Applying Lessons From the COVID-19 Pandemic to Adult RSV

Key Takeaways

• In older adults, respiratory syncytial virus causes a burden of disease equal to seasonal influenza.
• Respiratory syncytial virus testing is underused in adults.
• Masking and other preventive measures―including vaccines―may reduce the burden of disease among older adults.

The Societal Burden of RSV
If we have learned anything from the COVID-19 pandemic, it is that respiratory viruses can cause massive societal disruptions. We know this is the case for influenza and SARS-CoV-2, but the influence of respiratory syncytial virus (RSV) has not been as well-recognized by the public or the internal medicine community.

RSV is the leading cause of infant hospitalization in the United States and has a burden of disease equal to that of seasonal influenza in older adults. RSV can result in difficulty breathing and, in adults with lung and heart disease, can trigger congestive heart failure, chronic obstructive pulmonary disease, and asthma exacerbations.

RSV Testing
The pandemic has provided us with several opportunities to better understand both the burden of RSV and measures that may limit its transmission and prevent disease.

Increased testing for SARS-CoV-2 has expanded the number of locations offering testing the different types of testing, and the number of tested pathogens. Many molecular tests are now multiplex and include influenza, RSV, and SARS-CoV-2. These diagnostic tests allow healthcare professionals to better determine the etiology of respiratory illnesses in adults.

Prior to the COVID-19 pandemic, RSV testing was rarely performed in adults. Now, tests are used much more routinely in outpatient and inpatient settings, and there is increasing recognition of the value of testing asymptomatic populations to identify early cases and interrupt transmission. The increase in RSV testing provides more accurate estimates of disease burden in adult populations to help us understand the future impact of interventions such as treatments and vaccines.

In the future, it is likely that home-based testing will include SARS-CoV-2, influenza, and RSV, potentially allowing individuals to increase appropriate antiviral use and decrease inappropriate antibiotic use.

Community Transmission of RSV
Based on pre‒COVID-19 studies, we already knew droplets and fomites play a role in the transmission of RSV, particularly through direct contact with mucosal surfaces. We also knew that RSV is transmitted in childcare and hospital settings. Additional studies conducted in pediatric hospitals showed that masks and eye protection reduce RSV transmission among staff. During the pandemic, these protective measures used to mitigate transmission of SARS-CoV-2 also significantly reduced RSV transmission and its burden of disease in the population.

During the COVID-19 pandemic, we developed a better understanding of the role of airborne transmission in other respiratory viruses, including RSV and influenza. The closure of schools and workplaces, widespread use of surgical or N95 masks, improved indoor ventilation, and limitations on large gatherings during early stages of the pandemic led to suppression of RSV transmission, demonstrating the effectiveness of nonpharmaceutical interventions in the prevention of RSV. However, this has been followed by unusual interseasonal RSV waves during the spring and summer months and a recent surge in cases affecting young children, older children, and adults.

Applying Lessons From the COVID-19 Pandemic
In the future, as we return to a more normal circulation pattern of respiratory viruses, we can use lessons learned during the COVID-19 pandemic to better understand the impact of RSV in causing disease among older adults and how measures such as masking may be used to interrupt transmission.

It is important to emphasize the importance of masking and testing, especially in healthcare settings, during periods of heightened circulation of respiratory viruses to mitigate transmission.

Preventive vaccines for RSV are now under review by the FDA. The implementation of an effective vaccine against RSV would significantly impact both the epidemiology and healthcare burden of disease due to viral and bacterial pneumonia in older adults.

Your Thoughts?
In what situations do you recommend RSV testing in your older adult patients who present with upper respiratory infections? Join the discussion by posting a comment.