This report sets out the case for protecting all infants and adults rather than high-risk groups alone: it examines the strain on hospitals and ICUs, the link between RSV and antimicrobial resistance, the family transmission cycle that fuels epidemics, and the socioeconomic toll on families, before weighing prevention approaches from maternal immunization to long-acting monoclonal antibodies.
Working Group Report · 2022
Conclusions of the 2022 EiP Annual Conference RSV Working Group Meeting
Excellence in Pediatrics Institute × Vaccines Together
Sir Terence Stephenson (UCL GOS Institute of Child Health, UK) · Susanna Esposito (World Association for Infectious Diseases and Immunological Disorders) · George Syrogiannopoulos (University of Thessaly) · Anne Teirlinck (RIVM – Centre for Infectious Disease Control, Netherlands) · Francois Angoulvant (Centre Hospitalier Universitaire Vaudois, Switzerland) · Lies Kriek (ReSViNET Foundation, RSV Patient Network, Patient Advisory Board) · Brenda Wyninga (RSV Patient Network – Patient Advisory Board) · George Valiotis (European Health Management Association, EHMA) · Jonne Terstappen (Wilhelmina Children's Hospital, Utrecht, Netherlands) · Daniel Bausch (Global Health Security, FIND Switzerland – London School of Hygiene & Tropical Medicine, United Kingdom) · Elizabeth Adams (European Federation of Nurses Associations) · Mihai Craiu (Carol Davila University of Medicine, Romania) · Simon Nadel (Imperial College Healthcare NHS Trust) · Catherine Weil-Olivier (Paris VII University) · Timo Vesikari (Nordic Research Network) · Roy Philip (University Maternity Hospital Limerick GEMS, Ireland) · Jane Barratt (International Federation on Ageing – IFA) · Alison Maassen (EuroHealthNet)
Respiratory Syncytial Virus (RSV) infections are a major global health priority and are increasingly seen as a major health burden on over-stretched healthcare systems across Europe. Most hospitalisations happen in otherwise healthy infants, highlighting the need to protect all infants against RSV. However, the elderly (65+) can also present a high-risk infection, especially with underlying diseases, as RSV can cause respiratory exacerbations.
RSV is the primary cause of lower respiratory tract infections and illnesses in infants and young children that may lead to hospitalisations and a substantial number of outpatient visits, resulting in a huge economic and healthcare burden. The impact on healthcare systems — including hospitals, ICUs, primary care settings and healthcare workers — is massive, as documented by the EHMA in its 2022 survey on the Health System Burden of RSV in Europe, especially during the peak winter season of respiratory infections (generally October to April).
With this in mind, developing prevention strategies against RSV for all infants entering their first RSV season constitutes a large unmet medical need. Coupled with this is an unmet need to educate healthcare professionals on the nature of RSV circulation and to increase disease awareness and knowledge among the healthcare communities and patients on RSV in general.
Finally, there is a high medical need for a prevention solution that is easy to administer in current settings and cost-effective compared with the overall disease burden. Prevention is essential to decrease RSV's burden on European healthcare systems.
Healthcare systems are already stretched to their limits during the peak season due to admissions from respiratory infections. Hospitals are overwhelmed with admissions for infants with bronchiolitis, most of which is caused by RSV. Equally, ICUs are overstressed by admissions caused by RSV infection. This is a massive burden for hospitals trying to cope with the flood of admissions within their limited capacity.
Most children with a bronchiolitis-related intensive care admission require prolonged ICU stays, with a mean duration of around seven days in intensive care and, in many cases, another seven days in hospital afterwards. The reality is that overall demand exceeds the capacity of the settings within the hospitals, resulting in patients being transferred to another hospital, usually away from where the family lives.
Staff are severely impacted across care settings, especially when operating at overcapacity with a high number of staff sickness absences on top of the high direct demand for care. RSV has a domino effect across hospitals and health systems that pushes them to their limits. To estimate the overall burden and impact of RSV on the healthcare systems, it is essential to incorporate the outpatient visits before hospital admission and the visits to manage the long-term consequences and the rehabilitation period after admission.
A similar impact on the broader healthcare systems is caused by the admissions of older people with RSV infection, especially considering the long-term consequences of chronic co-morbidities.
Bronchiolitis and RSV infections are the leading reason for healthcare professionals and paediatricians to administer unnecessary antibiotics to young children, contributing significantly to antimicrobial resistance, to the recent antibiotic supply shortages across European countries, and to rising health-system costs. This status quo must be changed through the education of HCPs, demonstrating the importance of effective prevention strategies against RSV infection in the first place.
The seasonality of RSV has been a decisive factor in impacting health-system performance, usually with infection peaks in the winter months, contributing to a significant patient surge to hospitals, ICUs and Emergency Departments when the healthcare systems are already operating at maximum capacity. The seasonality of RSV must also be taken into serious consideration when planning efficient and effective prevention strategies.
The ability to immunise patients before the start of the infection season, within the already existing settings, could significantly contribute to a successful prevention programme. This flexibility will also be of value if the dynamics of RSV infections continue to change, as observed this year.
There is a significant discrepancy between the high prevalence of RSV infections and the lack of awareness and knowledge among parents, elders and healthcare professionals. All groups are insufficiently informed about this infectious disease, its short-term risks and the potential long-term consequences associated with RSV. The same applies to the infection's epidemiology and transmission cycle, especially between family members — children, adults and elders. There is an urgent need to educate and train healthcare providers, including pharmacists and nurses, and to offer parents more information on RSV.
Apart from the disease burden on the healthcare systems, the already stressed capacity of healthcare providers and the health systems' cost, RSV infections are a significant burden to families, one that is often underestimated or ignored. Healthcare professionals often underestimate RSV prevalence and the associated risks, causing confusion, stress and anxiety among parents who are not sufficiently informed or aware of the disease.
The toll on families and the disruption to their social and economic life from a lengthy hospitalisation of a child in a hospital ward or ICU is tremendous. Apart from the stress and uncertainties during the hospitalisation, parents are anxious about the long-term consequences of the infection while being unprepared for the very long rehabilitation period needed after discharge, which could stretch to months or even years.
Herd immunity is essential to combat RSV epidemics. When a child presents with the typical signs and symptoms of an RSV lower respiratory tract infection, there is already a significant spread of RSV among the family members. In most cases, an older sibling or a parent is the most likely source for a young child with an RSV infection. There is a group critical in triggering RSV epidemics: it is considered to be mainly children younger than ten years, and particularly those between the ages of three and six.
The impact of RSV on different age groups remains underestimated. The spread of RSV within the family is pivotal for severe infection in infants, younger children and older adults, especially those with underlying conditions. Paediatricians must become aware of the RSV burden in infants and toddlers, and of the primary and secondary cases within families and the whole community.
Our recent experience with the COVID pandemic has shown that addressing an infection epidemic at national level is insufficient, especially in regions where people often travel between countries, such as Europe. Whatever happens in one country affects the rest of the region. A pan-European coordinated approach is needed to prevent RSV infections across all European countries.
There are significant discrepancies between European healthcare systems, and inconsistencies in surveillance and reporting. With open borders between European countries and frequent travel from one to another, only a Europe-wide consensus on prevention could efficiently reduce RSV across the region.
With most hospitalisations coming from a previously healthy group of children, prevention strategies targeting only high-risk children will not be successful. In addition, the identification of at-risk patients differs from country to country, and sometimes from region to region within the same country. There is therefore a need to protect all children under five years of age and all adults over 65 against RSV, in order to tackle the high burden of the disease.
However, to achieve this, policymakers need concrete evidence and data to prioritise and implement new prevention policies in times of budget constraint and financial challenge.
Potential prevention approaches for infants and young children include maternal immunisation, immunisation of infants with vaccines, immunisation of infants with licensed monoclonal antibodies (mAbs), and immunisation of infants with long-acting mAbs. In particular, the expected new prevention solution using monoclonal antibodies — the most advanced being long-lasting monoclonal antibodies for all infants' protection, with EMA marketing authorisation already granted for one of them — could help address the problem if implemented successfully.
Monoclonal antibodies do not interfere with the scheduled routine vaccinations, making the prevention strategy easier to implement, since frontline paediatricians could administer them during regular visits. They could also be administered before the peak season starts, allowing easy adjustment based on the dynamics of the virus's seasonality. Based on current data, immunisation of infants with long-acting mAbs might represent the most effective approach for protecting all infants entering their first RSV season.
The medical community must demonstrate the current constraints on hospitals, primary care and health workers from RSV infections in children and elders, and the immediate savings that a prevention strategy offers to healthcare-system costs from visits, hospitalisations, ICU admissions, materials and antibiotics.
The medical community must also provide evidence of the long-term consequences of RSV infections and their associated costs to the healthcare systems, so that these are considered in the cost/benefit analysis when evaluating the prevention strategy. While budget constraints often drive short-sighted actions, the long-term consequences of RSV are too important to ignore and cause a significant economic burden to healthcare systems.
Finally, the medical community must work with civil and patient groups to demonstrate the tremendous socioeconomic impact RSV infections have on families — not only from the numerous visits to primary care physicians and the hospitalisation, but also from the rehabilitation period, which could last many weeks or months after the infection.
Recommendations from the RSV Working Group
The Working Group set out three streams of action for healthcare professionals and their associations, each with concrete actions to be taken forward by EiP.
HCPs' engagement is crucial for the successful implementation of a prevention programme. First, we need to establish the level of awareness, the education gaps and any false perceptions relating to the prevalence and risks of RSV.
An online RSV Awareness Survey to EiP's 46,000+ network.
HCPs need to know that they are heard, and need to be involved from the initial stages of implementing the prevention programme. We must hear and share their experiences, ideas, suggestions, educational needs and patient concerns.
An online Suggestion Box for HCPs to submit personal experiences and ideas.
Frontline and primary care HCPs cannot easily access the latest evidence. We must ensure they are kept informed of trends and shifts in the dynamics of RSV epidemics.
Monthly and quarterly newsletters on the latest RSV trends, so HCPs are prepared ahead of the peaks and have RSV in mind.
i) Educate HCPs on monoclonal antibody administration and safety profile. The public's immunisation literacy has improved in recent years, but monoclonal antibodies remain a relatively new term. It is essential that paediatricians have the knowledge to provide correct information on the safety and the benefits of prevention versus the risks associated with an infection.
ii) Paediatricians explaining the potential risk of RSV infections to parents. It must be the paediatrician's role and duty to explain to parents the potential risks associated with a usually perceived-as-mild infection. But we must first ensure that healthcare professionals know the epidemiology and associated risks of the disease in depth.
Plenary and parallel conference sessions at the 15th EiP Conference in Paris in December 2023; free-to-attend online training; and HCP awareness and information campaigns.
Cross-specialty collaboration is needed to understand the broader consequences of RSV infections and establish the actual extent of the burden. Prevention of RSV should not be an issue just for infectious-disease specialists, and should include many other specialists.
Cross-specialty, free-to-view online training programmes.
Paediatricians need to feel more confident in avoiding the use of antibiotics, corticosteroids and bronchodilators when they are not needed. Clear guidelines and recommendations are required from medical associations on the use of antibiotics to manage RSV infection.
An educational programme to train paediatricians on identifying and managing an RSV infection in a hospital or primary care setting.
There is a need to share personal stories and experiences from families with policymakers and HCPs, and to equip paediatricians, family physicians and general practitioners to inform and advise the whole family, including older members, on RSV risks and prevention.
Patient-group-led conference sessions at the 15th EiP, free-to-attend online education, and an HCP-led social media campaign.
There is a need to mobilise physicians to disseminate communication materials to families and through social media, using their accounts to reach colleagues, friends and patients.
Fact sheets, patient/parent checklists, infographics, and short videos (parents' talks) with experts answering the most common questions asked by patients.
i) Present solid evidence on the cost/benefit of the prevention policy. Policymakers operating in times of budget constraint need evidence of the cost avoidance and cost-cutting the new policy will achieve, compared with the cost of implementing it. Experts and medical associations must work with health managers and public health experts to quantify the overall burden of RSV in hospitals, ICUs and primary care settings.
ii) Work with hospital facilities and primary care managers on the RSV infection burden. Health managers and HCPs are best positioned to speak about the RSV burden on their already stressed facilities. For a prevention policy to be adopted, it is crucial to demonstrate immediate benefits to healthcare systems and workers' capacity.
An RSV Working Group at the 8th LifeCourse Immunisation Summit in 2023, with a dedicated implementation section led by EHMA, sharing the outcomes in a position paper and with policymakers.
Making decision-makers fully understand the experiences that paediatricians, neonatologists and adult physicians have from the seasons when admissions from RSV surge is crucial to driving action and change.
Share the outcomes and materials collected with policymakers and hospital managers, to demonstrate the impact at the organisational level and on the individuals working there.
Showcase to policymakers that RSV infections are one of the most important reasons for administering unnecessary antibiotics, both in-patient and out-patient, heavily contributing to the antimicrobial resistance problem and its increased costs.
A round-table discussion at the 15th EiP with experts to examine the issue and provide recommendations on how the use of antibiotics for RSV patients could be minimised.
