What Can Be Done for Severe RSV Cases in Adults?

Though there are now respiratory syncytial virus (RSV) vaccines approved by the FDA and recommended by the CDC for certain high-risk adults, what happens when someone ends up with severe illness from the virus?

“It really is just supportive care,” Angela Branche, MD, of the University of Rochester Medical Center in New York, told MedPage Today, adding that this is “why the focus is largely in prevention.”

Currently, the CDC recommends a single dose of any FDA-approved RSV vaccine for all adults ages 75 years and older, as well as for 60- to 74-year-olds who are at increased risk of severe illness.

However, the FDA approval is for all adults ages 60 and older for all three RSV vaccines — GSK’s Arexvy, Pfizer’s Abrysvo, and Moderna’s mRESVIA. And some of the vaccines recently picked up expanded indications for use in younger populations at higher risk from RSV.

In June, Arexvy won expanded approval for use in at-risk adults ages 50 to 59; and in October, Abrysvo was granted expanded approval for use in at-risk adults ages 18 to 59.

Clinicians can certainly administer these vaccines in these broader age groups, taking into consideration individuals’ health risks, experts told MedPage Today.

When high-risk people do become infected, no medical treatments are a home run to help them recover, said Albert Shaw, MD, PhD, of Yale School of Medicine in New Haven, Connecticut.

For adults who are at highest risk, like people with lung or bone marrow transplants or those with leukemia, antiviral agents like ribavirin are sometimes used, although the benefits are not entirely clear and come with associated toxicity, said Shaw, who is a voting member of the CDC’s Advisory Committee on Immunization Practices (ACIP), but was not speaking on behalf of the committee.

Intravenous immunoglobulin has been tried based on clinical experience in some centers but cannot be recommended for generalized use, Shaw noted. However, patients for whom such potential therapies are tried are those with substantial mortality associated with RSV infection.

Branche said that for internal medicine colleagues, it is important to “manage the expectations of their patients.”

When individuals in high-risk groups do contract RSV, “there is a good chance” of issues like heart failure exacerbations, myocardial infarction, atrial fibrillation, or arrhythmia. “RSV and COPD do not go well together,” Branche said.

Physicians should explain to high-risk patients that if they become infected, they need to be mindful and careful about how they are feeling and keep their doctor up-to-date, Branche added. She also urged a low bar for visiting the emergency department if needed.

Recent research has indicated that although RSV was less common than COVID-19 and influenza as a cause of hospitalization, hospitalized RSV patients were more likely to need oxygen, be admitted to the intensive care unit (ICU), need mechanical ventilation, or even die, Branche noted.

In the findings of a cohort study published earlier this year, “among adults hospitalized in the U.S. during the 16 months preceding recommendations for the first adult RSV vaccines [February 2022-May 2023], RSV disease severity was similar to severity of COVID-19 and influenza disease among unvaccinated patients and substantially higher than COVID-19 and influenza disease among vaccinated patients,” wrote Diya Surie, MD, of the CDC, and colleagues in JAMA Network Open. “Severity of RSV disease among adults may be important to consider as RSV vaccine policy evolves.”

As MedPage Today reported based on a CDC study published in Morbidity and Mortality Weekly Report, the likelihood of requiring invasive mechanical ventilation or dying with RSV was double that of the flu (adjusted OR 2.08, 95% CI 1.33-3.26) and similar to COVID (aOR 1.39, 95% CI 0.98-1.96). RSV patients were also more likely to be admitted to an ICU than either those with COVID (aOR 1.49, 95% CI 1.13-1.97) or the flu (aOR 1.55, 95% CI 1.11-2.19).

“One thing that often gets missed is that RSV is associated with a lot of exacerbations of underlying health problems,” Branche said.

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