine output, labored breathing, retractions, head bobbing and grunting.

“Be very careful with young infants,” he said. “Babies less than 2 months of age, I would not take any chances. If that baby has bronchiolitis, we want to see that baby in the hospital and there’s a good chance we’re going to admit them because those babies usually end up in the intensive care unit.”

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A pediatric emergency medicine physician discusses the epidemic factors that still perturb experts, and the status of vaccination and treatment strategies.

Why Health Care Was Unprepared for the 2022 RSV Surge

Let’s talk about anything that you can think of on unmet needs, or future directions in the treatment of people with type 2 diabetes. What does it look like? One of the things I would throw out there is that we can no longer think of diabetes as a glucose disease. It’s a cardiovascular disease. The cardiovascular disease must be treated aggressively with all of the wonderful things you’ve brought to the table today. And your thoughts?

: That’s the staple to everything is getting ahead of a potential big problem. When we see someone who is a type 2 diabetic, it’s like thinking about that young woman I was telling you about who had gestational diabetes, for example. If we can get ahead of their type 2 diabetes and we can comprehensively work on their nutrition, their lifestyle, get them on the right national guidelines recommended medications, we can completely change and alter their heart health trajectory. That means avoiding strokes, avoiding heart attacks, avoiding amputations, and other terrible things that just can wreck a family. Trust me I know. Getting in front of this is not rocket science either but it definitely takes a comprehensive team, and it takes a team that understands all the nuances behind adherence and compliance and will sit and teach and take the time with the patient so that they understand why it is that they’re taking and they’re doing what it is that they’re doing. It’s more meaningful and likely they will be continuing the therapy more than 6 months or a year after you started them on it.

That’s like the patient who says to me, “Well, my blood pressure is good can I stop taking my blood pressure medication?” No, you can’t. To remind people that just by having diabetes they have lost 7 years on their lives and if we can prevent them from going on and having an MI [myocardial infarction] or a stroke, which will further decrease their life expectancy. That really is all our jobs to work together as a team to prevent that.

Thank you for all of your wisdom. I’ve learned so much from you today, Margo.

Yes. Great. I want to thank our audience for watching 

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: Thank you so much for having me and thank you audience for your attention.

Limitations managing type 2 diabetes with new technologies used as monitoring tools that need to be addressed moving forward.

New Technologies, Type 2 Diabetes, and Cardiovascular Prevention

We’ve decided that every person who has diabetes should be given a CGM [continuous glucose monitor]. We’ve got that taken care of, now we have to just get the insurance companies to agree with us. Check. The other new technology, and again, I have to remind you one more time that I have been in diabetes for 40 years and you can’t believe what we did not have when I started in the world of diabetes. Now I came right in to work in the diabetes control and complication trial. That’s what I was hired to do. Insulin pumps for that study, this is not an exaggeration, they were this big. They were this thick. We had to plug them in at night and you had to dilute out the insulin and only metal needles were available, and we had to take those down and tape them down. I had to teach people to stop peeing on the blood glucose strip because they were so used to urine strips and now I was asking them to do blood glucose strips for the DCCT [Diabetes Control and Complications Trial] and other things in clinical practice. It’s been huge for me to watch the changes that have occurred. Now, we have itty bitty insulin pumps and I always laugh when a patient goes, “Oh my God, that pump is so big.” I’m like, “Oh, let me show you.”

You have no idea. But we also now have insulin pumps that will integrate with CGM, which is totally geeky. I just finished a study with Beta Bionics and that is an actual integrated pump that does everything for the patient. We use hybrids. We have a couple of hybrids that we use. But to me it’s just amazing what these pumps could do. They get the data from the continuous glucose monitoring and they adjust the insulin. If the blood sugar goes high, it gives more insulin. If the blood sugar goes low, it turns it off during sleep mode. There are all kinds of things that these pumps use and they’re kind of mind-blowing in terms of thinking about that. We’re giving more and more use for those individuals who have type 2 diabetes and they’re on insulin. They really want to move that out to that population as well and discuss how do we get these patients on insulin pumps.

: And can I say, it’s about time? Think about having a discussion with someone about a new pair of shoes or a purse that you were looking at. You go and hop online, and you get on your computer, and you go to search something and that purse that you were talking about pops up in the side window. They have been using AI [artificial intelligence] in marketing forever. To the point where we’re constantly having data gathered on us and almost everything that we’re doing. It would make perfect sense that they would be able to fine tune this pump to be able to utilize AI to inform the dosing of the insulin. So, bravo for getting all this put together and for helping to lead this because this is going to be life changing, especially for our juveniles. It’s vitally important that we’re able to help people to have a better quality of life, which is what it’s all about at the end of the day.

Yes, and I see mostly 15 and above. But I must tell you that we probably have 2000 people on insulin pumps in our clinical practice, in our group. It is mind-blowing the changes and how much these impact and how much quicker we can get to patients to treatment goal when we have the assistance of the insulin pump doing its job. Because if the patient misses an injection or a bolus of insulin for a meal and the pump says, “Wait a minute something is wrong here.” Your blood sugar is going high after you eat and the pump says, “Oh, let me fix this. Let me fix this for you.” It really is mind-blowing how many more people can get to an A1c [glycated hemoglobin] treatment goal by doing that. Just a quick sidestep, I just want to remind people again that if your patients move to insulin there’s no reason that you must take them off of the GLP-1 [glucagon-like peptide 1] or the SGLT2 [sodium-glucose cotransporter-2] inhibitor. We just get to use less insulin if, in fact, we’re using both.

: And remember, we’re not just treating numbers. We’re treating risk. We have to think less about people as numbers and think more about people as an entity, as a whole self. That risk reduction comprehensively is the most important piece beyond whether it’s their blood sugar number, their hemoglobin A1c, or their lipid LDL for that matter.

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A description of hybrid artificial insulin pump systems for type 2 diabetes and a discussion highlighting potential integration with continuous glucose monitoring systems.

Hybrid Artificial Insulin Pump Systems for T2DM

What is interesting is the research in the past, 5 to 7 years [ago], research has been done in the children, the adults, the teens, the older individuals. I sort of get testy when we talk about older individuals because I’m not sure how to define that. If it’s old, it has to be older than me. But we’ve looked at all age groups. We’ve looked at all learning abilities. We’ve looked at different ethnicities to see how CGM [continuous glucose monitoring] improves lives and how it can be utilized in practice. We’ve done a great job to say that this can be applied to all people with diabetes and certainly in the world of type 2 diabetes that that outcome would benefit. For now, we have only coverage [for] multiple daily injections. It looks like we might, soon, get coverage for just basal insulin and then we’ll have to go from there. The other thing is it’s becoming more and more affordable. If, and you know I’d never want to spend anyone else’s money, but if people wanted to be able to purchase, there are ways to do that as well.

: The more that we can submit to insurance companies. You know we had the same thing with coronary calcium scoring, for example, and insurance companies not wanting to initially pay for that. Other types—the ambulatory blood pressure monitoring wasn’t always covered either. Those became out of pocket expenses that add up quickly, especially with the struggles that so many people are facing, especially those who have chronic disease management that us submitting information to these insurance companies helps to elevate that bar for more coverage. For more coverage for most, which is what should be happening.

: I agree 100%. It’s all about you know finger sticks, when they first came out, I jokingly say but seriously mean, I remember thinking, “Oh, who gets this?” And of course, everyone with diabetes should be doing either blood glucose monitoring or continuous glucose monitoring. I am now at the point where I feel like continuous glucose monitoring should be a right not a privilege and we should be offering to more and more people with diabetes. Think about that, if you had diabetes, for me, the greatest risk for being [able] to go to sleep at night would be, “Oh my gosh, what if I have a hypoglycemic event and I miss it and something happens?” If I wore a continuous glucose monitoring and it alarmed when it started getting low, then I would be able to. The other thing is that, as a healthcare provider, there’s a great way to learn how to interpret the data. It’s not complicated. It can be put on your computer and guess what, you can bill for those interpretations. We give too much away. Not that we shouldn’t be providing the highest level of care but because most patients who have type 2 diabetes are in the primary care world, we need to extend that into the primary care world. How do you use continuous glucose monitoring? How does it enhance your practice and your relationship with your patient? Let me tell you, you can bill for it and insurance companies do pay for the interpretation and, if you use a professional, for the placement of CGM.

: Yes, absolutely. And remember, we’re fighting a war on health equity here. When you think about those who don’t have access to CGM, it tends to be those individuals that would fall within these disparities. We need to stop this. This is unacceptable, especially when we have such robust data that we can significantly improve their lives. This really needs to happen and we shouldn’t, as providers, tolerate it. Or patients either, tolerate it any longer with what we currently know.

: I feel like too, the other end of the spectrum is our Medicare patients who do go into the donut hole, and they’ve been doing so well in the therapies we provide. Then we can’t get medication for them for a particular period of time and that’s heartbreaking.

: It is. It really is. I have a husband and wife that share medications and they will split up their meds because one of them is in a donut hole—it’s just…it’s so heartbreaking. This is when working with a pharmacist closely, is vitally important and another key takeaway, I feel, that is if you are working with a diabetes team then a pharmacist should be included in that care team and that there’s some great data demonstrating cost reduction for the institution when the pharmacist is included. Many times, they can help us combat these different barriers and find alternate ways of funding for essential medications.

You’re absolutely right. That’s the one person we’re seeing in addition. We’ve always had the educator. We’ve always had someone in nutrition, but what I’m seeing more and more is the addition of the pharmacist for exactly the reasons you’ve described and also they can work closer with the patient too if they’re having drug-to-drug interactions. Why are you stopping a medication? They can watch for refills and making sure that the patient is in fact refilling their medication. Those are good points. Really good points.

Recommendations to address accessibility and coverage issues that affect the use of continuous glucose monitoring into widespread clinical practice.

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