What the HCP community can do to change our approach
Opinion: Dr. Joseph Domachowske, Professor of Pediatrics, Professor of Microbiology and Immunology, and Director of the Global Maternal-Child and Pediatric Health Program at the SUNY Upstate Medical University
According to the CDC, respiratory syncytial virus (RSV) infects nearly every child before their second birthday, and while it may be expected that most infants will come into contact with RSV during that time, the impact of severe disease is unpredictable.1 Any infant, whether born at term and healthy or premature with underlying conditions, can be hospitalized during their first RSV disease season.2,i While RSV disease causes cold-like symptoms, it often progresses to lower respiratory tract infections (LRTI) in infants, such as bronchiolitis and pneumonia, making it the leading cause of infant hospitalization under 12 months.3,ii
Even healthy infants with no underlying conditions can end up in the intensive care unit (ICU) due to severe RSV disease; furthermore, a study found that one in four otherwise healthy infants in the United States were admitted for intensive care as a result of RSV-related complications.4,iii Approximately 72% of infants hospitalized for RSV disease were born at term with no underlying conditions.2,i Given the prevalence of RSV disease among infants, caregivers and families of all infants should understand how to recognize the typical signs and symptoms of the infection.
2021’s atypical onset of RSV disease
Annually, seasonal epidemics of RSV disease can result in substantial pressure on health care systems due to hospitalizations, demands on emergency department resources and the need for both initial and follow-up evaluations by the primary care provider.5 In fact, the CDC estimates that there are around 17 times as many RSV-associated LRTI cases that are treated in emergency department (ED) and office visits compared to hospital admissions in infants under 12 months of age.6,iv Raising awareness about the burden that RSV disease places on infants, families, health care providers and their systems is essential.
The precise timing and severity of annual epidemics vary, but the seasonal re-emergence of disease activity across temperate climates reliably occurs in the late fall or early winter, and peaks mid to late winter before tapering off in the spring.1,7 During the COVID-19 pandemic’s first fall and winter in 2020 however, RSV disease activity remained low. The lack of a seasonal epidemic that year has been attributed, at least in part, to the widespread practices of social distancing and use of face masks during that period of time. As COVID-19 prevention measures began to relax, the United States witnessed an increase in cases of RSV disease, beginning in the Southern part of the United States and spreading nationwide.8
These surges have also been detected in other countries across the globe, including Australia and the United Kingdom.9,10 The unexpected onset of disease activity last year during early summer, combined with the unique circumstances resulting in two complete birth cohorts at risk for developing their first infection during the same season, have raised concerns about the potential burden of disease during upcoming RSV disease seasons. Most recently, a modeling study using hospitalization data that reproduced the annual epidemics of RSV disease prior to the COVID-19 pandemic in New York and California concluded that emergent RSV disease epidemics in 2021 to 2022 were expected to be more intense and to affect patients in a broader age range than in the typical RSV disease season.11
Preparing families for RSV disease during the typical season and off-season surges in disease activity
Health care providers of newborns and infants have always been in an excellent position to provide detailed anticipatory guidance to caregivers about RSV disease. Such guidance is even more important now, given the off-season spikes in disease activity and that we are in the RSV disease season.11
According to a 2018 national survey of caregivers and specialty health care providers conducted by the National Coalition for Infant Health, only 18% of families said they knew “a lot” about RSV disease. Furthermore, 70% of surveyed specialty HCPs emphasized that caregivers of their patients have a low awareness of RSV.12 There are limited options to address RSV disease and they are not approved for all infants, which is why education on what you can do to help protect all infants is so important. A paper published in 2018 in Pediatric Annals showed that the best current treatment is supportive.13
To help prepare new caregivers entering their first RSV disease season, particularly now as we are in the RSV disease season, I encourage all community HCPs of newborns and infants to speak with their families about the symptoms, mode of transmission, and prevalence of RSV disease. As part of that effort, I encourage discussion about the potential for household transmission of RSV disease from other family members to the infant with an emphasis on good handwashing habits.
As social distancing measures continue to loosen, we must retain safety measures learned during the onset of COVID-19, such as avoiding exposure to individuals who are sick and frequent handwashing. These basic infection control practices will help to protect all infants and young children from exposure to a long list of respiratory viruses, including RSV disease.
In recent years, there has also been marked or exciting progress in the area of medical interventions for the prevention of RSV disease. As physicians and advocates of all children, let’s challenge ourselves to review and stay current about the new innovations in RSV disease research. Emerging scientific innovations hold the promise that we may soon have the ability to change the landscape of infant RSV disease burden, finally helping to reduce the impact associated with it for all infants.
i. Surveillance data between October 2014 and April 2015. Among 1,176 RSV-hospitalized infants aged 12 months or under, 851 had no reported underlying condition (prematurity was classified as an underlying condition in the study).
ii. According to a study of pediatric hospitalizations between 1997 and 2000.
iii. An observational retrospective cohort study of preterm and term infants <6 months of age that assessed the costs of RSV hospitalizations, severity, and costs for the 2011 to 2014 and 2014 to 2017 RSV seasons.
iv. Based on a CDC modeling study of active surveillance data that extrapolated to the US population.
1. Centers for Disease Control and Prevention. Respiratory Syncytial Virus (RSV): Infants and Young Children. Accessed February 20222. https://www.cdc.gov/rsv/high-risk/infants-young-children.html
2. Arriola C, Kim L, Langley G, et al. Estimated burden of community-onset respiratory syncytial virus-associated hospitalizations among children aged <2 years in the United States 2014-15. J Pediatric Infect Dis Soc. 2020;9(5):587–595. doi:10.1093/jpids/piz087
3. Leader S, Kohlhase K. Recent trends in severe respiratory syncytial virus (RSV) among US infants, 1997 to 2000. J Pediatr. 2003;143(5):127-132. doi:10.1067/s0022-3476(03)00510-9
4. Krilov LR, Fergie J, Goldstein M, Brannman L. Impact of the 2014 American Academy of Pediatrics immunoprophylaxis policy on the rate, severity, and cost of respiratory syncytialvirus hospitalizations among preterm infants. Am J Perinatol 2020 Jan;37(2):174-183.doi:10.1055/s-0039-1694008
5. Zhang S, Akmar LZ, Bailey F, Rath BA, Alchikh M. Cost of respiratory syncytial virus-associated acute lower respiratory infection management in young children at the regional and global level: a systematic review and meta-analysis. J Infect Dis. 2020.doi:10.1093/infdis/jiz683
6. Rainisch G, Adhikari B, Meltzer MI, Langley G. Estimating the impact of multiple immunization products on medically-attended respiratory syncytial virus (RSV) infections ininfants. Vaccine. 2020;38(2):251-257. doi:10.1016/j.vaccine.2019.10.023
7. Rose EB, Wheatley A, Langley G, Gerber S, Haynes A. Respiratory syncytial virus seasonality-United States, 2014-2017. 2018;67(2):71-76.(v1.0). MMWR. doi:10.15585/mmwr.mm6702a4.
8. Centers for Disease Control and Prevention. Increased Interseasonal Respiratory Syncytial Virus (RSV) Activity in Parts of the Southern United States. Accessed February 2022. https://emergency.cdc.gov/han/2021/han00443.asp
9. NSW Health. COVID-19 WEEKLY SURVEILLANCE IN NSW. Accessed February 2022. https://www.health.nsw.gov.au/Infectious/covid-19/Documents/covid-19-surveillance-report-20220120.pdf
10. Public Health England. Weekly national influenza and COVID-19 surveillance report Week 3 report (up to week 2 data). Accessed February 2022. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1048531/Weekly_Flu_and_COVID-19_report_w3.pdf
11. Zheng Z, Pitzer VE, Shapiro ED, Bont LJ, Weinberger DM. Estimation of the timing and intensity of reemergence of respiratory syncytial virus following the COVID-19 pandemic in the US. JAMA Network. 2021;4(12):e2141779. doi:10.1001/jamanetworkopen.2021.41779
12. National Coalition for Infant Health. RSV awareness: a national poll of parents & healthcare providers. May 2019. Accessed January 10, 2022. https://static1.squarespace.com/static/5523fcf7e4b0fef011e668e6/t/5bd1092b15fcc038c1f7cc1e/1540426027979/NCfIH_RSV+Survey+Results_Oct+2018.pdf
13. Domachowske J, Halczyn J, Bonville C. Preventing Pediatric Respiratory Syncytial Virus Infection. Pediatr Ann. 2018;47(9). doi:10.3928/19382359-20180816-01