Episode 188: RSV Management and Prevention

Dr. Sandhu and future Dr. Mohamed summarize the management of RSV and describe how to prevent it with chemoprophylaxis and vaccines. Dr Arreaza adds some comments about RSV vaccines.

Written by Abdolhakim Mohamed, MSIV, Ross University School of Medicine. Comments by Ranbir Sandhu, MD, and Hector Arreaza, MD.

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What is RSV? 

-The Respiratory syncytial Virus (RSV) is an enveloped, negative-sense, single-stranded RNA virus of the Orthopneumovirus genus within the Pneumoviridae family. 

-RSV is a major cause of acute respiratory tract infections, particularly bronchiolitis and pneumonia, in infants and young children, and it also significantly affects older adults and immunocompromised individuals. 

-RSV infections cause an estimated 58,000–80,000 hospitalizations among children younger than 5 years and 60,000–160,000 hospitalizations among adults older than 65 years each year.

-RSV is highly contagious and spreads through respiratory droplets and direct contact with contaminated surfaces. The virus typically causes seasonal epidemics, peaking in the winter months in temperate climates and during the rainy season in tropical regions. 

-Virtually all children are infected with RSV by the age of two, and reinfections can occur throughout life, often with milder symptoms.

-Per the 2014 Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis, from the American Academy of Pediatrics, the most common etiology of bronchiolitis is RSV. 

-About 97% of children are infected with RSV in the first 2 years of life, about 40% will experience lower respiratory tract infection during the initial infection. Other viruses that cause bronchiolitis include human rhinovirus, human metapneumovirus, influenza, adenovirus, coronavirus, and parainfluenza viruses.

When is RSV season?

-Classically, the highest incidence of infection occurs between December and March in North America. Per CDC, there were typical prepandemic RSV season patterns, but the COVID-19 pandemic disrupted RSV seasonality during 2020–2022. 

-Before we dive into the seasonality patterns, for context, in order to describe RSV seasonality in the US, data was gathered and analyzed from polymerase chain reaction (PCR) test results reported to the National Respiratory and Enteric Virus Surveillance System (NREVSS) during July 2017–February 2023. 

-Seasonal RSV epidemics were defined as the weeks during which the percentage of PCR test results that were positive for RSV was ≥3%. Per 2017–2020 data, RSV epidemics in the United States typically follow seasonal patterns, that began in October, peaked in December or January, and ended in April. 

-However, during 2020–21, the typical winter RSV epidemic did not occur. The 2021–22 season began in May, peaked in July, and ended in January. 

-The 2022–23 season started (June) and peaked (November) later than the 2021–22 season, but earlier than prepandemic seasons. CDC notes that the timing of the 2022–23 season suggests that seasonal patterns are returning toward those observed in prepandemic years, however, warn that clinicians should be aware that off-season RSV circulation might continue.

Treatment of RSV

Some key points of the 2014 pediatric guidelines from the American Academy of Pediatrics.

-AAP strongly do not recommend beta agonists or steroids for viral associated bronchiolitis because of no significant improved outcomes. “Clinicians should not administer albuterol (or salbutamol) to infants and children with a diagnosis of bronchiolitis (Evidence Quality: B; Recommendation Strength: Strong Recommendation).”

-Epinephrine is not recommended for infants and children with a diagnosis of bronchiolitis (Evidence Quality: B; Recommendation Strength: Strong Recommendation).

-Nebulized hypertonic saline should not be administered to infants with a diagnosis of bronchiolitis in the emergency department (Evidence Quality: B; Recommendation Strength: Moderate Recommendation), but hypertonic saline may be administered when they are hospitalized (Evidence Quality: B; Recommendation Strength: Weak Recommendation [based on randomized controlled trials with inconsistent findings]).

-Chest physiotherapy should not be used in infants and children with a diagnosis of bronchiolitis (Evidence Quality: B; Recommendation Strength: Moderate Recommendation).

-Antibiotics should not be administered in bronchiolitis unless there is a concomitant bacterial infection, or a strong suspicion of one (Evidence Quality: B; Recommendation Strength: Strong Recommendation).

-Oxygen therapy may not be administered if the oxyhemoglobin saturation exceeds 90% in infants and children with a diagnosis of bronchiolitis (Evidence Quality: D; Recommendation Strength: Weak Recommendation [based on low level evidence and reasoning from first principles]).

-Clinicians should administer nasogastric or intravenous fluids for infants with a diagnosis of bronchiolitis who cannot maintain hydration orally (Evidence Quality: X; Recommendation Strength: Strong Recommendation).

How do we prevent RSV?

Infant Immuno-prophylaxis:

A clinical trial in 2022 demonstrated that a single injection of nirsevimab (Beyfortus®), administered before the RSV season, protected healthy late-preterm and term infants from RSV-associated lower respiratory tract that required medical treatment. Nirsevimab is a monoclonal antibody to the RSV fusion protein that has an extended half-life.

Additionally, on August 3, 2023, the Advisory Committee on Immunization Practices (ACIP) recommended nirsevimab for all infants younger than 8 months who are born during or entering their first RSV season and for infants and children between 8-19 months who are at increased risk for severe RSV disease and are entering their second RSV season. On the basis of pre-COVID-19 pandemic patterns, nirsevimab could be administered in most of the continental United States from October through the end of March.

Maternal Vaccination: 

The CDC recommends the administration of the RSVPreF vaccine to pregnant women between 32 0/7 and 36 6/7 weeks of gestation. This vaccination aims to reduce the risk of RSV-associated lower respiratory tract infection in infants during the first 6 months of life.

At this time, if a pregnant woman has already received a maternal RSV vaccine during any previous pregnancy, CDC does not recommend another dose of RSV vaccine during subsequent pregnancies.

Older individuals: 

-Each year in the U.S., it is estimated that between 60,000 and 160,000 older adults are hospitalized and between 6,000 and 10,000 die due to RSV infection

-ABRYSVO’s approval will help offer older adults protection in the RSV season.

-On June 26, 2024, ACIP voted to give these recommendations: all adults older than 75 years and adults between 60–74 years who are at increased risk for severe RSV disease should receive a single dose of RSV vaccine (Abrysvo®).

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References:

1. Hamid S, Winn A, Parikh R, et al. Seasonality of Respiratory Syncytial Virus — United States, 2017–2023. MMWR Morb Mortal Wkly Rep 2023;72:355–361. DOI: http://dx.doi.org/10.15585/mmwr.mm7214a1
2. Hammitt LL, Dagan R, Yuan Y, Baca Cots M, Bosheva M, Madhi SA, Muller WJ, Zar HJ, Brooks D, Grenham A, Wählby Hamrén U, Mankad VS, Ren P, Takas T, Abram ME, Leach A, Griffin MP, Villafana T; MELODY Study Group. Nirsevimab for Prevention of RSV in Healthy Late-Preterm and Term Infants. N Engl J Med. 2022 Mar 3;386(9):837-846. doi: 10.1056/NEJMoa2110275. PMID: 35235726.
3. Ralston SL, Lieberthal AS, Meissner HC, Alverson BK, Baley JE, Gadomski AM, Johnson DW, Light MJ, Maraqa NF, Mendonca EA, Phelan KJ, Zorc JJ, Stanko-Lopp D, Brown MA, Nathanson I, Rosenblum E, Sayles S 3rd, Hernandez-Cancio S; American Academy of Pediatrics. Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics. 2014 Nov;134(5):e1474-502. doi: 10.1542/peds.2014-2742. Erratum in: Pediatrics. 2015 Oct;136(4):782. doi: 10.1542/peds.2015-2862. PMID: 25349312.
4. CDC, per their published article Seasonality of Respiratory Syncytial Virus — United States for 2017–2023, in the United States
5. What U.S. Obstetricians Need to Know About Respiratory Syncytial Virus.Debessai H, Jones JM, Meaney-Delman D, Rasmussen SA. Obstetrics and Gynecology. 2024;143(3):e54-e62. doi:10.1097/AOG.0000000000005492.
6. Maternal Respiratory Syncytial Virus Vaccination and Receipt of Respiratory Syncytial Virus Antibody (Nirsevimab) by Infants Aged <8 Months - United States, April 2024.Razzaghi H, Garacci E, Kahn KE, et al. MMWR. Morbidity and Mortality Weekly Report. 2024;73(38):837-843. doi:10.15585/mmwr.mm7338a2. 
7. Use of Nirsevimab for the Prevention of Respiratory Syncytial Virus Disease Among Infants and Young Children: Recommendations of the Advisory Committee on Immunization Practices - United States, 2023.Jones JM, Fleming-Dutra KE, Prill MM, et al. MMWR. Morbidity and Mortality Weekly Report. 2023;72(34):920-925. doi:10.15585/mmwr.mm7234a4.
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