Do we take respiratory syncytial virus seriously enough?

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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

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 season.2,i While RSV 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; 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 Approximately 72% of infants hospitalized for RSV were born at term with no underlying conditions.2,iii Given the prevalence of RSV 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

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,iii Raising awareness about the burden that RSV infection 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.7,8 During the COVID-19 pandemic’s first fall and winter in 2020 however, RSV 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, beginning in the Southern part of the United States and spreading nationwide.

These surges have also been detected in other countries across the globe, including New Zealand, Australia, Japan and the United Kingdom. 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 seasons. Most recently, a simulation modeling study that reproduced the annual epidemics of RSV prior to the COVID-19 pandemic in New York and California concluded that emergent RSV 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 season.9

Preparing families for RSV 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 infection. Such guidance is even more important now, given the off-season spikes in disease activity and that we have entered the RSV season.

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. Furthermore, 70% of surveyed specialty HCPs emphasized that caregivers of their patients have a low awareness of RSV.10 This may be due, at least in part, to an absence of a preventive option for all infants.

To help prepare new caregivers entering their first RSV season, particularly now as we are in the RSV 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 from older children 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.

In recent years, there has also been marked or exciting progress in the area of medical interventions for the prevention of RSV infection. As physicians and advocates of all children, let’s challenge ourselves to review and stay current about the new advances in RSV research. Emerging scientific advances and exciting new publications describing results of clinical trials hold the promise that we will 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. Based on a CDC modeling study of active surveillance data extrapolated to the U.S. population.

References

1. Glezen WP, Taber LH, Frank AL, Kasel JA. Risk of primary infection and reinfection with respiratory syncytial virus. Am J Dis Child. 1986 Jun;140(6):543-6. doi: 10.1001/archpedi.1986.02140200053026. PMID: 3706232.

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. 9, 587–595 (2020)

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 syncytial virus hospitalizations among preterm infants. Am J Perinatol 2020 Jan;37(2):174-183

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 in infants. Vaccine. 2020;38(2):251-257. doi:10.1016/j.vaccine.2019.10.023

7. Centers for Disease Control and Prevention. Respiratory syncytial virus (RSV): infants and young children. Accessed January 10, 2022. https://www.cdc.gov/rsv/high-risk/infants-young-children.html.

8. Rose EB, Wheatley A, Langley G, Gerber S, Haynes A. Respiratory syncytial virus seasonality - United States, 2014-2017. 67(2) 71-76. (v1.0) MMWR. 2018. doi:10.15585/mmwr.mm6702a4

9. Zheng Z, Pitzer VE, Shapiro ED, Bont LJ, Weinberger DM. Estimation of the timing and intensity of reemergence of respiratory syncytial Vvrus following the COVID-19 pandemic in the US. JAMA Network. 2021;4(12):e2141779. doi:10.1001/jamanetworkopen.2021.41779.

10. National Coalition for Infant Health. RSV awareness: a national poll of parents & health care providers. May 2019. Accessed January 10, 2022. https://static1.squarespace.com/static/5523fcf7e4b0fef011e668e6/t/5bd1092b15fcc038c1f7cc1e/1540426027979/NCfIH_RSV+Survey+Results_Oct+2018.pdf