Respiratory Syncytial Virus in Older Patients: Prevention, Management, and Long-Term Impact

Respiratory syncytial virus (RSV) is a common respiratory infection affecting the lower lungs and known for causing mild symptoms similar to those of a cold. While most patients recover within 1 to 2 weeks, most adults experience complications, requiring hospitalization.¹ The virus was first isolated in 1956 from a laboratory chimpanzee with upper respiratory tract disease.² RSV is an RNA virus classified within the genus Orthopneumovirus, part of the family Pneumoviridae and the order Mononegavirales.³ Addressing the long-term effects of RSV in older adults is crucial for public health and patient care because it can reduce morbidity, improve quality of life, and lessen the burden on health care systems.

Image Credit: freshidea - stock.adobe.com

RSV primarily spreads through respiratory droplets expelled when an infected patient coughs or sneezes. It can also be transmitted by touching surfaces contaminated with the virus and then touching the mouth, nose, or eyes. Therefore, maintaining proper hand hygiene; practicing respiratory etiquette are essential in preventing RSV transmission. In elderly populations, RSV infections typically manifest with symptoms such runny nose, fever, cough, sneezing, reduced appetite, wheezing, and dyspnea. However, severe cases can lead to pneumonia or exacerbation of underlying respiratory conditions like asthma, chronic obstructive pulmonary disease (COPD), and bronchiolitis. Elderly individuals are at higher risk of developing severe complications due to age-related declines in immune function and the presence of comorbidities.

RSV infections usually begin in the fall and peak in the winter. In the United States, RSV causes around 60,000 to 160,000 hospitalizations annually, and up to 10,000 deaths among adults aged ≥65 years.^4,5 The most commonly impacted are individuals living in institutional settings. Consequently, elderly patients experience prolonged hospitalization, heightened health care expenses, and increased susceptibility to respiratory complications like pneumonia. These outbreaks in long-term care facilities present substantial challenges for infection control and management within this vulnerable population. Individuals at high risk of being infected are those who are 65 years and older who have other comorbidities such as a chronic lung disease, heart disease, and a weakened immune system.⁵

A cross-sectional study focused on the prevalence and severity of acute cardiac events among hospitalized older adults with RSV infection. The study, conducted over 5 RSV seasons, found that nearly one-quarter of adults aged 50 years or older hospitalized with RSV experienced acute cardiac events, with acute heart failure being the most common. Additionally, 8.5% of these patients had no documented underlying cardiovascular disease, suggesting that RSV infection itself may precipitate cardiac complications. Adults with underlying cardiovascular disease faced a significantly higher risk of acute cardiac events, emphasizing the importance of considering cardiac comorbidities in RSV management. Furthermore, patients who experienced acute cardiac events had nearly twice the risk of severe outcomes, including intensive care unit admission and in-hospital death.⁶ These findings provide a heightened awareness of cardiac complications in RSV infection and highlight the potential impact of RSV vaccination in mitigating severe outcomes in older adults.

Another study in The Journal of Infectious Diseases examined how RSV affects the nervous system using peripheral nerve and spinal cord cultures. The findings indicate that RSV directly and indirectly impacts peripheral nerve cells, causing inflammation and nerve damage. Although RSV also affects certain cells in the spinal cord, it does not directly infect spinal neurons.⁷ Overall, the study highlights the various ways RSV can affect the nervous system and emphasizes the need for further research on protective measures against the virus's neurological effects.

Immunizations for the Prevention of RSV

Adults ages 60 and older: 2 RSV vaccines (GSK Arexvy and Pfizer Abrysvo) have been licensed by FDA and recommended by CDC for adults ages 60 and older, using shared clinical decision-making.

Graphic From Author

Clinical Efficacy

One dose of the RSV vaccines, Arexvy and Abrysvo, showed promising efficacy in adults aged 60 and older during the first RSV season post-vaccination. Arexvy was 83% effective in preventing lung infections during the first season, and 56% effective during the second season. Abrysvo demonstrated 89% efficacy during the first season, with ongoing protection into the second season, although final results are pending.⁸ These findings suggest both vaccines offer considerable protection against RSV-related lung infections in this demographic for at least 2 winter seasons.

Treatments

For mild cases of RSV infection, there's no specific treatment, so the best course of action involves staying hydrated and getting adequate rest. If the patient has COPD or asthma, it's essential to continue the prescribed medications to manage breathing difficulties.

When to seek emergency care

RSV typically starts with mild cold-like symptoms such as a runny nose, sore throat, cough, and headache. However, certain emergency signs suggest a severe respiratory illness, necessitating immediate medical attention. These include shortness of breath, fever, bluish skin discoloration, wheezing, and a worsening cough.

In the event of hospital admission, dehydration may be addressed with intravenous fluids, and supplemental oxygen may be administered to enhance oxygen saturation levels. If a secondary infection such as bacterial pneumonia arises, antibiotics may be prescribed.

Overall, understanding and addressing the long-term effects of RSV in older adults is crucial for public health and patient care. While the virus initially presents as a mild respiratory infection, it can lead to severe complications, particularly among the elderly population, resulting in hospitalization and even death. The virus not only exacerbates underlying respiratory conditions like asthma and COPD but also poses risks of acute cardiac events and neurological impacts. Prevention through proper hand hygiene, respiratory etiquette, and vaccination is key in reducing the burden of RSV infections. Moreover, recognition of emergency signs and appropriate medical intervention can help mitigate severe outcomes and improve patient outcomes. Integrating preventive measures, vaccination strategies, and timely treatment protocols enables effective management of RSV infections in older adults, resulting in reduced illness severity, enhanced quality of life, and decreased strain on health care systems.

References

1. CDC. Learn about Respiratory Syncytial Virus Infection (RSV). Centers for Disease Control and Prevention. Published August 4, 2023. https://www.cdc.gov/rsv/index.html#:~:text=Print

2. Collins PL, Graham BS. Viral and Host Factors in Human Respiratory Syncytial Virus Pathogenesis. Journal of Virology. 2008;82(5):2040-2055. doi:https://doi.org/10.1128/JVI.01625-07

3. Respiratory Syncytial Virus (RSV) disease. www.who.int. https://www.who.int/teams/health-product-policy-and-standards/standards-and-specifications/vaccine-standardization/respiratory-syncytial-virus-disease#:~:text=Respiratory%20syncytial%20virus%20(RSV)%20belongs

4. Linder KA, Malani PN. RSV Infection in Older Adults. JAMA. 2023;330(12):1200-1200. doi:https://doi.org/10.1001/jama.2023.16932

5. Association AL. RSV in Adults. www.lung.org. https://www.lung.org/lung-health-diseases/lung-disease-lookup/rsv/rsv-in-adults#:~:text=RSV%20is%20the%20most%20common

6. Woodruff RC, Melgar M, Pham H, et al. Acute Cardiac Events in Hospitalized Older Adults With Respiratory Syncytial Virus Infection. JAMA internal medicine. Published online April 15, 2024:e240212. doi:https://doi.org/10.1001/jamainternmed.2024.0212

7. Pollard K, Traina‐Dorge V, Medearis S, et al. Respiratory syncytial virus infects peripheral and spinal nerves and induces chemokine-mediated neuropathy. The Journal of Infectious Diseases. Published online December 22, 2023. doi:https://doi.org/10.1093/infdis/jiad596

8. RSV Vaccination: What Older Adults 60 Years of Age and Over Should Know | CDC. www.cdc.gov. Published March 1, 2024. https://www.cdc.gov/vaccines/vpd/rsv/public/older-adults.html#:~:text=In%20adults%20ages%2060%20years%20and%20older%20with%20healthy%20immune