Version May 2024
INTRODUCTION — Respiratory syncytial virus (RSV) is an important respiratory pathogen in adults and children. Although RSV is commonly recognized as a significant cause of morbidity and mortality in children, its impact in adults is less well characterized [1]. Most adults with RSV experience mild upper respiratory tract infections, but life-threatening lower respiratory tract infections can occur, especially in older persons, immunocompromised patients, and those with underlying cardiac or pulmonary disease [2,3].
The clinical manifestations, diagnosis, treatment, and prevention of RSV in adults will be reviewed here. Topic reviews that discuss the virology and pathogenesis of RSV, as well as RSV infection in children, are presented separately. (See "Respiratory syncytial virus infection: Clinical features and diagnosis in infants and children" and "Respiratory syncytial virus infection: Treatment in infants and children" and "Respiratory syncytial virus infection: Prevention in infants and children" and "Bronchiolitis in infants and children: Treatment, outcome, and prevention".)
EPIDEMIOLOGY IN ADULTS — RSV typically causes seasonal outbreaks throughout the world. In the northern hemisphere, these usually occur from October or November to April or May, with a peak in January or February. In the southern hemisphere, wintertime epidemics occur from May to September, with a peak in May, June, or July. (See "Respiratory syncytial virus infection: Clinical features and diagnosis in infants and children", section on 'Epidemiology' and "Respiratory syncytial virus infection: Clinical features and diagnosis in infants and children", section on 'Transmission and incubation period'.)
RSV is increasingly recognized as a common cause of respiratory illness in adults [1,4-11]. It is associated with up to 12 percent of medically attended acute respiratory illness in adults [12]. While it is estimated that less than 1 percent of adults affected require hospitalization [13], RSV is the third most commonly identified viral cause among respiratory viruses resulting in hospitalization [14-16]. In the United States, there is an estimated 60,000 to 160,000 hospitalizations and 6000 to 10,000 deaths annually among adults aged ≥65 year [17].
Data suggests that the annual incidence of RSV-associated hospitalization ranges from 44.2 to 58.9/100,000 for all adults with rates as high as 136.9 to 255.6/100,000 in adults ≥65 years of age [2]. The incidence of RSV-associated hospitalization among adults increases with age, with the highest rates among those aged ≥75 years [17]. Rates are also higher in patients with comorbid conditions, such as lung or heart disease. RSV is a major cause of exacerbation of airway diseases such as asthma or chronic obstructive pulmonary disease (COPD). Hospitalized adults with RSV more frequently have underlying chronic lung diseases (35.6 versus 24.1 percent) than patients with other respiratory viruses, such as influenza [4].
Among hospitalized adults with positive RSV testing, approximately 10 to 31 percent of patients require intensive care unit (ICU) admission, with 3 to 17 percent requiring mechanical ventilation [12]. In hospitalized adults with RSV, lower respiratory tract symptoms are greater compared with hospitalized adults with influenza; the symptoms are especially worse among those with risk factors for severe disease [18]. In a report of 5784 adults ≥60 years of age who were hospitalized with an acute respiratory illness between February 2022 and May 2023, the rate of ICU admission was 24.3, 17.3, and 16.8 percent for those with RSV, COVID-19, or influenza, respectively (figure 1) [19]. The risk of invasive mechanical ventilation or death was 1.39 times higher for RSV than COVID-19 and 2.08 times higher for RSV than influenza.
Emerging data have identified a number of genetic markers as demonstrating enhanced risk of severe RSV disease. Polymorphisms in cytokine- and chemokine-related genes including interleukin (IL)-4 and its receptor, IL-8, IL-10, IL-13, and chemokine receptor (CCR) 5, as well as polymorphisms in genes associated with virus-cell surface interactions or cell signaling such as toll-like receptor (TL)-4, chemokine receptor 1 (CX3CR1), surfactant protein (SP)-A, and SP-D also have been associated with severe RSV disease [20]. (See 'Severe disease' below.)
CLINICAL PRESENTATION — In adults, the clinical presentation of RSV varies and can range from cold-like symptoms to acute respiratory distress. Although asymptomatic infection can occur, it is rare in adults or the elderly (<5 percent) [21,22]. Patients with multiple comorbidities (ie, immunocompromising conditions, chronic obstructive pulmonary disease [COPD] and congestive heart failure [CHF]) are more likely to develop symptomatic RSV illness [23].
Presenting features — Most symptomatic adults develop upper respiratory tract infection (URTI) signs such as nasal congestion and rhinorrhea (22 to 78 percent) and sore throat (16 to 64 percent) three to five days after infection [13]. Other nonspecific symptoms (eg, asthenia, anorexia, and fever) develop in approximately 50 percent of cases, and they can vary in severity. Overall, RSV infection is not clinically distinguishable from other respiratory viruses [24]. (See 'Differential diagnosis' below.)
Clinical course — In many cases, infection progresses to involve the lower respiratory tract, and symptoms such as cough (85 to 95 percent), wheezing (33 to 90 percent), and dyspnea (51 to 93 percent) can develop [5,14,24-28]. Wheezing and shortness of breath have been described in adult patients with and without underlying comorbidities or hyperreactive airways [5,29]. One study from Hong Kong found that up to 70 percent of hospitalized adults with RSV had lower respiratory tract infection (LRTI), including pneumonia, acute bronchitis, or COPD/asthma exacerbations [4]. LRTI can also result in respiratory failure (8 to 13 percent) or death (2 to 5 percent) [26]. (See 'Epidemiology in adults' above and 'Severe disease' below and 'Prognosis' below.)
In patients with underlying cardiovascular disease and RSV, patients can present with exacerbations of CHF, arrhythmias, acute coronary syndromes, and even myocarditis [30,31]. It is estimated that 5.4 percent of all hospital admissions for CHF during respiratory viral season are attributable to RSV infection [14]. Mortality with these cardiovascular exacerbations appears to be higher when RSV infection is also present [4,32].
Severe disease — Since most RSV infections in adults are not their first infection, most patients experience mild to moderate clinical disease. However, some patients may develop severe disease (eg, pneumonia and respiratory failure).
●Risk factors – Risk factors for progression to viral pneumonia and complications include being immunocompromised and/or having underlying lung or cardiac disease (eg, COPD, asthma, CHF, coronary artery disease), cerebrovascular disease, diabetes mellitus, or chronic kidney disease [17]. Severe disease is also more likely in those who are elderly, frail, or live in a long-term care facility, in addition to those who live at high altitudes [33-36]. Disease progression has been associated with tobacco use and lymphopenia [37-39].
Among immunocompromised patients, the greatest burden is noted in hematopoietic cell transplant (HCT) recipients and lung transplant patients, who have an incidence of RSV of 11.6 to 16 percent [40-42]. However, emerging data has highlighted an enhanced risk of RSV infection and poor outcomes in patients actively undergoing chemotherapy for leukemia and lymphoma as well as those receiving cancer chemotherapy and long-term immunosuppression [43]. (See "Epidemiology of pulmonary infections in immunocompromised patients", section on 'Community-acquired respiratory viruses'.)
●Role of coinfection – In adults with RSV and LRTI, coinfection is common, with 12.5 to 23.4 percent having bacterial [4,34] and 21.8 percent having viral coinfections [34]. Adults with bacterial coinfection or superinfection are more likely to experience a more severe disease course and enhanced mortality [4,34].
Imaging — In adults, radiographic findings are not specific to RSV and may be similar to other respiratory viruses. As an example, on chest x-ray, bilateral alveolar opacities and/or interstitial changes may be seen [44,45].
In adults with RSV pneumonia, chest computed tomography (CT) usually demonstrates an airway-centric pattern of disease, which may include ground glass opacities, nodules, small focal areas of consolidation, and bronchial wall thickening [45]. In addition, nodules and tree-in-bud opacities (commonly with a peripheral halo of ground glass) may be present during the early phase of disease [46-48].
Prognosis
Mortality — Among all adults, RSV-attributed mortality is generally estimated to be less than 1 percent [6,25]; however, RSV may account for as much as 25 percent of the excess winter mortality that was historically attributed solely to influenza [15]. In a report of hospitalized adults with RSV, mortality occurred in 2.5 percent; in addition, 11.6 percent needed institutional care after discharge, and 26.9 percent required readmission in the three months following index discharge [49]. The highest annual RSV-associated pneumonia mortality rate is in adults ≥65 years of age (7.2 per 100,000 person-years) [12,15].
Mortality associated with severe RSV appears to be greater than influenza. In one study, one-year survival for those hospitalized with RSV was lower than those hospitalized with influenza (74.2 percent versus 81.2 percent [OR 1.3; 95% CI 1.0–1.6]) [7]. In another report, the risk of invasive mechanical ventilation or death was 2.08 times higher for RSV than influenza in hospitalized adults (figure 1) [19].
Considerations in immunocompromised patients — Among adult HCT recipients with RSV infection, progression from URTI to LRTI occurs in 40 to 60 percent of cases; LRTI is associated with mortality rates up to 80 percent [50-54]. Scoring systems that predict the progression of RSV in HCT recipients have been developed [55,56]. As an example, when using the Immunodeficiency Scoring Index (ISI), there is an increased risk of disease progression (7, 15, and 48 percent, respectively) and mortality (0, 3, and 29 percent, respectively) with increasing scores [56]. This scoring system takes into account factors such as age, neutropenia, lymphocytopenia, use of a myeloablative conditioning regimen, presence of graft versus host disease (GVHD), corticosteroid use, recent HCT, and lack of stem cell engraftment. Additional information on the use of these scoring systems is discussed below. (See 'Immunocompromised patients' below.)
In solid organ transplant recipients with LRTIs due to RSV, LRTIs due to RSV are a risk factor for chronic rejection (bronchiolitis obliterans syndrome/chronic lung allograft dysfunction), and mortality rates up to 20 percent have been reported [57,58]. In one meta-analysis, pooled 30-day mortality (0 to 3 percent) in lung transplant recipients was low, but progression of chronic lung allograft dysfunction was substantial 180 to 360 days post-infection (pooled incidences 19 to 24 percent) and was probably associated with a history of severe infection [59].
DIAGNOSIS
Clinical suspicion — RSV should be suspected in adults with upper respiratory tract symptoms, especially if they have had a known exposure to RSV. It should also be suspected in hospitalized patients with acute lower respiratory tract disease (eg, pneumonia, bronchitis, exacerbation of asthma, or chronic obstructive pulmonary disease [COPD]). (See "Respiratory syncytial virus infection: Clinical features and diagnosis in infants and children", section on 'Transmission and incubation period' and 'Presenting features' above.)
Other respiratory pathogens share the clinical patterns of RSV, and clinical features alone are insufficient to reliably distinguish RSV from these other infections. (See 'Differential diagnosis' below.)
When to test — There is frequent cocirculation of multiple viruses, including SARS-CoV-2, influenza, parainfluenza, and human metapneumovirus, at the same time as most RSV epidemics. It is difficult to clinically distinguish RSV from other respiratory viruses, thus diagnostic testing is required to identify the causative virus [28], particularly in the inpatient setting.
The decision to test for RSV depends in part on the immune status of the patient:
●Immunocompetent adults – For immunocompetent adults, laboratory diagnosis of RSV should be pursued if identification of RSV will affect clinical management. As an example, although identifying RSV does not lead to specific RSV treatment, testing may be helpful to rule out the presence of other pathogens that may benefit from treatment (eg, influenza, COVID-19). In addition, identifying RSV may prevent the unnecessary use of antibiotics and, among hospitalized patients, may impact infection control precautions. (See "Seasonal influenza in nonpregnant adults: Treatment" and "COVID-19: Management of adults with acute illness in the outpatient setting" and "COVID-19: Management in hospitalized adults" and "Acute bronchitis in adults", section on 'Antimicrobial therapy'.)
●Immunocompromised adults – For immunocompromised patients, particularly hematopoietic cell transplant (HCT) and lung transplant recipients, testing for RSV should be performed in those with fever or respiratory symptoms. In such patients, there may be a role for antiviral therapy with ribavirin. (See 'Immunocompromised patients' below.)
Types of tests — Reverse transcription polymerase chain reaction (RT-PCR) is the preferred testing method for RSV in adults due to its superior sensitivity, specificity, time to virus identification, and breadth of pathogen detection. In younger patients (those <20 years of age), RSV can also be diagnosed by antigen detection. Both of these tests can be applied to samples collected from the upper or lower airway. Sampling of the lower airway is more sensitive in detecting infections in those with lower tract signs and symptoms with negative upper airway testing [42].
●RT-PCR – RT-PCR has become the gold standard for detecting RSV (sensitivity of 85 to 100 percent) [26]. Although RSV-specific PCRs are available, assays that detect multiple viruses (especially SARS-CoV-2, influenza, and RSV) are preferred. Multiplex tests are now widely available in most hospitals, particularly for rapid diagnosis, but they are not used as commonly in ambulatory care settings.
For most patients, nasopharyngeal (NP) swabs can be used; these are more sensitive than oropharyngeal swab specimens [60]. However, testing of salivary samples has similar yield to NP swabs and can be considered an alternative sampling approach [61,62].
For patients with severe disease requiring intubation, lower respiratory samples are preferred as viral replication is higher in the lower respiratory tract in advanced diseases. The use of diluted sputum samples in adults is being investigated [63,64].
●Antigen testing – Rapid antigen testing with enzyme immunoassays (EIAs) is a point-of-care test with results available in 15 to 30 minutes. However, these tests are generally reserved for patients under 20 years of age since they have lower sensitivity in older adults compared to children (likely due to differences in viral loads) [65,66]. The sensitivity of first generation EIAs for RSV in older adults is at best <20 percent when compared to serology and PCR [66,67]. Second generation EIAs have improved sensitivities (approximately 70 percent) but are still intended for patients under 20 years of age [65].
Other types of tests may be available but are rarely used due to significant limitations compared with PCR and antigen testing. As an example, results from direct fluorescent antibody (DFA) tests are available for RSV (within approximately two hours); however, specimens need to include an adequate number of epithelial cells. The sensitivity is also low (20 to74 percent) and therefore is not favored in adults [67]. Much of the older surveillance data utilized DFA testing, which likely underestimated the true incidence of RSV [68].
Cell culture has also fallen out of favor for clinical use because of long time to diagnosis (several days), low yield given the lability of the virus, need for well-trained staff, and low sensitivity (17 to 39 percent) compared to PCR [69,70]. (See "Respiratory syncytial virus infection: Clinical features and diagnosis in infants and children", section on 'Laboratory confirmation'.)
Serology (immunoglobulin [Ig]M and IgG) is not clinically useful in adults and is generally reserved for epidemiologic studies [69].
DIFFERENTIAL DIAGNOSIS — Other respiratory pathogens (eg, SARS-CoV-2, influenza virus, rhinovirus, parainfluenza virus) share the same clinical features of RSV, and clinical features are insufficient to reliably distinguish these infections. Nucleic acid testing and/or culture are the most reliable ways to differentiate these different pathogens. (See "The common cold in adults: Diagnosis and clinical features" and "Clinical evaluation and diagnostic testing for community-acquired pneumonia in adults".)
More detailed discussions of respiratory pathogens are presented in separate topic reviews:
●(See "COVID-19: Clinical features" and "COVID-19: Diagnosis".)
●(See "Epidemiology, clinical manifestations, and pathogenesis of rhinovirus infections".)
●(See "Role of viruses in wheezing and asthma: An overview", section on 'Specific viruses'.)
●(See "Epidemiology of pulmonary infections in immunocompromised patients", section on 'Pathogens'.)
TREATMENT — Despite decades of research, there are currently few approved therapies for the treatment of RSV [1].
Most adults — For most adults, treatment is supportive. (See "The common cold in adults: Treatment and prevention".)
In addition, for those with lower tract infection who present with cough and wheezing, bronchodilators may result in symptom relief, particularly if the patient has underlying reactive airway disease.
Immunocompromised patients — Decisions regarding the treatment of RSV infection in immunocompromised patients should be individualized. Treatment in immunocompromised patients has not been well studied and the optimal approach is uncertain [71,72]. Such patients should be managed in consultation with an infectious diseases specialist.
In general, we reserve treatment with antiviral therapy for those who are severely immunocompromised, such as selected persons with leukemia and selected hematopoietic cell and lung-transplant recipients.
●Hematopoietic cell transplant recipients and those with leukemia – Adult hematopoietic cell transplant (HCT) patients with RSV pneumonia have a high risk of mortality (up to 80 percent). (See 'Considerations in immunocompromised patients' above.)
The decision to initiate therapy in HCT recipients and persons with leukemia depends primarily upon the severity of immune compromise [53]. As an example, using the Immunodeficiency Scoring Index (ISI)-RSV scoring system, a patient ≥40 years of age with neutropenia and lymphopenia would be at very high risk for RSV-related mortality, and we would initiate therapy, even if symptoms were mild [56]. Existing data suggests the greatest benefit of treatment is in patients who initiate therapy prior to developing lower tract disease [1,42,73]. (See 'Considerations in immunocompromised patients' above.)
If treatment is initiated, we administer combination therapy with ribavirin (highest tolerable dose, usually 600 to 800 mg twice daily) plus intravenous immune globulin (IVIG; 500 mg/kg as a single dose). High titer RSV immunoglobulin can be used instead of IVIG, but it is often not available. These doses are based upon expert opinion given the lack of data to inform this decision.
Uncontrolled trials suggest that combination therapy with nebulized ribavirin and intravenous immune globulin is associated with improved survival in adult HCT recipients with RSV infection [50,53,73-78]. However, aerosolized ribavirin is generally avoided given the difficulty and toxicity associated with administration.
Oral ribavirin appears to be a reasonable alternative to nebulized ribavirin. A number of studies have described outcomes after oral ribavirin [42,72]. In a small case series of HCT recipients with RSV upper and lower respiratory tract infection, oral ribavirin was associated with reduced morbidity and mortality [79-81]. In a review of 124 HCT recipients with RSV infections, the rate of progression to lower respiratory tract infection (LRTI; approximately 27 percent) and 30-day mortality (approximately 10 percent) were similar among those treated with oral and nebulized ribavirin (54 and 70, respectively) [82]. However, none of these trials have been placebo controlled so the true clinical efficacy cannot be assessed. In addition, in one trial, only a minority of patients were classified as high risk, so these findings may not be generalizable to this population [83].
●Lung transplant recipients – Among lung transplant patients, a meta-analysis of existing studies found that ribavirin therapy resulted in lower rates of chronic lung allograft dysfunction compared to untreated controls [59].The management of RSV in lung transplant recipients is discussed in detail separately. (See "Viral infections following lung transplantation", section on 'Respiratory syncytial virus'.)
●Other solid organ transplant recipients – The management of RSV in patients with other types of solid organ transplant is individualized. Oral or nebulized ribavirin is often administered to heart-lung transplant recipients with upper respiratory tract infection (URTI) or LRTI and may be warranted for non-lung solid organ transplant recipients with LRTI [84,85].
PREVENTION
Infection control precautions — In patients with RSV, the period of viral shedding is typically three to eight days. (See "Respiratory syncytial virus infection: Clinical features and diagnosis in infants and children", section on 'Transmission and incubation period'.)
RSV is effectively transmitted by large droplets from infected individuals. Transmission typically occurs when these droplets enter via the mucus membranes of the eyes, nose, and mouth after close contact [86,87]. It can also occur through self-inoculation after touching contaminated surfaces. Transmission through this route is facilitated by the fact that the virus can remain stable for several hours on hard surfaces and hands. Aerosolization is felt to be less important for transmission of RSV.
Infection control precautions vary depending upon the location:
●In the outpatient setting, the use of hand hygiene and covering one's mouth when coughing are the mainstay of prevention.
●For hospitalized patients, the United States Centers for Disease Control and Prevention (CDC) guidelines recommend contact precautions for the duration of illness with mask wearing according to standard precautions [88]. (See "Infection prevention: Precautions for preventing transmission of infection", section on 'Standard precautions'.)
The duration of contact precautions should be extended in immunocompromised patients due to prolonged shedding.
Transmission risk varies from 6 to 12 percent (median 7 percent) in inpatient units with immunocompromised adults (eg, those with hematologic cancers and/or hematopoietic cell transplant [HCT] recipients) to 30 to 32 percent in other adult care settings [89]. This may be due in part to enhanced precautions used when caring for patients with severe immunocompromise. Studies have demonstrated decreased nosocomial transmission of RSV with more universal mask use, particularly in HCT recipients [90-92].
Vaccination
Available formulations — Available vaccines are subunit vaccines based on prefusion conformations of prefusion RSV F glycoproteins [93]. One includes an adjuvant and the other is non-adjuvanted. In the United States, both vaccines were approved by the US Food and Drug Administration (FDA) in 2023 for persons 60 years and older. The efficacy and safety of these vaccines is discussed below. (See 'Efficacy and safety data' below.)
The non-adjuvanted vaccine is also approved for pregnant women to prevent infection in the infant. More detailed information on vaccination during pregnancy is presented elsewhere. (See "Immunizations during pregnancy", section on 'Respiratory syncytial virus'.)
An mRNA vaccine is being evaluated in older adults, and clinical trial data have shown that it can lead to a lower incidence of RSV-associated lower respiratory tract disease and RSV-associated acute respiratory disease [94]; however, this vaccine is not yet available outside of the research setting.
Other types of vaccines have also been evaluated in adults. Initial attempts to develop RSV vaccination were stalled after a heat and formalin activated whole virus vaccine in the 1960s resulted in enhanced disease in children who received the vaccine. After studies helped to better define contributors to the immune enhancement, other structure-based studies focused on improving antibody production and potency to the F protein. Introduction of disulfide and cavity-filling mutations and proline substitutions stabilized the F protein in the pre-F conformation which allowed improved access to key immunogenic epitopes [93,95,96]. Studies demonstrated that the preF is more immunogenic than postF and that the antibodies that exclusively bind the preF have greater neutralizing potency than antibodies that bind both preF and postF [97,98]. Several other strategies have been utilized, including the use of live-attenuated or live chimeric vaccines, gene-based vectors, or nucleic acid approaches [99].
Indications — We offer RSV vaccination to all individuals ≥60 years of age.
●We suggest RSV vaccination for individuals who are ≥60 years of age and have comorbidities that put them at increased risk for severe disease (table 1). In such patients, the risk of hospitalization can range from 136.9 to 255.6/100 000 population (0.14 to 0.26 percent) [2]. (See 'Epidemiology in adults' above.)
●For others, we explain that they would still benefit from vaccination since age is one of the main risk factors for developing severe disease. However, their baseline risk of developing severe disease and requiring hospitalization is likely to be lower compared to those with comorbidities in addition to age.
Our approach is consistent with recommendations from the United States CDC [17]. As discussed below, both of the available vaccines reduce the risk of symptomatic RSV and prevent hospitalizations in persons 60 and over. (See 'Adjuvanted RSV vaccine (RSVPreF3) [Arexvy]' below and 'Bivalent PreF vaccine (RSVPreF) [Abrysvo]' below.)
Indications for vaccination during pregnancy are presented separately. (See "Immunizations during pregnancy", section on 'Respiratory syncytial virus'.)
There are no data or guidelines yet to inform the use of this vaccine in other individuals <60 years, including those who are immunocompromised [100]. In addition, there are no recommendations regarding when to administer this vaccine in persons with recent RSV.
Choice of vaccine — For most nonpregnant adults, the choice of vaccine is determined by availability. There are no data to support the use of one vaccine over the other. However, for immunocompromised patients, there may be a theoretical benefit to using the adjuvanted vaccine. Such patients generally have a worse response to vaccination and adjuvanted vaccines are more immunogenic. Detailed information on vaccination during pregnancy is presented elsewhere. (See "Immunizations during pregnancy", section on 'Respiratory syncytial virus'.)
Dosing and administration — RSV vaccines are administered as a one-time single dose. Available data suggest that boosting annually may not be required [17], although the dosing interval of vaccines is still under investigation.
Optimally, vaccination should occur in late summer/early fall, which is before RSV season (typically October to April). However, vaccination at other times is still reasonable since RSV seasonality may be disrupted (eg, during the COVID-19 pandemic), and the duration of protection from vaccination appears to extend beyond a single season [17].
For patients with conditions that require immunosuppressive therapy, the vaccine should be administered prior to initiating treatment, if possible. There are no data on the efficacy of this vaccine in immunocompromised patients; ongoing studies will inform immunogenicity and need for boosting doses in this population.
Efficacy and safety data
Adjuvanted RSV vaccine (RSVPreF3) [Arexvy] — RSVPreF3 is an AS01E-adjuvanted RSV prefusion F vaccine. In a clinical trial of 24,966 participants who received one dose of the RSVPreF3 OA vaccine or placebo before the RSV season, vaccine efficacy was nearly 83 percent against symptomatic RSV infection during the first RSV season after vaccination (7 versus 40 cases in the vaccine and placebo group, respectively) and 94 percent against severe RSV-related lower track disease [101]. Available data obtained during the second RSV season after vaccination found that there was still a reduction in symptomatic disease, but the vaccine efficacy decreased to 56.1 percent [17].
Revaccination at 12 months did not appear to confer additional efficacy benefit. In those who received a second dose of the vaccine 12 months after the first dose, the efficacy at preventing symptomatic disease during the second RSV season was 55.9 percent and hospitalizations at 64.1 percent [17]. Patients in this study are continuing to be followed for at least one more season, and this will help to inform the efficacy and need for subsequent booster doses.
In general, vaccination was well tolerated. In the randomized trial above, most adverse reactions were self-limited and included pain at the injection site, headache, myalgias, and fatigue [101]. For those who received RSVPreF3, there was slightly higher incidence of atrial fibrillation among vaccine recipients when compared to the control group (10 out of 12,500 in those who received the vaccine, while 4 in 12,500 who received the placebo) [17]. Two patients developed acute disseminated encephalomyelitis (ADEM) after receiving influenza and RSV vaccines together at the same time, and it is not known if either or both vaccines were the cause. There was one case of Guillain-Barré syndrome in a patient who received just the RSV vaccine. Guillain Barré is known to occur in 1.85 per 100,000 population for those in their 60s, and up to 2.66 per 100,000 population for those in their 80s.
Bivalent PreF vaccine (RSVPreF) [Abrysvo] — RSVPreF is a non-adjuvanted bivalent RSV prefusion F vaccine. In a trial enrolling over 37,000 participants, vaccination demonstrated nearly 67 percent efficacy against lower respiratory tract infection with two or more symptoms and 86 percent efficacy against lower respiratory tract infection with three or more symptoms [102]. During the middle of the second RSV season, the efficacy was 48.9 percent against the infection with two or more symptoms, and 78.6 percent against infection with three or more symptoms.
In the clinical trials of this unadjuvanted preF RSV vaccine conducted to date, there was one case of Guillain-Barré syndrome, Miller Fisher syndrome, and Chronic inflammatory demyelinating polyneuropathy (CIDP) out of the 20,255 individuals that received the vaccine [17]. It is unclear if this is a significant increase from the background rate of Guillain-Barré syndrome among older adults. Further active surveillance studies are underway.
RSVPreF has also been studied in pregnant people at 24 to 36 weeks of gestation and has been shown to decrease medically attended RSV-associated respiratory tract infection in infants up to six months old. This is discussed in detail elsewhere. (See "Immunizations during pregnancy", section on 'Respiratory syncytial virus'.)
No role for monoclonal antibodies in adults — Monoclonal antibodies can be used to prevent RSV infection in infants. (See "Respiratory syncytial virus infection: Prevention in infants and children".)
However, there is no role for monoclonal antibodies in preventing disease in adults. Appropriate doses are not able to be delivered intramuscularly or subcutaneously using the available formulations.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Immunizations in adults" and "Society guideline links: Infections in solid organ transplant recipients".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics (see "Patient education: RSV in adults – Discharge instructions (The Basics)" and "Patient education: Cough, runny nose, and the common cold (The Basics)")
●Beyond the Basics topics (see "Patient education: The common cold in adults (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●Epidemiology in adults – Respiratory syncytial virus (RSV) is an important respiratory pathogen that is recognized as a significant cause of morbidity and mortality in children and is increasingly recognized as a common cause of respiratory illness in adults.
The incidence of RSV-associated hospitalization among adults increases with age, with the highest rates among those aged ≥75 years. Rates are also higher in patients with comorbid conditions, such as lung or heart disease (table 1). (See 'Epidemiology in adults' above.)
●Clinical presentation
•Presenting features – Most symptomatic adults develop upper respiratory tract infection (URTI) signs such as nasal congestion and rhinorrhea and sore throat three to five days after infection. (See 'Presenting features' above.)
•Clinical course – In many cases, the virus progresses to involve the lower respiratory tract, and symptoms such as cough, wheezing, and dyspnea can develop. Some patients may develop severe disease (eg, pneumonia and respiratory failure). (See 'Clinical course' above.)
•Prognosis – Among all adults, RSV-attributed mortality is generally estimated to be less than 1 percent; however, among hospitalized patients, mortality associated with RSV appears to be greater than influenza.
Mortality in severely immunocompromised patients can be much higher. Among adult hematopoietic cell transplant (HCT) recipients with RSV infection, progression to lower respiratory tract infection is associated with mortality rates up to 80 percent. (See 'Prognosis' above.)
●Diagnosis – RSV should be suspected in adults with upper respiratory tract symptoms and hospitalized patients with acute lower respiratory tract disease. (See 'Clinical suspicion' above.)
•Immunocompetent adults – For immunocompetent adults, testing for RSV should be pursued if identification of RSV will impact clinical management. As an example, identifying RSV does not lead to specific RSV treatment, but its presence can rule out infection due to other pathogens that may benefit from treatment (eg, influenza, COVID-19). (See 'When to test' above.)
•Immunocompromised patients – For immunocompromised patients, particularly HCT and lung transplant recipients, testing for RSV should be performed in those with fever or respiratory symptoms. In such patients, there may be a role for antiviral therapy. (See 'When to test' above and 'Treatment' above.)
If testing is performed, reverse transcription polymerase chain reaction (RT-PCR) is favored over other methods due to superior assay sensitivity, specificity, and time to virus identification. (See 'Types of tests' above.)
●Treatment – For most adults, treatment is supportive. (See 'Most adults' above.)
However, there may be a role for antiviral therapy for those who are severely immunocompromised. Such patients should be managed in consultation with an infectious diseases specialist.
•We suggest treatment for HCT recipients with severe immunocompromise (Grade 2C). As an example, a patient ≥40 years of age with neutropenia and lymphopenia would be at very high risk for RSV-related mortality, and we would initiate therapy (ribavirin and intravenous immune globulin [IVIG]), even if symptoms were mild. (See 'Immunocompromised patients' above.)
•Treatment for lung transplant recipients is presented in a separate topic review. (See "Viral infections following lung transplantation", section on 'Respiratory syncytial virus'.)
●Vaccination – There are two available vaccines for prevention of RSV, an AS01E-adjuvanted RSV prefusion F vaccine (sold as Arexvy) and a non-adjuvanted bivalent RSV prefusion F vaccine (sold as Abrysvo). The choice of vaccine is usually dictated by availability. (See 'Available formulations' above and 'Choice of vaccine' above.)
•Indications – For adults ≥60 years of age and with comorbidities that put them at increased risk for severe disease (table 1), we suggest vaccination (Grade 2B). Vaccination reduces the incidence of symptomatic infection and can prevent hospitalizations. (See 'Indications' above and 'Efficacy and safety data' above.)
We also offer RSV vaccine to those ≥60 years of age without comorbidities that put them at risk for severe disease. We explain that they would likely benefit from vaccination given their age, but their baseline risk of developing severe disease and requiring hospitalization is lower.
Indications for vaccination during pregnancy are presented separately. (See "Immunizations during pregnancy", section on 'Respiratory syncytial virus'.)
•Dose and administration – RSV vaccines are administered as a one-time single dose. Available data suggest that boosting annually may not be required, although the ultimate dosing interval is still under investigation. (See 'Dosing and administration' above.)
•Adverse events – In general, RSV vaccines are well tolerated. Most adverse reactions include self-limited discomfort at the injection site, headache, fatigue, and myalgias. Rare adverse events (eg, Guillain-Barré syndrome) have been observed in clinical trials, but the association with the RSV vaccine has not been clearly established. (See 'Efficacy and safety data' above.)
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