Commentary
Article
Respiratory Syncytial Virus in Older Adults: Research Insights and Recommendations
Although RSV has long been associated with infants and young children, research demonstrates that it is also a significant health risk for adults over the age of 60.
Respiratory syncytial virus (RSV) is estimated to hospitalize 100,000 to 150,000 adults 60 years of age and older each year.1 Adults who contract RSV may be asymptomatic or have only mild symptoms, which typically resolve completely within 14 days. However, some patients present with upper respiratory tract symptoms, including rhinorrhea, pharyngitis, cough, headache, fatigue, and fever. In some cases, RSV can lead to more severe symptoms and hospitalization, particularly in those older than 60.1 Recent studies emphasize the importance of recognizing RSV as a serious health risk in older adults, with some studies comparing the health studies comparing the health care burden of RSV to that of influenza.
Health care providers should prioritize education | Image credit: WesLens/peopleimages.com | stock.adobe.com
Although RSV has long been associated with infants and young children, research demonstrates that it is also a significant health risk for adults over the age of 60. One key meta-analysis of 21 different studies published in 2022 evaluated RSV burden in these patients from the United States, Canada, Japan, South Korea, and multiple European countries.2 The authors of this analysis hypothesize that the burden of disease for RSV in older adults will be comparable to influenza and subsequently warrant greater emphasis on educating patients and providers. Within the 21 studies, there were over 90,000 patients included and analyzed for acute respiratory infection incidence rate, hospitalization rate, and hospital case mortality. These end points were examined by comparing findings from the 21 studies with 2019 census data.
For the first end point of incidence rate in adults over 60, using the studies and census data, authors concluded that the RSV acute respiratory infection incidence rate was 16.2 per 1000 on average in the countries evaluated.2 For a semi-comparable reference, the CDC-estimated incidence rate for the 2023-2024 influenza season in adults over 65 was 4405.50 per 100,000, or 44.055 per 1000.3 A previous meta-analysis published by Shi et al. in 2020 that included studies from 1996 through 2018 had determined the incidence rate to be 6.7 per 1000, which the authors considered potentially biased because RSV testing in adults has only started to become more frequent in recent years.4 The authors also believe that the incidence rates observed in this analysis are likely lower than actual rates due to the reduced overall frequency of testing for RSV in adults compared to testing for COVID-19 or influenza.
For the second end point of RSV hospitalizations in adults over 60, the data demonstrated an average RSV hospitalization rate of 1.5 per 1000 people in the countries listed above. This was comparable to the 2020 Shi et al. meta-analysis finding of 1.0 per 1000 and had overlapping 95% confidence intervals. Compared to influenza, the CDC-estimated hospitalization rate for the 2023-2024 influenza season in adults over 65 was 40.05 per 1000 people.2,3
The final end point of hospital-case mortality rate for RSV was found to be 7.13 per 1000 cases. This end point differs from the previous 2 in that it only describes the mortality rate for RSV cases requiring hospitalization rather than the population as a whole. Although most cases of mortality would likely include hospitalization, this end point is not directly comparable with the CDC’s 2023-2024 influenza report, as the CDC evaluates influenza mortality across the entire population. The 2020 Shi et al. meta-analysis, however, did analyze the hospital-case mortality rate and had a finding of 1.6 per 1000 cases with a non-overlapping 95% confidence interval. The authors note that one of the sources of this variation could be the inclusion of more recent studies that had increased polymerase chain reaction testing for RSV and subsequent confirmed RSV cases and deaths, as well as including all patients over 60 regardless of their other comorbidities or their living situation (eg, long-term care facility).2-4
Based on their findings, the authors argue that RSV poses a greater burden in older adults than previously thought and warrants greater vigilance, particularly regarding testing. They also advocate for surveillance systems dedicated solely to RSV, similar to those available for COVID-19 and influenza, and for looser standards for providing RSV prophylaxis to at-risk patients.2 The CDC National Respiratory and Enteric Virus Surveillance System for key respiratory viruses in all patients for the 2023-2024 season does show RSV to be one of the more commonly detected viruses in the United States, with a peak comparable to the COVID-19 peak that season (see Image).5 However, these data are not restricted to older adults and include infants and children, who are also known to have a higher susceptibility to RSV.
Image 1: National Respiratory and Enteric Virus Surveillance System Dashboard.5
Although the data from this meta-analysis do highlight the greater burden for RSV in older adults than previously thought, RSV is also typically less severe than viruses such as influenza or COVID-19 and has no approved antivirals for treatment. From the opposing perspective, some health care providers may think RSV testing is a waste of resources because the patient would continue receiving supportive care regardless of the test’s outcome. However, testing for RSV can help rule out other causes of infection and improve our understanding of the impact this disease has on patient populations. RSV is proven to be potentially dangerous for both children and older adults, requiring improved education and awareness for patients and health care providers about available vaccinations and prevention measures.
Preventative Measures and Diagnostic Options for RSV in Older Adults
Although RSV can be dangerous in at-risk patients, including adults over 60, there are options available for preventing and managing the infection. Currently, first-line treatment includes supportive care, OTC medications, and adequate hydration.6,7 Antibiotics and antivirals are not recommended for treating RSV at this time, and older adults can reduce the risk of RSV by receiving an RSV vaccination.6 There are 3 vaccines on the market: Arexvy (GSK), Abrysvo (Pfizer), and mResvia (Moderna).8,9
All adults 75 years of age and older are eligible for vaccination, as well as adults 60 to 74 years of age who are at increased risk of RSV. Examples of risk factors may be chronic cardiovascular disease, chronic lung disease, end-stage renal disease, a body mass index of 40 kg/m2 or greater, and residing in a long-term care facility, to name a few. Eligible adults can choose any 1 of the 3 available vaccines for a 1-time dose, and the CDC currently does not have a preferential recommendation for a specific brand. This is not an annual vaccine, but to maximize benefit, the ideal time for patients to get vaccinated is in late summer or early fall—immediately prior to the start of RSV season.9
Although an RSV test is not required for diagnosis, it may be a way to rule out other respiratory diseases such as influenza or COVID-19. Many times, providers will assess symptoms with a physical exam and questions regarding fever and fatigue. An RSV test may be utilized for adults at higher risk for complications. Common types of RSV tests include nucleic acid amplification tests (NAATs) and antigentests. Real-time reverse transcription-polymerase chain reaction is a type of NAAT and is seen as highly sensitive. On the other hand, antigen tests can provide quick results but may be less sensitive than NAATs. There are also convenient at-home testing kits that test for multiple respiratory viruses with one nasal swab. These at-home kits usually take 1 to 2 days after sending to a laboratory to receive results.10,11
Conclusion: Addressing the Challenges of RSV in the Aging Population
These findings show that RSV poses a significant health risk to adults over the age of 60. The recent meta-analysis provides compelling evidence of the considerable burden RSV places on older adults, revealing that its incidence and hospitalization rates in this age group are notable. Moreover, although current treatment primarily involves supportive care, preventive measures such as vaccination with options like Arexvy, Abrysvo, and mResvia are recommended in high-risk patients for reducing susceptibility. To reduce the burden of RSV for these patients, increased awareness, better surveillance, and optimized access to preventive care are essential. Health care providers should prioritize education about the importance of RSV testing, vaccination, and early intervention, ensuring that older adults are adequately protected against this often-overlooked disease.
