What doctors wish patients knew about RSV infection

Respiratory syncytial virus (RSV) is a common respiratory virus that usually causes mild, cold-like symptoms. While most people recover in a week or two, RSV can be serious, especially for infants, older adults and adults with chronic medical conditions.

RSV leads to about 2.1 million outpatient visits annually in the U.S., between 58,000 and 80,000 hospitalizations, and 100–300 deaths among children under 5. For patients 65 or older, each year brings about 60,000–120,000 hospitalizations and 6,000–10,000 deaths, according to the Centers for Disease Control and Prevention.

The AMA’s What Doctors Wish Patients Knew™ series provides physicians with a platform to share what they want patients to understand about today’s health care headlines.

For this installment, two physicians took time to discuss what patients need to know about RSV infections. They are:

• Sandra Fryhofer, MD, an Atlanta internal medicine physician and immediate past chair of the AMA Board of Trustees. Dr. Fryhofer also serves as the AMA’s liaison to the CDC Advisory Committee on Immunization Practices (ACIP) and is a member of ACIP’s COVID-19 Vaccine Work Group.
• Preeti Malani, MD, an infectious diseases specialist and professor of medicine in the infectious diseases division at the University of Michigan Medical School. Dr. Malani is also deputy editor of JAMA^®.

“Outbreak timing and severity can vary geographically and from season to season. RSV usually starts in the fall and peaks in the winter,” Dr. Fryhofer said. “But the timing of both the onset and peak of RSV can vary. RSV seasonality during the COVID pandemic deviated from prior seasons.

“For example, in 2021, RSV started in the spring and peaked in July,” she added, noting that in 2022 “we had that tripledemic of flu, COVID and RSV in December. And that was terrible,” she added. 

“Those at highest risk of severe complications of RSV infections include infants under 6 months old—especially premature infants—and those 60 and older,” said Dr. Fryhofer. “RSV is especially dangerous for those with underlying medical conditions including heart or lung problems, as well as weakened immune systems.”

“The highest RSV-hospitalization rates for children are in the first few months of life. RSV risk declines with increasing age in early childhood,” said Dr. Fryhofer. “Prematurity and other chronic medical conditions increase risk of RSV-associated hospitalizations, but most hospitalizations are in healthy term infants. Most children have had it by their second birthday.”

For older adults, “RSV is a frequent cause of severe respiratory illness that is likely under detected,” she explained. “RSV infections in adults can trigger acute myocardial infarction, stroke and can exacerbate asthma and chronic cardiopulmonary disease, or COPD. RSV infection rates are nearly two times higher in patients with COPD as compared to others.”

The first ever vaccines to prevent lower respiratory tract disease caused by RSV were approved by the Food and Drug Administration (FDA) in 2023 for older adults and have are recommended for those 75 or older and for adults 60–74 years who are at increased risk of severe RSV. If you have already received an RSV vaccine, you do not need to get another one at this time. While you can get an RSV vaccine at any time, the best time to get vaccinated is in late summer and early fall.

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One vaccine is from GSK and will be marketed under the brand name Arexvy. It contains an adjuvant, the same adjuvant used in the recombinant shingles vaccine, Shingrix.

The other vaccine is from Pfizer and is called ABRYSVO. It does not contain an adjuvant, but it is bivalent. ABYSVO is FDA-approved for use in adults 60 or older and pregnant people in 32 to 36 weeks gestational age of pregnancy. This vaccine helps a pregnant person produce protective antibodies that are then passed on to the fetus through the placenta.

Additionally, the FDA has approved, and the CDC has recommended, use of nirsevimab, a long-acting monoclonal antibody product intended for use in newborns and infants to protect against RSV disease. Nirsevimab is recommended for infants younger than 8 months born during or entering their first RSV season, and infants and children 8–19 months old who are at increased risk of severe RSV disease and entering their second RSV season.

“The biggest sign is just like with other infections—there’s a range. So, little babies may have difficulty breathing, fever, cough, wheezing, chest congestion or it could just be a runny nose and they don’t want to eat,” said Dr. Malani. “For many of us, RSV could look like any other common cold.”

“One thing that is a bit specific to RSV is that wheezing and bronchospasm,” she said. “Then in older adults—particularly those in nursing homes—it is pneumonia.”

“You get it from exposure to respiratory droplets when an infected person coughs or sneezes,” said Dr. Fryhofer. “You can also get it from direct exposure to virus droplets including kissing the face of an infected child or from contact with surfaces.

“The virus can live for many hours on hard surfaces,” she added, noting that “people with RSV are contagious for about three to eight days. However, some with weakened immune systems can be ill for up to eight weeks.”

With symptoms of RSV, flu and COVID-19 all similar, “it’s a perfect storm of all three viruses circulating. The only way to know for sure is to test,” said Dr. Fryhofer. “Rapid antigen tests, direct fluorescent antibody testing and polymerase chain reaction, or PCR, testing are the most common.”

“There is also respiratory panel testing, which tests for spectrum of respiratory viruses,” she said, adding that “viral culture is the gold standard, but it takes a while for results to come back.”

“Consider testing those 6 months or younger as well as those 65 and older and those with underlying heart or lung problems or weakened immune systems,” Dr Fryhofer said.

“The care is like with other colds: Treating the symptoms” with pain relievers such as acetaminophen, said Dr. Malani, adding that “sometimes you need medications for wheezing to treat asthma type symptoms, so inhalers or nebulizers.”

For RSV, “some infants—especially those under 6 months old and older adults—may require hospitalization if breathing problems are severe,” she explained. In those instances, “treatment is supportive with oxygen, IV fluids, and for some, intubation and mechanical ventilation.”

Additionally, “monoclonal antibody products like monthly palivizumab injections or a single injection of nirsevimab, which is new and longer lasting, can prevent severe disease in certain high-risk infants,” Dr. Fryhofer said.

“There are not specific medications that are given for this infection, except in the case of very immunocompromised individuals,” said Dr. Malani. “Someone who has a bone-marrow transplant, for example, we would treat them with an antiviral, but in most people, antivirals are not going to be used.”

“It’s helpful for people to understand what they have and what recovery might look like,” said Dr. Malani, who noted that “you’re not going to be better in a day.”

“For little kids, it might be three days, it might be seven days,” she said, adding that “for parents who have to take time off to take care of them or they have to bring somebody in to help take care of them, those are difficult conversations because you don’t want an older family member to be exposed either.”

“Symptoms usually start to improve within a week and certainly by two weeks you would expect them to improve, but it can take a long time to feel completely better,” Dr. Malani explained. “And a lot of us have had that experience too where that cough is lingering.”

“RSV is spread from person to person and it’s people coughing and sneezing, but it’s also hands,” said Dr. Malani. “And this is something that we spent a lot of time early in the pandemic talking about—surfaces.

“Everyone was cleaning surfaces, but this is one where you do want to clean up the surface and you want to keep your hands clean,” she added.

That’s because “the best RSV prevention is to stop the spread. Cover coughs and sneezes and wash your hands for 20 seconds with soap and water,” said Dr. Fryhofer. And “keep that hand sanitizer with you.”

Additionally, “if you are sick or your child is sick, don't go into a crowded space. Don't go to class, don't go to work,” said Dr. Malani.

“Masks may also help provide protection from COVID, flu, and RSV,” Dr. Fryhofer recommended.

“It’s a little odd to wear a mask around your child, but wear a mask,” said Dr. Malani. “Part of it is that you need to stay healthy to take care of your child and we have found that masks really do work well.”

“Any kind of difficulty breathing is going to be one of the biggest concerns, especially little babies because they don’t have a lot of reserve and a baby who’s struggling to breathe needs to be seen,” said Dr. Malani. Then “older adults who aren’t eating, they have a fever, they’re having difficulty breathing, those are going to be what I am going to look for clinically.”

“I would just err on the side of caution taking the child in, because there are things doctors can do even though there’s not an antiviral or a vaccine or an antibiotic, but they can treat the breathing difficulties with nebulizers,” she said, noting that “young children can also get dehydrated because they have difficulty eating and drinking if they’re having difficulty breathing.”

“As a parent, when you feel like your child isn’t well, rely on that instinct,” said Dr. Malani. “Trust your gut because this can be quite serious, but it can be treated and managed.”