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Respiratory Syncytial Virus (RSV) in Adults Learning Zone

RSV burden

Read time: 65 mins
Last updated:14th Apr 2022
Published:27th Oct 2021

Respiratory syncytial virus (RSV) usually causes mild coughs and colds, but in some populations, such as infants, the elderly, and adults with comorbidities, RSV infections can be life-threatening, resulting in pneumonia, bronchiolitis, bronchitis and hospitalisation. Discover:

  • The nature of RSV infections
  • The burden of RSV on patients, society and healthcare systems
  • Populations at risk of severe RSV infections

What is RSV?

Infections with respiratory syncytial virus (RSV) are common and in healthy individuals usually result in coughs or colds with mild symptoms1. However, in high-risk populations, RSV can result in bronchitis (inflammation of the airway), bronchiolitis (inflammation of the small airways) and pneumonia (inflammation of the lungs) requiring hospitalisation2,3.

Severe RSV infection most often affects young infants as well as older adults, and adults with comorbidities; severe RSV can be life-threatening2,4,5

The majority of children will have been infected with RSV by the age of two years, but the incidence of RSV infections in adult populations is unclear1,2,5,6. This is likely due to misdiagnosis, because of unspecific symptoms that are shared with other respiratory infections, and a lack of routine screening for RSV, which may be driven by the absence of an approved therapy for adults, and the view that the symptoms of RSV are mild and manageable1,3.

Due to limited data on adults with RSV, it is likely that the full burden of this potentially life-threatening infection is underestimated3

RSV

Now known to be a leading cause of paediatric lower respiratory tract infections (LRTIs), RSV was first identified as a cause of bronchiolitis in babies and children in the 1960s7–9. RSV is a member of the Pneumoviridae subfamily of the Paramyxoviridae virus family, along with the viruses that cause influenza, mumps and measles1,6,10. RSV is an enveloped RNA virus, consisting of a single-stranded RNA genome, within a membrane10–12.

The RNA genome encodes 11 proteins involved in infection and virus replication, which are given alphabetical names10–12. Some have roles in viral replication, but two key proteins (named F and G) are involved in infecting host cells10,13. Indeed, protein G has been found to bind to a cell surface molecule (CX3CR1) found in human epithelia airway cells, and this interaction controls levels of infection of host cells grown in laboratories14,15. Protein F plays a role in viral entry and fusion between infected and neighbouring healthy cells, resulting in syncytia (a mass of cytoplasm containing multiple nuclei)6. The F and G proteins are the only two antigens involved in inducing a neutralising antibody response by the infected individual12.

Two subtypes of RSV are in existence, A and B, which vary in terms of the structure of protein G, and can influence disease severity10,16.

Transmission of RSV and the RSV season

RSV is transmitted by droplets and secretions from infected individuals1. The virus can survive on hard surfaces for 4–7 hours and on skin for 20 minutes1,6.

RSV is highly contagious with an incubation period of approximately 4.4 days6,17

RSV is a seasonal infection, with variations occurring according to the climate of the region in question6. In the Northern hemisphere, RSV season usually occurs between October/November and March/April, with the highest numbers of infections in December (Figure 1)1,6.

RSV_T1_Fig_1.png

Figure 1. Seasonal variation in influenza and respiratory syncytial virus in a Canadian population, and in the COVID-19 era (Adapted18). RSV, respiratory syncytial virus.

In more Southerly regions, the season may begin earlier and last for longer, and in tropical regions of South America, Asia and Africa, the RSV season is more variable in terms of onset, duration and peak6,19. Much of the available data on the RSV season is from industrialised countries, with temperate climates. In order to prepare for and appropriately manage patients during regional RSV seasons, specific surveillance programmes are needed to understand how regional climate changes affect the timing and number of infections19.

There is also evidence from France and South Africa that lockdowns and social restrictions, such as those associated with the COVID-19 pandemic, may affect the timing of RSV epidemics and the populations affected, and this must further be accounted for when developing strategies to manage RSV20,21.

RSV pathophysiology

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What is the burden of RSV?

Respiratory syncytial virus (RSV) has a negative impact on the lives of severely affected patients, due to the requirement for hospitalisation, potential long-term symptoms and high mortality rates (Figure 3).

RSV_T1_Fig_3.png

Figure 3. Estimated global hospitalisations and mortality from lower respiratory infections caused by RSV in 20154,5. RSV, respiratory syncytial virus.

Burden of RSV in children

RSV is the most common cause of lower respiratory tract infections (LRTIs) in children and is also the most common cause of pneumonia in children aged under 18 years, present in 28% of children hospitalised due to pneumonia in a US surveillance study7,33. Acute bronchiolitis symptoms are the most common complication in children infected with RSV, affecting 85% of patients aged ≤1 year, up to 77.5% of infected children <2 years old, and 31% of infected children aged 2–5 years22.

A systematic review has reported that 3.2 million children aged <5 years and 1.4 million infants <6 months across the world were hospitalised with RSV in 2015 (Figure 4)4

RSV_T1_Fig_4.png

Figure 4. Hospitalisation rates by age for RSV infection in developing and industrialised countries (Adapted4,5). *Total individuals.

Hospitalisation rates associated with RSV infection in infants are approximately 15.6 times higher than those caused by influenza infections34.

In severe cases of RSV, intensive care is required, with ventilatory support. In premature infants with RSV and children aged <2 years old, intensive care may be required in up to 48.4% of patients and 17.5% of patients, respectively22. The requirement for ventilatory support could be as high as 34% in premature infants under 90 days old35.

A systematic review also estimates that 59,600 children <5 years (27,300 infants <6 months) died from RSV infections globally in 20154. This mortality burden is not evenly distributed, with over 90% of infections and deaths in developing countries, where otherwise healthy infants experience complications, such as bacterial sepsis and collapsed lung (pneumothorax), possibly due to limited treatment availability3,36.

Following RSV infection, some children experience recurrent wheezing, persistent lung problems or asthma22,33,37,38. Recurrent wheezing has a negative impact on health-related quality of life, as assessed using the HRQoL questionnaire in children aged 3 years who had been infected with RSV prior to 13 months of age, not only affecting the respiratory system, but also the gastrointestinal tract and sleep39. Allergic rhinoconjunctivitis is also more common in children who have had RSV infections prior to the age of 1 year compared with controls (P=0.004)40.

Burden of RSV in adults

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What are the risk factors for severe RSV?

Given the patient and socioeconomic burden of respiratory syncytial virus (RSV) in paediatric and adult populations, an understanding of risk factors is required to help to isolate high-risk individuals and identify patients at risk of a severe infection.

Risk factors for RSV infection in infants and children

The risk of infants or children experiencing a severe RSV infection or requiring admission to hospital is affected by a range of medical and socioeconomic factors (Figure 7).

RSV_T1_Fig_7.png

Figure 7. Risk factors for severe RSV or admission to hospital in infants and children22,23,33,36,53,54. RSV, respiratory syncytial virus.

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