This report examines RSV across five themes: trends in prevalence, the wider implications of infection, the strain on hospitals and PICUs each winter, the timing and range of prevention, and how to communicate the burden and, with new prevention tools such as long-acting antibodies and maternal vaccination on the horizon, pairs each observation with the challenge it raises and sets out concrete strategies for clinicians, planners and policymakers.
Draft Report
Observations · Challenges · Strategies
6th LifeCourse Immunisation Summit, 2021–2022
Excellence in Pediatrics Institute × Vaccines Together
Topic 01
There are an estimated 33 million new infections worldwide each year, 10% of them severe enough for hospital admission. RSV is a significant problem globally and a considerable concern in the paediatric world, with 95% of children infected before the age of five.
Surveillance for RSV infections is lacking in many developed countries and, above all, in the developing world, making it extremely difficult to know the exact burden. Very little has been done to trace the other infections and complications triggered by RSV, which increase the overall disease burden.
There is a significant increase in RSV admissions in developing countries, with very high mortality. Mortality and morbidity are higher in low- and middle-income countries.
On infection prevalence and mortality in the developing world we are in uncharted waters, and better surveillance is needed to establish the scale of the burden — given that access to hospitals and healthcare systems in many countries is limited, with infections not always reaching hospitals.
RSV infections and admissions with bronchiolitis show a strong seasonality, with a spike concentrated every year during winter, in the period from the beginning of November to mid-December. Seasonality can, however, vary from country to country.
There is a need to identify the mix of infections and conditions that stress healthcare systems to their limit, taking their seasonality into account. A more targeted approach would let us prepare ahead, develop cleverer strategies and relieve health systems when they are most needed.
While RSV is the most common single cause of respiratory hospitalisation in infants, it is the second-largest cause of lower respiratory infections and mortality worldwide. Although often characterised as a paediatric disease, the burden of RSV in adults is also significant, with a mortality rate of 7 to 8% across all adults.
With most adult vaccine-preventable diseases not being a priority for most healthcare planners, RSV infections in adults are largely unchecked and uncontrolled. In moving towards a more meaningful life-course approach, RSV should be included in the equation, and more studies are needed to provide evidence of the disease burden.
The COVID pandemic, social distancing and other restrictions affected the prevalence of RSV. Infections vary from year to year: we saw a massive spike in 2019, while infections decreased significantly in 2020–2021. Social mixing patterns and how much social contact drives the epidemiology are a critical point. It remains to be seen what will happen now that restrictions are gradually lifting, and the first indications show infections rising again.
Close monitoring of RSV infections after the removal of COVID restrictions is needed to see whether they return to the pre-COVID pattern and whether RSV epidemiology and seasonality have changed. It is also essential to see whether RSV will follow the same trend as other seasonal infections such as influenza, allowing us to develop cross-infection seasonal prevention strategies.
We need more studies to get a complete picture of the RSV burden in the under-fives. We know what happens during the first year, but RSV should not be studied as a single agent, since its role in triggering bacterial and other infections could be significant across all age groups up to five. It is therefore essential to have the data that will let us design the most efficient immunisation policy.
The cost-versus-benefit factor is critical, especially now, when all healthcare systems' budgets are strained and exhausted by COVID. On the other hand, with health-system preparedness better understood and the possibility of COVID becoming a seasonal infection, there is ground to discuss a more holistic approach to preventing RSV if the evidence supports it.
RSV has a high prevalence but a very uneven distribution. All children will have at least one infection in their lives, but this affects children from low-, middle- and high-income and developing countries differently. In developing countries, deaths outside hospital account for approximately more than 50% of the burden — a hidden burden of the virus.
It is challenging to establish the burden and mortality of RSV outside hospitals, especially in the developing world where access to healthcare systems is limited. It is critical to engage primary healthcare physicians and community pharmacists to help trace and report infections outside hospitals, in order to better understand the size of the problem.
Engaging not only hospital facilities but also primary care and community settings. We need to establish the burden of RSV not only on secondary facilities but also across the broader socioeconomic effects associated with the disease.
They are the only ones who can contribute to improving surveillance in the developing world. An education campaign is needed, with materials in various languages, to increase their awareness and commitment.
Healthcare professionals must advocate for a LifeCourse immunisation strategy covering all ages against all vaccine-preventable diseases. We must work with civil and patient advocacy groups so the message is clear: it is no longer acceptable for otherwise preventable diseases to remain uncontrolled.
We need better planning and prevention strategies for seasonal infections to protect our facilities and resources, and to ensure the quality of healthcare services is not compromised during the winter peaks.
Better surveillance is needed to establish the epidemiology of RSV relative to other seasonal infectious diseases. We must use our findings to design and implement effective prevention strategies for the expected seasonal peaks of RSV.
We must design and implement new seasonal infection strategies that allow us to better manage peaks in admissions and visits, without stretching systems beyond their limits or increasing costs by expanding capacity for the whole year — focusing instead only on the busy periods.
We can train primary-care community healthcare professionals in the developing world to manage infections better, volunteer to report them, and help establish the actual burden of the disease in countries with limited or no central surveillance systems.
Topic 02
Data from the UK has shown that infections and hospital admission rates for bronchiolitis are increasing — and we know that 75% of all bronchiolitis is due to RSV.
We must increase awareness among healthcare professionals and decision-makers so that the prevalence and size of the burden are understood, and prevention becomes a priority.
Preterm infants and children with severe respiratory disease, congenital heart disease, cancer, cystic fibrosis, immunodeficiency and Down syndrome are at increased risk of severe RSV infection. Morbidity and mortality in children with RSV are strongly related to existing comorbidities — but a significant proportion of children admitted to hospital and intensive care have no recognised risk factor.
We must strongly advocate that a holistic approach is needed for RSV prevention, demonstrating that not only preterm infants or infants with serious conditions are at risk, but all infants, even well-grown and healthy ones. A risk-group-based policy will not be sufficient and would leave many infants in danger, unprotected.
RSV is not just a problem for the preterm infant. Even though prematurity is a significant risk factor, the commonality of admissions comes from normal, well-formed, well-grown children — the majority from the full-term group.
It will be challenging to change the long-held perception among providers, planners and decision-makers that RSV is a problem related only to the preterm infant. With more prevention solutions becoming available in the coming months and years, education must begin now to increase understanding and awareness among all stakeholders.
In many cases, RSV bronchiolitis can trigger wheezing and asthma. Further studies are needed to demonstrate that preventing the infection would probably also prevent recurrent wheezing and asthma. There is also a significant risk of bacterial infection in babies with RSV, with RSV appearing to act as a precursor to invasive bacterial disease.
We suspect that the implications of RSV beyond the infection itself are profound and significantly increase the overall burden. Even so, it will be challenging to make decisions, persuade planners and prioritise budget while we lack the evidence to demonstrate the benefit beyond doubt.
With prevention solutions being made available in the coming months, we must launch a campaign to increase awareness and change the narrative that RSV infections are not preventable and that there is nothing we can do.
An educational campaign is needed for frontline paediatricians to understand the epidemiology of the disease across the various age groups, and the complications often associated with these infections, helping them see the scale of the problem.
Changing perceptions and established practice is challenging, and broad training will be required for healthcare professionals to understand the full extent of a previously under-recognised and under-reported problem, for which they had very few prevention tools available.
Cross-specialty collaboration is needed to understand the broader consequences of RSV and establish the actual extent of the burden. Prevention should not be an issue only for infectious-disease specialists, but should include many others, among them those responsible for managing and planning healthcare facilities.
Topic 03
The number of hospitalisations is increasing each year, probably for multifactorial reasons: increased RSV prevalence, more children with underlying conditions, more at-risk children and more preterm infants could all be contributing to the rise in admissions.
If the trend of increased RSV hospitalisations continues in the years to come, it will add further stress to already stressed systems. We must change the way we plan our capacity, take action and prepare early, given the clear trends in disease prevalence.
The seasonality of RSV is a decisive factor for health-system performance. With RSV peaking in winter, when health systems are already operating at maximum capacity, it exhausts facilities and staff's ability to deliver quality care.
We now know that better planning and preventive strategies are needed so that hospitals and resources are not exhausted and remain ready to address other threats we cannot predict. The challenge is not to forget the lessons learnt once the imminent danger from COVID has passed.
Winter admissions of infants with RSV bronchiolitis are often complex and co-exist with other viruses, including rhinovirus, adenovirus, metapneumovirus and flu (though flu is rare). These patients often require longer hospitalisations and increased attention to their care.
Eliminating hospitalisations that can be prevented by other means — vaccination being one of the main tools — must now become a top priority. We now know that new infection pandemics will be a constant threat in the years to come, while we have realised there are limits to expanding capacity and resources to address existing and new threats.
RSV is a significant cost burden to parents and health systems even before, or without, hospital admission. Parents of an infant with RSV can consume a great deal of healthcare resource on call centres and visits to private practices and primary care, often going back and forth many times before ending up at hospital.
The cost burden of RSV to healthcare systems, excluding hospitals, is challenging to estimate and measure. For a benefit-cost analysis of prevention strategies to be accurate, RSV costs at all three levels of the healthcare system — primary care, hospitals and PICUs — must be considered.
RSV is a significant cost burden for hospitals and PICUs. The average length of stay for an infant with bronchiolitis is five to seven days; if admitted to the PICU, the stay extends to one month, resulting in extremely high costs for the healthcare systems.
ICU beds and staff capacity have been the most crucial element during the COVID pandemic. Avoiding unnecessary ICU admissions is therefore extremely important, given the related cost and the limited availability, and this must be taken into consideration when evaluating prevention strategies.
Beyond the burden of RSV on health systems and hospitals, families carry a significant social and economic burden. Parents lose time from work and children lose time from school.
With the RSV burden extending far beyond hospitals and stressing families, we must ensure it is understood that RSV is a multidimensional problem with a serious social and economic toll on both hospital budgets and societies. It is essential to persuade planners to incorporate all these factors when deciding on a prevention strategy.
Healthcare personnel across all care settings report extended working hours and significantly increased stress, exhaustion and burnout during the RSV season. In previous seasons, the large majority of ward-bed occupancy was due to respiratory patients, and more than half of these cases were due to RSV.
Seasonality is not taken seriously into consideration when planning capacity and resources. Since increasing capacity for a specific season is difficult, if not impossible, we must use other tools to reduce demand so that our systems are not stressed and the quality of care remains intact.
We need to change the narrative on how we plan our capacity, use the available prevention tools and prepare for the challenges ahead. Healthcare professionals must sound the alarm to decision-makers so that preparing healthcare systems becomes a priority.
Healthcare professionals must actively engage in the planning of healthcare facilities, ensuring that the epidemiology and management requirements of infections and other conditions are factored in as the most crucial element when designing capacity and resource needs.
Primary care physicians must step in and make their voices heard, helping decision-makers understand the burden of RSV on hospitals, primary care facilities and private practices, especially during the seasonal peaks.
Healthcare professionals must advocate for more efficient prevention strategies to improve their facility's performance during the seasonal infection period, protecting their resources and ensuring better quality of services in periods of constraint and high demand.
Hospital and ICU physicians must advocate the importance of prevention strategies in reducing unnecessary hospitalisations. Expanding capacity in infrastructure and human resources is financially unsustainable and extremely difficult, especially when it comes to finding sufficiently trained personnel.
It is time to establish all the hidden social and economic costs related to RSV, ensuring they are seriously factored into decisions when planning prevention strategies. Primary care physicians and national medical associations need to help establish the real burden.
Healthcare workers must advocate for changes to planning and prevention strategies to minimise the delivery of services under pressure and with limited resources, which affects the quality of care they provide and proves dangerous when set against the experience of the recent pandemic.
Topic 04
There is a high burden of disease and a real need to invest in prevention. The prevention tools available today are used only on very select children; some studies advocate the inclusion of all children, given the burden RSV places on health systems.
With the focus now on investing in capacity and resources to overcome the recent pandemic, decision-makers often treat prevention as a luxury for better times. The COVID experience has, however, highlighted the importance of vaccination in maintaining capacity and protecting resources.
The consensus is that the focus should be placed on infants, especially in the first six months of life, when the severe risk associated with respiratory disease is high. But we must also consider that children under five are the group predominantly responsible for transmission, suggesting that vaccinating this age group would likely produce a considerable reduction in disease among unvaccinated age groups.
Even though vaccination under six months is considered essential by all experts, we must persuade policymakers to think broader and plan wider to reduce infection rates among all children, including the unvaccinated. The challenge here is, again, budgets and cost-effectiveness.
More evidence of protection for early infant RSV prevention through maternal vaccination — and of the benefits of maternal immunisation versus direct protection of the infant — is needed to help define the best immunisation strategies to follow.
Vaccination during pregnancy is lagging behind even for already-approved and recommended vaccines. Pregnancy is a very sensitive period, and women are reluctant to be vaccinated, as the recent pandemic and COVID vaccinations have shown.
Careful consideration is needed to decide the optimum intervention on the basis of cost-effectiveness. There is no doubt that infections are higher, and the most severe cases appear, in the 0–6 month age group; we must then examine what to do with the next group, 6–12 months, and whether the epidemiological data support a decision from a cost-benefit point of view.
In periods of budget constraint, especially now after COVID, cost-effectiveness will be one of the main elements decision-makers consider. It is possible that the contribution to systems, resource availability and capacity will not be incorporated into the equation and will be ignored.
Healthcare professionals should help policymakers understand that the importance of prevention exceeds COVID and is essential for all infections causing unnecessary hospitalisations, since all of them significantly contribute to the exhaustion of available resources.
We must advocate a more holistic approach to preventing and managing seasonal infections, guarding against the challenge of acquiring hospital capacity and experienced personnel. With resources needed for emerging new infections, eliminating existing infections through prevention must become a priority.
Healthcare professional organisations must reach out to policymakers, pointing out that expanding resources has limits and that finding trained, experienced personnel will become increasingly difficult, as proven during the pandemic. It is therefore not only cost-benefit that should define decisions, but also the realities of the real world.
Vaccination during pregnancy could become a choice only when we have more evidence of its benefits. More studies are needed before healthcare professionals decide to advise RSV prevention during pregnancy.
Topic 05
RSV is one of the most critical paediatric infectious diseases and a significant global burden for healthcare systems, with serious social and economic costs to families. We need to work together to make parents, care providers and policymakers aware of the prevention tools available and of the disease burden.
Awareness of RSV is low among policymakers, healthcare professionals and families. With everyone tired from the recent pandemic, it will be challenging to speak — and be heard — about the risks of already-existing infections that have until now been considered common.
Bronchiolitis is under-represented to policymakers and health-service planners. There does not seem to be a clear understanding of the burden or of the considerable pressure the infection places on already-stressed health systems during winter. Primary, secondary and tertiary care can be completely overwhelmed by the massive surge of bronchiolitis cases.
Policy planners have little understanding of the overall seasonal strains on healthcare systems. Planning for capacity and resources does not account for the winter infection peaks, and current prevention strategies are fragmented and incomplete. With COVID probably becoming a more seasonal infection, still more constraints will be added to the systems.
There is an interesting comparison with meningococcal disease. Everyone is aware that meningococcal disease can be terrifying. Because RSV will infect most children at some stage without further implications, everyone misses the point that the disease will be critical for a significant percentage of infected children — almost as meningococcal disease is.
As proven by COVID, the perception that an infection is mild and easy for a child to overcome changes the risk assessment parents make when weighing the risk of vaccination using a new technology perceived as insufficiently tested. We will face the same challenges as with COVID when introducing RSV prevention tools.
When new prevention solutions become available, it will be challenging to communicate the benefits of an antibody rather than a conventional vaccine. We must start building understanding among parents early, and increase knowledge among healthcare providers of the role, mechanism and benefits of antibodies.
The usual reluctance towards new technologies for children's prevention intensified during the pandemic with the introduction of mRNA vaccines for children. Introducing yet another technology, different from vaccines, for children could be challenging.
A campaign is needed to increase awareness among policymakers, healthcare professionals and patients of the real burden of the infection and the possible short- and long-term risks associated with it. RSV must be top of mind ahead of the next winter season.
Educating healthcare professionals to understand the epidemiology and the prevention tools is necessary if they are to advocate prevention in every consultation. New prevention tools for RSV should be aligned with the universal immunisation programme for children.
We must train frontline paediatricians and GPs to understand the technology and become sufficiently equipped to address parents' concerns. In the end, they are the most trusted source of information and advice, and must step in to persuade parents to make the right decisions.
It must be the paediatrician's role and duty to explain to parents the potential risks associated with an infection usually perceived as mild. But we must first ensure that healthcare professionals know in depth the epidemiology and the risks associated with the infection.
