Infectious Disease Experts Sound Alarm on True Toll of RSV

October 26th, 2022

Respiratory syncytial virus (RSV) is something of a contradiction: The leading cause of hospitalization of infants in the United States (58,000 annually) is largely unappreciated beyond the pediatric population. In what essentially is a hidden seasonal epidemic, RSV causes 177,000 hospitalizations and 14,000 deaths annually in the United States in those age 65 years and older, the National Foundation for Infectious Diseases (NFID) emphasizes in a call-to-action report.¹

“RSV is a well-known problem in young infants and toddlers — and, certainly, we know that adults can get RSV,” says Patsy Stinchfield, RN, MS, CPNP, president-elect of the NFID. “But I think the details of the number of hospitalizations and deaths attributable to RSV are not well known, even amongst us healthcare providers.”

This general lack of awareness of RSV as a potentially severe respiratory infection can be traced back to diagnostic challenges and underreporting, both of which lead to underappreciation and ignorance of its actual disease burden across the lifespan.

Complicating the matter, many physicians in current practice were taught in medical school that RSV primarily was a problem for their pediatric colleagues. It is, to a considerable degree.

“Among children age 5 years and younger, RSV is associated with an estimated 100 to 500 deaths per year,” the NFID report states. However, in emphasizing the threat to older adults, the NFID call to action seeks to heighten clinical awareness beyond pediatrics.

“Most of us who care for adults learned in medical school that RSV is a pediatric virus — that’s what we were taught, because that’s what was known,” says William Schaffner, MD, medical director at the NFID.

The NFID report calls for immediate educational outreach to healthcare workers — before anticipated new vaccines and treatments are available — to increase disease knowledge and heighten awareness of its effect. “Key stakeholders include internists and healthcare providers who routinely care for older adults,” the report states.

Accumulating Evidence

Over the last 10 to 15 years, there have been accumulating data showing that a lot of seasonal illness classified as “non-influenza” was caused by RSV, says Schaffner, a professor of preventive medicine and infectious diseases at Vanderbilt University.

“And so, the impact of RSV, particularly in older adults, particularly in those with underlying illnesses, such as heart disease and chronic obstructive pulmonary disease, is noteworthy, and still continues to be defined,” he says. “As I said, this may come as a surprise to the average internist, because that’s not what they were taught in medical school.”

Fever may be absent in older patients with RSV, making the diagnosis more difficult, he says.

“By and large, pneumonia and severe respiratory distress are the major reasons that patients with RSV are being hospitalized,” Schaffner says. “It’s a clinical presentation that is akin to influenza.”

RSV is an infection at risk of complications in premature infants, young children with heart and lung disease, and immunocompromised individuals of any age, the NFID reports.

In addition to healthcare workers, the foundation recommends a public health messaging effort to raise RSV awareness through multimedia consumer and patient campaigns. One possible strategy is “influencer campaigns to reach parents of young children as well as older adults and their caregivers,” the NFID suggests.

Making the business case for action, the foundation notes that RSV is one of the most common causes of bronchiolitis in young children. One study cited in the report found that bronchiolitis in children age 2 years and younger costs about $1.7 billion annually in 2009 dollars.² “More recent analysis has confirmed the economic impact of RSV and determined that the highest cost burden is in older age groups,” the NFID adds.³

With the pandemic exposing healthcare equity gaps, the foundation report cites a 2020 study that found RSV and other respiratory viruses cause disproportionate hospitalizations directly related to race, ethnicity, and socioeconomic status.

“Data from the COVID-19 pandemic [have] underscored that the burden of respiratory viruses actually reflect and magnify existing socioeconomic inequalities,” the study found.⁴

HAIs and ‘Presenteeism’

RSV is a known risk of healthcare-associated infections (HAIs) in pediatric hospitals, and the NFID call to action should reinforce the risk to adult patients in acute care.

“RSV is not usually thought of in a pulmonary clinical differential for older adults, and therefore targeted infection prevention opportunities could be missed,” says Linda Dickey, RN, MPH, CIC, FAPIC, president of the Association for Professionals in Infection Control and Epidemiology (APIC).

Dickey was not involved in the NFID report, but supports the findings and said APIC is open to partnering with the foundation in raising RSV awareness.

“APIC agrees that RSV prevalence and increased risk of severe disease is largely unknown and unrecognized,” she says. “In the context of COVID, there is likely a significant risk of clinical confusion as well, especially with insufficient lab testing.”

The Centers for Disease Control and Prevention (CDC) recommends contact and droplet isolation precautions for RSV patients, since transmission may occur within three feet of the bed and linger in the environment on surfaces and fomites.⁵

“It definitely spreads in hospitals,” says Stinchfield, who recently retired as the senior director of infection prevention for Children’s Minnesota, which has hospitals in Minneapolis and St. Paul. “I’m sure almost all infection preventionists in that role have seen an RSV outbreak where you’ll have an [infected] sibling come into a children’s hospital.”

RSV, along with other respiratory pathogens, has led to longstanding policies to limit visitors during the winter season in pediatric hospitals, she says. A pattern Stinchfield has seen over the years is that RSV spreads among children in daycare, who then transmit the virus to their older relatives.

“It goes from kid to kid in daycare and then up to a grandparent,” she says. “Then you have them in a hospital setting and it doesn’t take much for it to spread patient to patient.”

RSV also is another reason to discourage presenteeism in healthcare workers, who may write it off as a cold and report for duty, she adds.

“Just a cold could be a significant RSV infection that could be really difficult for someone who is immunocompromised or quite a bit older,” Stinchfield says. “Heart or lung patients, transplant patients, cancer patients — there are a lot of patients [for whom] RSV would not be a simple cold. It would be a very severe disease.”

COVID-19 has brought presenteeism to the forefront, particularly as staffing shortages have drawn attention to healthcare workers out sick.

“I really think that presenteeism, even before COVID, has been a problem in healthcare,” Stinchfield says. “There is a real need to change the culture. Even though you may feel heroic in helping your coworkers, you’re actually potentially going to cause greater problems.”

In that regard, a controversial temporary California state health policy allowed asymptomatic healthcare workers who test positive for SARS-CoV-2 to continue working without isolation and testing if they wear N95 respirators. Expiring Feb. 1, the policy was in effect about three weeks in the state as an option for those facing critical staff shortages.⁶

Dickey stuck to antigen testing and isolation at her facility in the state.

“Most of our workers and nurses don’t test negative at day 5, and many of them are not ready to come back that quickly,” says Dickey, senior director for quality, patient safety, and infection prevention at UC Irvine Health in Orange County, CA. “I think the intention was good on the part of the state, but from the provider perspective, we feel it is safer to have the [negative antigen test]. Also, it is tough working in an N95 respirator, especially if you are not feeling well.”

The NFID report intentionally is pushing RSV action now because awareness of respiratory diseases has reached apex in the high, thin air of a global pandemic of SARS-CoV-2. In doing so, the NFID acknowledged and strongly recommended that public health capacity lost because of COVID-19 must be rebuilt.

“While RSV is not the only priority to have been overshadowed by COVID-19, many of the strategies discussed depend on a robust and efficient public health infrastructure,” the NFID stated.

A Promising Array of Research

While RSV largely has flown under the radar in adults, pediatric infections have pushed a research agenda that is close to bearing fruit.

The result of this research is a promising line of RSV vaccines, monoclonal antibodies, and antivirals that can better prevent and treat the virus.

The vaccines in the latter stages of clinical trials include immunization for pregnant women, says Stinchfield, who also is a member of a newly formed CDC working group on the virus.

“I’m really excited about the maternal vaccines,” she says. “If we can get moms vaccinated against RSV — the same way we do against pertussis, flu, and COVID — then you’re passing those antibodies on to that baby and getting them through those first vulnerable several weeks and months.”

With the expectation that some of this research will yield positive results in two to five years, the NFID decided to begin raising awareness now about RSV, Schaffner says.

It is hoped that increased medical and public awareness can give the NFID campaign some momentum, particularly in the early creation of inexpensive and widely available diagnostics.

“One of the hang-ups is that doctors respond to what they can test for, and testing for RSV is not nearly as widely available or as inexpensive as we would like,” Schaffner says.

The conundrum is that the lack of testing undermines accurate surveillance and effectively masks the full burden of RSV, which sometimes is diagnosed by a process of eliminating other respiratory viruses.

“We’ve got some very fancy, expensive tests for hospitalized children and adults, but we reserve them for intensive care and severe respiratory [infections] when we don’t know what they have,” Stinchfield says. “These are PCR (polymerase chain reaction) tests — big panels that are so helpful, but they’re extremely expensive. We need more affordable diagnostics and better insurance coverage [of testing].”

There are testing panels that can discern flu from COVID-19, but those that include RSV are not cheap, Schaffner concurs. Given their expense and the lack of clearly established treatments for RSV, the use of test panels that include the virus has not been generally “encouraged” at Vanderbilt, he says.

“The doctors always ask, what are you going to do differently, depending upon the result?” he says. “At the present time all [RSV] treatment is symptomatic. We have treatments for COVID now and for flu, but not yet for RSV.”

It is difficult to raise awareness about an infection you cannot accurately identify and measure, but if the testing problem could be solved, the medical community might begin to buy in to the issue even before an RSV vaccine or therapies are available.

“If they see it documented in their own patients, [clinicians] will begin to appreciate the extent of the RSV problem,” Schaffner says.

Editor’s note: The NFID call to action report is based on discussions at a virtual roundtable convened in November 2021. According to the report, “Participants included a range of multidisciplinary stakeholders and subject matter experts who explored the burden of RSV across the lifespan and identified key strategic priorities based on prevention, diagnostic, and treatment interventions in the pipeline.”

REFERENCES

1. National Foundation for Infectious Diseases. Call to action: Reducing the burden of RSV across the lifespan. Published January 2022. https://www.nfid.org/wp-content/uploads/2022/01/NFID-RSV-Call-to-Action.pdf
2. Hasegawa K, Tsugawa Y, Brown DFM, et al. Trends in bronchiolitis hospitalizations in the United States, 2000-2009. Pediatrics 2013;132:28-36.
3. Amand C, Tong S, Kieffer A, Kyaw MH. Healthcare resource use and economic burden attributable to respiratory syncytial virus in the United States: A claims database analysis. BMC Health Serv Res 2018;18:294.
4. Moran E, Kubale J, Noppert G, et al. Inequality in acute respiratory infection outcomes in the United States: A review of the literature and its implications for public health policy and practice. medRxiv 2020; Apr 26. doi: https://doi.org/10.1101/2020.04.22.20069781. [Preprint].
5. Centers for Disease Control and Prevention. Guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings (2007). Reviewed July 22, 2019. https://www.cdc.gov/infectioncontrol/guidelines/isolation/precautions.html

California Department of Public Health. Guidance on quarantine and isolation for health care personnel (HCP) exposed to SARS-CoV-2 and return to work for HCP with COVID-19. Published Jan. 8, 2022. https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/AFL-21-08.aspx