M&D Clinical Corner: Community Pharmacist’s Guide to RSV

The Clinical Corner is a monthly feature that highlights a variety of important pharmacist topics that is written by Morris & Dickson’s staff pharmacist, Paula Belle (RPh).

This month’s Clinical Corner will discuss Respiratory Syncytial Virus (RSV):

• RSV General Information
• The Role of The Pharmacist
• RSV in Infants
• RSV in Adults
• Resources for Pharmacists

GENERAL INFORMATION

• Respiratory Syncytial Virus (RSV) is a common respiratory virus that causes cold-like symptoms in children and adults. [1]
• Most people recover in a week or two, but RSV can be serious. [2]
• Severe RSV can be unpredictable and is the leading cause of hospitalization in infants.[1]
• Adults 65 and over and adults with chronic conditions or weakened immune systems are at high risk for developing severe RSV. [1]
• People do not form long-lasting immunity to RSV and can become infected repeatedly over their lifetime. [1]
• RSV causes annual outbreaks of respiratory illnesses in all age groups. [3]
• In most regions of the United States, RSV season starts in the fall and peaks in the winter, but the timing and severity of RSV season in a given community can vary from year to year. [3]
• RSV can spread when [4] :
  • An infected person coughs or sneezes
  • A person gets virus droplets from a cough or sneeze in their eyes, nose, or mouth
  • A person has direct contact with the virus, like kissing the face of a child with RSV
  • A person touches a surface that has the virus on it, like a doorknob, and then touches their face before washing their hands
• People infected with RSV are usually contagious for 3 to 8 days and may become contagious a day or two before they start showing signs of illness. [4]
• However, some infants, and people with weakened immune systems, can continue to spread the virus even after they stop showing symptoms, for as long as 4 weeks. [4]
• Children are often exposed to and infected with RSV outside the home, such as in school or childcare centers. They can then transmit the virus to other members of the family. [4]
• Vaccines are available to protect older adults from severe RSV. [2]
• Monoclonal antibody products are available to protect infants and young children from severe RSV. [2]

THE ROLE OF THE PHARMACIST

• Pharmacists are in a prime position to help care for patients affected by RSV and to educate such patients and their families. [5]
• Pharmacists can play an integral role in the fight against RSV by educating patients on using best practices for prevention, recognizing early symptoms, and helping patients decide when to call their healthcare provider. [6]
• Through the relationship pharmacists build with their patients, they have the opportunity to identify and tailor education needs dependent upon each person’s situation. [6]
• While some most commonly think of high-risk infants as the target population for RSV management, it is important to remember that many pharmacy patients have certain chronic conditions, are adults over 65 with heart or lung disease or weakened immune systems, and are also at increased risk for complications. [6]
• Even if a particular patient does not fall into these categories, the pharmacist can identify through conversation whether someone may be a caregiver to an older high-risk relative or grandparent to a new infant and can benefit from additional education on disease prevention. [6]
• Pharmacists can also assist in the selection of appropriate products for symptom control. [5]

RSV IN INFANTS

• RSV is the most common cause of hospitalization in infants. [3]
• It most commonly causes a cold-like illness but can also cause lower respiratory infections like bronchiolitis and pneumonia. [3]
• Most otherwise healthy infants and young children who are infected with RSV do not need hospitalization. [3]
• Two to three percent of infants with RSV infection may need to be hospitalized. [3]

RSV SYMPTOMS IN INFANTS

• Infants and young children with RSV infection may have rhinorrhea and a decrease in appetite before any other symptoms appear. [3]
• Cough usually develops 1 to 3 days later. [3]
• Soon after the cough develops, sneezing, fever, and wheezing may occur. [3]
• Symptoms in very young infants can include irritability, decreased activity, and/or apnea.[3]
  Severe disease most commonly occurs in very young infants. Additionally, children with any of the following underlying conditions are considered at increased risk [3]:
• Premature infants
  • Infants, especially those 6 months and younger
  • Children younger than 2 years old with chronic lung disease or congenital heart disease
  • Children with suppressed or weakened immune systems
  • Children who have neuromuscular disorders or a congenital anomaly, including those who have difficulty swallowing or clearing mucus secretions
  • Children with severe cystic fibrosis

RSV TREATMENT IN INFANTS

• Those who are hospitalized may require oxygen, rehydration, and/or mechanical ventilation. Most improve with supportive care and are discharged in a few days. [3]

RSV PREVENTION IN INFANTS

• RSV VACCINE
  • ABRYSVO™
    • Pfizer Inc. announced on August 21,2023 that the U.S. Food and Drug Administration (FDA) has approved ABRYSVO™ for the prevention of lower respiratory tract disease (LRTD) and severe LRTD caused by RSV in infants from birth up to six months of age by active immunization of pregnant individuals at 32 through 36 weeks gestational age. [7]
    • The approval of ABRYSVO™ marks the first and only maternal immunization to help protect newborns immediately at birth through six months from RSV. [7]
    • Before Pfizer’s shot can be distributed to the public, an advisory committee to the Centers for Disease Control and Prevention must still recommend who should receive it. [8]
    • After that, it’s up to CDC Director Dr. Mandy Cohen to officially recommend the vaccine.[8]
    • Pfizer said that the CDC advisory committee will most likely meet by early October and that the company plans to make the vaccine publicly available shortly after it is officially recommended. [8]
• MONOCLONAL ANTIBODIES
  • BEYFORTUS™
    • Beyfortus™ (Nirsevimab) is a monoclonal antibody product designed to protect infants and young children at increased risk from severe RSV disease. [3]
    • It is administered by intramuscular injection. [3]
    • It is long-acting, providing protection for at least 5 months (the average length of one season). [3]
    • Only one dose is recommended for an RSV season. However, immune protection will wane over time. [3]
    • All infants younger than 8 months who are born during – or entering – their first RSV season should receive one dose of nirsevimab.[3]
    • For some children between the ages of 8 and 19 months who are at increased risk of severe RSV disease, a dose is recommended at the start of their second RSV season. [3]
  • SYNAGIS™
    • Synagis™ (Palivizumab) is a monoclonal antibody product recommended by the American Academy of Pediatrics (AAP) for administration to infants and young children who are at increased risk of severe RSV disease based on gestational age and certain underlying medical conditions. [3]
    • It is given in monthly intramuscular injections during RSV season. [3]

RSV IN ADULTS

RSV SYMPTOMS IN ADULTS

• Adults who get infected with RSV usually have mild or no symptoms. [3]
• Symptoms are usually consistent with an upper respiratory tract infection which can include rhinorrhea, pharyngitis, cough, headache, fatigue, and fever. [3]
• Disease usually lasts less than 5 days. [3]
• Some adults, however, may have more severe symptoms consistent with a lower respiratory tract infection, such as pneumonia. [3]

RSV TREATMENT IN ADULTS

• There is no specific treatment for RSV infection, so fluids and rest are the best advice for mild symptoms. [9]
• Patients with COPD or asthma, should be sure to maintain use of prescribed medications to reduce breathing difficulties and should speak with their healthcare provider to discuss medications that might need to be adjusted. [9]
• Signs that indicate severe respiratory illness that requires prompt emergency care can include shortness of breath, a fever, bluish tint to skin, wheezing, worsening cough. [9]
• When admitted to the hospital, patients will likely be put on IV fluids if dehydrated. [9]
• Patients may be put on supplemental oxygen to improve oxygen saturation. [9]
• Antibiotics may be given if a secondary infection develops such as bacterial pneumonia. [9]

RSV PREVENTION IN ADULTS

• New vaccines against RSV are available for adults 60 and older. [3]
• RSV vaccine is recommended as a single dose. Studies are ongoing to determine whether (and if so, when) revaccination may be needed. [3]
• CDC recommends that adults 60 and older may receive an RSV vaccine, using shared clinical decision-making. The decision to vaccinate an individual patient should be based on a discussion between the healthcare provider and the patient. It may be informed by the patient’s risk of severe RSV disease and their characteristics, values, and preferences; the healthcare provider’s clinical discretion; and the characteristics of the vaccine. [3]
• Healthcare providers should be aware of underlying conditions that may increase the risk of severe RSV illness, and who might be most likely to benefit from these new vaccines. [3]
• Epidemiologic evidence indicates that people 60 and older who are at highest risk of severe RSV disease include those with any of the following chronic conditions [3]:
  • Lung disease (such as chronic obstructive pulmonary disease [COPD] and asthma)
  • Chronic cardiovascular diseases (such as congestive heart failure and coronary artery disease)
  • Diabetes mellitus
  • Neurologic conditions
  • Kidney disorders
  • Liver disorders
  • Hematologic disorders
  • Immune compromised
  • Other underlying conditions that a health care provider determines might increase the risk for severe respiratory disease
• Other underlying factors that the provider determines might increase the risk of severe RSV-associated respiratory illness may include the following [3]:
  • Frailty
  • Advanced age
  • Residence in a nursing home or other long-term care facility
  • Other underlying factors that a health care provider determines might increase the risk for severe respiratory disease
• RSV can sometimes also lead to exacerbation of serious conditions such as [3]:
  • Asthma
  • Chronic obstructive pulmonary disease (COPD)
  • Congestive heart failure

RSV RESOURCES FOR PHARMACISTS

• A fact sheet handout for parents is available at: https://www.cdc.gov/rsv/downloads/RSV-in-Infants-and-Young-Children.pdf
• Resources to track RSV seasonality in all geographic regions can be found at: https://www.cdc.gov/surveillance/nrevss/rsv/
• A downloadable handout, “Understanding RSV,” is available at: https://www.lung.org/getmedia/b6a827ed-7370-4846-9d99-14e9db321651/RSV-One-Pager-v4.pdf?ext=.pdf
• A handout discussing RSV hospitalization in infants is downloadable at: https://www.lung.org/getmedia/e1c9f01b-748c-4593-a691-fde10aa6491b/ALA-RSV-Family-Guide-V4.pdf
• A video (3:20) to assist with recognizing RSV in children is available at: https://www.youtube.com/embed/8-oadlhcp_0

SOURCES

1. American Lung Association. Learn About Respiratory Syncytial Virus (RSV). 2023 [cited 2023 August]; Available from: https://www.lung.org/lung-health-diseases/lung-disease-lookup/rsv/learn-about-rsv.
2. Centers for Disease Control and Prevention. RSV (Respiratory Syncytial Virus) | CDC. 2023 2023-08-09T12:30:45Z [cited 2023 August]; Available from: https://www.cdc.gov/rsv/index.html.
3. Centers for Disease Control and Prevention. For Healthcare Professionals: RSV (Respiratory Syncytial Virus) | CDC. 2023 2023-08-04T09:34:16Z [cited 2023 August]; Available from: https://www.cdc.gov/rsv/clinical/index.html.
4. Centers for Disease Control and Prevention. Transmission of RSV (Respiratory Syncytial Virus) | CDC. 2023 2023-04-27T05:56:47Z; Available from: https://www.cdc.gov/rsv/about/transmission.html.
5. Marie Katie Bozman , P.C.C.E., PharmD Assistant Professor of Pharmacy Practice Jennifer Andres, PharmD , BCPS Assistant Professor of Pharmacy Practice Philadelphia College of Osteopathic Medicine School of Pharmacy Suwanee, Georgia, Respiratory Syncytial Virus: Diagnosis, Prevention, and Management of Complications. 2023.
6. PharmaNewsIntelligence. RSV, How Pharmacists Can Help Patients Prevent and Manage Infections. 2023 2023-01-18 [cited 2023; Available from: https://pharmanewsintel.com/features/rsv-how-pharmacists-can-help-patients-prevent-and-manage-infections.
7. Pfizer Inc. U.S. FDA Approves ABRYSVO™, Pfizer’s Vaccine for the Prevention of Respiratory Syncytial Virus (RSV) in Infants Through Active Immunization of Pregnant Individuals 32-36 Weeks of Gestational Age. 2023; Available from: https://www.pfizer.com/news/press-release/press-release-detail/us-fda-approves-abrysvotm-pfizers-vaccine-prevention-0.
8. Aria Bendix. FDA approves first RSV vaccine for pregnant mothers to protect babies. 2023 [cited 2023 August]; Available from: https://www.nbcnews.com/health/health-news/fda-approves-rsv-vaccine-pregnant-mothers-protect-babies-rcna100946.
9. American Lung Association. RSV in Adults. 2023; Available from: https://www.lung.org/lung-health-diseases/lung-disease-lookup/rsv/rsv-in-adults.