RSV this year: Clinician insights and urgent vaccination strategies

In the 2022 to 2023 season, a significant spike in respiratory syncytial virus (RSV) cases was observed. As the 2023 to 2024 RSV season began, concerns arose that similarly high rates of RSV incidence and hospitalization would be reported. A panel of clinicians gathered to address these concerns and report preliminary findings.

According to William Muller, MD, PhD, an early RSV season was observed in 2022. Cases began in August and September and peaked in October and November. In 2023, rises in RSV case rates began in November, with peaks expected in January.

While this is slightly earlier than expected, it is closer to the regular seasonality observed before 2022. However, the rates of reported cases are still high. Neil Silverman, MD, reported a rise in the rate of positive tests from 5% to 8% in California in the week prior to the panel.

Click here to view each episode from our RSV Roundtable video series

Silverman also discussed counseling pregnant patients about the risks to newborns and mothers. He has observed improved awareness about RSV in these patients compared to other conditions, as well as less resistance toward accepting vaccination against RSV.

Laura Riley, MD, reported that while many pregnant women and mothers with toddlers sought RSV vaccination, these behaviors were less common among new mothers. This indicates a need to education new mothers on the importance of vaccination.

A significant amount of education on the RSV vaccine is needed in the older population, according to Robert Hopkins, MD. RSV is common across all age groups, but not all receive equal education on benefits, value, and using the appropriate product.

Discussion about the monoclonal antibody for newborns is also difficult because of a national shortage. Clinicians need to address this shortage with their patients and express that they are putting forth their best effort to help them and their children.

Insurers are also creating challenges for patients who are unable to access the vaccine because of cost. Hopkins reported that approximately 15% to 20% of birthing hospitals participate in the Medicaid VFC program, indicating disparities in vaccine availability.

Sallie Permar, MD, PhD, noted a rise in children hospitalized with RSV because they were unable to access the vaccine. This can lead to preventable intensive care unit admission. The panel also discussed the convenience of nirsevimab (Beyfortus; Sanofi) for managing RSV. Nirsevimab is more straightforward than alternative treatment options such as palivizumab, as it is single use rather than injected monthly and is cheaper. However, because of shortages, clinicians are unable to provide nirsevimab to their patients.

A rush to make therapeutics available too close to the season caused the supply of medication to be unable to meet the demand. Additionally, Riley noted how RSV was not as prevalent of a concern as influenza or COVID-19 prior to 2022. This caused RSV to be of low concern for many clinicians until the spike in cases, leaving many unprepared to manage patients and underscoring the importance of education.

Riley also expressed a concern over patients failing to understand the importance of vaccination against RSV in future seasons. If cases decrease significantly, some patients may not consider it important to get vaccinated against the disease. RSV is a severe condition, leading to 10% of hospitalizations in children aged over 2 years. Interventions must be implemented to reduce this severity.

Permar noted that the RSV vaccine was developed following a season where pediatric wards were filled with patients who presented with RSV. Similarly to conditions such as COVID-19, RSV should be treated as an emergency every year.

There are additional difficulties in helping the senior population receive RSV vaccination. This includes a lack of a one-size-fits-all recommendation for this population. Instead, providers and patients should discuss individual risks and benefits for vaccination. Risk factors such as heart failure and diabetes also impact RSV vaccination in the senior population.

Environmental risk factors should also be considered, including whether a patient lives in a congregate living facility or visits the hospital frequently. While shared decision making is necessary for the senior population, this creates a challenge of providing appropriate compensation reimbursement for clinicians, as stated by Muller.

Silverman added that when the CDC recently reported data on patients hospitalized for COVID-19, influenza, and RSV, the rate of morbidity and mortality was significantly increased for patients aged over 60 years with RSV. This is an additional message that needs to reach more patients and providers.

An additional challenge providers face when vaccinating their patients is vaccine fatigue. Riley noted that pregnant women experiencing what should be COVID fatigue instead feel fatigue around vaccines because of the number of recommended vaccines, including influenza, Tdap, RSV, and the COVID booster dose.

The possibility of combining vaccines should be considered, Permar said. The regulatory process is not incentivized to prioritize combination vaccines, but clinicians have a high number of vaccines to administer to their patients, making combined vaccines potentially more effective.

Introducing more combination vaccines is viable, according to Permar. Preliminary studies have evaluated a single shot against all influenza strains. However, additional efficacy and toxicity data is necessary.

As the panel began to conclude, Hopkins highlighted some key takeaways. The first takeaway is the importance of education about RSV risk. Therapeutics are not currently available against RSV, making vaccination vital for reducing risk.

Interventions such as the vaccine and nirsevimab weren’t available during the 2022 to 2023 season, indicating researchers and clinicians can address additional challenges within the next year. Silverman said if a noticeable drop in RSV hospitalizations is observed, clinicians will be able to make a stronger case for utilizing interventions.

According to Riley, it is vital for clinicians to, “press hard” this season. With a vaccine available, clinicians should ensure their patients receive either the vaccine or an alternative option. Additionally, once providers recommend the vaccine, they should make it as accessible as possible for their patients.

“We're not done with RSV,” Permar said. “We need to continue the promotion of vaccines that can be safely given to young children.”

Click here to view each episode from our RSV Roundtable video series

Panel experts:

• Robert H. Hopkins Jr., MD: medical director, National Foundation for Infectious Diseases; professor of Internal Medicine and Pediatrics; chief, Division of General Internal Medicine, University of Arkansas for Medical Sciences
• William Muller, MD, PhD: attending physician, Infectious Diseases; Ted Emerson Miller research scholar; professor of Pediatrics (Infectious Diseases), Northwestern University Feinberg School of Medicine; scientific director, Clinical and Community Trials, Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children’s Hospital
• Sallie Permar, MD, PhD: Nancy C. Paduano professor and chair, Department of Pediatrics, Weill Cornell Medicine; pediatrician-in-chief, New York-Presbyterian/Weill Cornell Medical Center
• Laura Riley, MD: chair, Department of Obstetrics and Gynecology, Weill Cornell Medicine; obstetrician and gynecologist-in-chief, New York-Presbyterian/Weill Cornell Medical Center
• Neil Silverman, MD: professor, obstetrics and gynecology, David Geffen School of Medicine, UCLA; director, Maternal-Fetal Medicine Fellowship Program

Click here to read more from the January/February issue of Contemporary Pediatrics.