The antiviral medication ribavirin can be administered orally or nebulized. It should be avoided in individuals who are pregnant or who have a pregnant partner. Additionally, pregnancy should be prevented for at least six months after taking ribavirin. The nebulized form can cause bronchoconstriction, so it is used very cautiously in patients with COPD and asthma. Some other adverse effects of ribavirin include depression, hemolytic anemia, blurred vision, photosensitivity and pruritus.
All patients taking ribavirin should be monitored for suicidal and homicidal ideation. The American Academy of Pediatrics recommends only using ribavirin in severe cases due to the high risk of toxicity to health care providers. Antibiotics may be used if there is a bacterial infection also present such as bacterial pneumonia or otitis media. Monoclonal antibodies may be used in those who are at high risk as a way to prevent infection.
You may see this referred to as passive immune prophylaxis. Palivizumab is a monoclonal antibody that reduces the ability of the virus to fuse with cell membranes, thereby preventing disease.
General nursing interventions include: Provide oxygen as ordered to maintain adequate oxygen levels. In severe cases, CPAP or mechanical ventilation may be necessary. Humidified oxygen is generally provided to avoid drying out secretions. Maintain a patent airway, suction as needed. Infants should have nasal secretions removed before feeding and sleeping. Older children and adults should have HOB elevated to help maintain airway patency.
Encourage PO fluids and consider administering fluids via IV or NG tube if the patient is unable to consume adequate fluids. Popsicles are a great way to get children to take in fluid, especially if they have a fever. Supplements such as pedialyte may be used to also replace electrolytes. This includes hand hygiene, avoiding touching the face, covering coughs and sneezes, and disinfecting high-use surfaces.
Treatment of RSV in the elderly is largely supportive, whereas early therapy with ribavirin and intravenous gamma globulin is associated with improved survival in immunocompromised persons. An effective RSV vaccine has not yet been developed, and thus prevention of RSV infection is limited to standard infection control practices such as hand washing and the use of gowns and gloves.
In , a novel virus was recovered from a chimpanzee with respiratory symptoms and designated chimpanzee coryza agent In the ensuing decade, the virus was renamed respiratory syncytial virus RSV to reflect the giant syncytia which formed in tissue culture, and epidemiological studies clearly established it as the most important cause of serious respiratory tract infection in infants and young children 19 , , Although RSV infection was reported in adults with pneumonia in the s, it has only been during the last decade that the potential for widespread occurrence with serious clinical impact in this population has been recognized 1 , 42 , 44 , Epidemiological studies suggest that the clinical impact of RSV in certain adult populations may approach that of nonpandemic influenza 52 , Those who appear to be at increased risk for serious disease include adults with underlying cardiopulmonary disease, frail elderly persons living in long-term care facilities or at home, and the severely immunocompromised 34 , 42 , 44 , Despite growing appreciation of this problem, there are significant gaps in our understanding of RSV infection in adults, especially with regard to immunology, diagnosis, treatment, and prevention.
Development of an RSV vaccine for both pediatric and adult immunization offers the best hope to reduce disease burden, although three decades of effort have yet to yield an effective and safe vaccine. This review will discuss the epidemiology, clinical manifestations, immunology, diagnosis, treatment, and prevention of RSV infection in adults. The Paramyxoviridae include two other genera, Morbillivirus measles virus and the Paramyxoviruses mumps and parainfluenza viruses.
The nonsegmented, single-stranded, negative-sense RNA genome is composed of approximately 15, nucleotides and 10 genes which encode 11 proteins 22 , 23 , The virus is composed of a nucleocapsid core of N, P, and L proteins which together is the viral replicase and virion RNA surrounded by a lipid bilayer obtained from the host cell membrane into which are embedded three transmembrane glycoproteins G, F, and SH. Infection is initiated with the G protein binding to a host cell receptor, possibly a heparin-like glycosaminoglycan, followed by F protein-mediated fusion of the viral and cell membranes and penetration of the nucleocapsid complex into the cytoplasm Antibodies directed against the F or G glycoprotein neutralize virus in vitro and in vivo.
Human RSV isolates can be classified into two major groups, A and B, each containing several distinct subgroup 5 , 16 , 86 , 94 , This classification is based upon antigenic and genomic differences found in several viral proteins, but especially the G protein , , Consistent with this, the antibody response to primary RSV infection is characterized by cross reactivity with F proteins from group A or B virus, while the response to the G protein is highly group and even subgroup specific 16 , Furthermore, immunization of animals with F protein from a group A virus provides resistance to group A and B virus challenge, while immunization with G proteins provides protection only from the homologous strain , Group A and B viruses generally circulate simultaneously within geographically confined epidemics, although group A viruses are more prevalent 4 , During a year period in Rochester, New York, group A viruses dominated in 9 years, group B dominated in 2 years, and the distribution was nearly equal in four seasons The dynamics of annual epidemics appear to be local rather than national or global 4.
In nosocomial outbreaks in a nursing home and a bone marrow transplant unit, both group A and B viruses were identified, indicating independent introduction and spread of several distinct viruses 30 , Some studies have found that disease severity in infants is more severe with group A RSV infection than with group B infection, but this relationship has not been evaluated in adults , RSV has important characteristics that can make it difficult to propagate in cell culture.
Although the virus grows in a variety of cell lines, including HEp-2, HeLa, and Vero cells, the typical syncytial cytopathic effect and viral titer vary considerably depending upon the virus strain and the condition of the cells RSV is thermolabile and rapidly loses titer at room temperature 32 , Typical of enveloped viruses, RSV is readily inactivated by detergents.
RSV is shed in high titers from infants hospitalized for lower respiratory tract disease for up to 21 days Shedding during natural RSV infection in adults has been most closely studied in hospital personnel, who are generally young, healthy adults, and averages 3 to 6 days, with a range of 1 to 12 days 82 , In adult challenge studies, volunteers excrete virus for approximately 4 to 5 days range, 1 to 8 days 85 , Shedding of virus in older adults has not been specifically studied but is presumed to be relatively low titer and of short duration, since diagnosis by viral culture is difficult RSV is believed to be spread primarily by large droplets and fomites and can survive on nonporous surfaces, skin, and gloves for many hours 77 , Thus, close person-to-person contact or contact with contaminated environmental surfaces and autoinoculation are required for transmission.
Small-particle aerosols are not considered a major mode of spread, since the virus is not stable when aerosolized Although RSV infection was reported in 18 hospitalized older adults in Sweden as early as , it was not until several nursing home outbreaks were described in the late s and early s that RSV was appreciated as a serious pathogen in the elderly 18 , 55 , 60 , Prospective studies in which all respiratory infections were evaluated and RSV cases were defined as a positive culture or a greater than fourfold rise in antibody probably reflect the most accurate RSV infection rates.
Infection rates in institutionalized persons may also be variable because the outbreaks occur in closed populations and the virus is subject to nosocomial spread. Again, these marked differences in severity may be due in part to case definitions used in outbreak situations, but there may also be differences in strain virulence or the chronic medical conditions of residents.
The true incidence of pneumonia in residents of LTCF may be underestimated because chest radiographs are not routinely obtained. Although rates of documented pneumonia can be variable, lower respiratory signs are common in most studies of RSV 44 , 60 , Elderly persons who attend senior daycare programs also appear to be at increased risk for RSV infection.
One study, which examined viral infections among staff and elderly participants of a daycare program, found RSV to be a common pathogen in both groups This agent was among the most commonly identified viruses, along with influenza A virus and coronaviruses. Of interest, children from a nearby center visited with elderly participants approximately once a week, although transmission of viruses was not evaluated specifically.
Although most of the current information on RSV in institutionalized persons involves elderly persons, there is one report of an RSV outbreak in a residential institution for mentally retarded young adults Both younger age and less time institutionalized were risk factors for infection with RSV. The incidence and impact of RSV infection in older persons who live independently in the community have not been well studied.
RSV is thought to be an underrecognized pathogen in older adults, based on case reports of RSV pneumonia, studies of adults with respiratory disease requiring hospitalization, and epidemiological studies from the United Kingdom.
An analysis of excess deaths and respiratory disease in England by Fleming and Cross showed that peaks of excess morbidity and mortality in persons over age 65 occurred when RSV activity was highest in the community, as judged from viral isolates recovered from children In most years, the peak of influenza activity occurred simultaneously with RSV, obscuring its effect. However, when the peaks in viral activity were temporally separated, the effect of RSV on excess morbidity and mortality was similar to that seen with influenza.
In another analysis of the impact of influenza and RSV in the United Kingdom, Nicholson applied statistical modeling to 15 years of data and estimated that the impact of RSV was greater than that of influenza In addition to the epidemiological evidence that RSV is a problem in adults, there are a number of reports of adults hospitalized with pneumonia. Many of the case reports involve adults with chronic medical conditions such as Wegener's granulomatosis, systemic lupus erythematosus, and renal failure , , However, some reports describe previously healthy adults whose only risk factor appeared to be advanced age , In one well-documented case, a year-old woman living independently at home with no chronic cardiopulmonary or immunosuppressive diseases died of RSV pneumonia The earliest large study which specifically sought RSV as a cause of lower respiratory tract disease in community-dwelling adults was performed by Fransen in Sweden from to In another Swedish study, RSV infections were identified serologically in 57 adult patients over a year period Two more recent, larger studies of hospitalized adults again show RSV to be a common pathogen 27 , A recent study by Dowell et al.
This compared to Streptococcus pneumoniae at 6. Surprisingly, the young adults were otherwise healthy. The variability in infection rates likely reflects the diagnostic tools used and seasons studied but may also reflect some differences in geographic distribution of the virus. Prospective studies, which evaluate the total burden of RSV disease in community-dwelling older persons, have yet to be done. A number of large surveillance studies of acute respiratory infection ARI show declining rates of infection with advancing age, yet the number of middle-aged and older adults studied was small Hodder et al.
The average incidence of ARI was 2. Nicholson conducted the only prospective study of ARI in elderly persons in the community to date, which examined the frequency of specific viral pathogens A true comparison of the burden of disease from specific pathogens is not possible because very different diagnostic tools were used for each pathogen. As with influenza, adults with underlying heart and lung conditions appear to be at high risk for severe RSV infections 27 , Infection is felt to be a common cause of exacerbations of COPD, although comprehensive studies which employ sensitive viral diagnostic tests are lacking 14 , Most of the published series to date have been small, and the percentage of illnesses caused by RSV in persons with COPD ranges widely, from 0 to In , Carilli studied 30 subjects between the ages of 26 and 80 years who met the criteria for chronic bronchitis During the same year, Sommerville, in Glasgow, Scotland, also found RSV to be a common pathogen in a retrospective study of persons with an exacerbation of chronic bronchitis.
A recent 2-year study of community-dwelling adults with cardiopulmonary disease documented eight RSV infections 4. The illnesses were associated with significant morbidity, as three of the eight were hospitalized with wheezing and worsening hypoxia Unexpectedly, regular contact with children did not appear to be a risk factor for infection in this small study. Although less information is available, chronic cardiac disease is also believed to be a risk factor for severe RSV disease.
Sixty-three percent of individuals hospitalized with RSV in a study from Rochester, New York, had underlying cardiac disease In the previously mentioned study of cardiopulmonary patients, 46 had congestive heart failure as their primary diagnosis. It was postulated that the frail cardiac patients may have been more mobile and thus more likely to be exposed to the virus than their pulmonary disease counterparts, who were commonly on oxygen at home.
Much of the increased morbidity and mortality associated with influenza is due to atherosclerotic vascular events following infection Whether RSV is associated with similar effects is unknown, but a recent study looking for viral antigens in the lung tissue from 20 persons dying of myocardial infarction found influenza A virus and RSV antigens in one person each A number of studies of children from birth to adolescence have indicated that RSV is one of the most common precipitants of infection-induced wheezing , , In addition, there is some evidence that severe RSV bronchiolitis early in life may be a risk factor for asthma in later life The association of viral infections and asthma exacerbations in adults is less well defined.
The results of several studies indicate that viral infections which appear clinically to be restricted to the upper airway may be associated with bronchial hyperactivity and small-airway dysfunction 29 , , Hall et al. In addition, a recent study of Norwegian adults found that increasing RSV complement-fixing antibody titers were related to progressively worse lung function The presence of RSV antibodies was an independent predictor of reduced 1-s forced expiratory volume in approximately 1, adults aged 18 to 73 years even after subjects with recent respiratory symptoms were excluded.
The low rates of documented viral infections in some asthma studies, despite high frequencies of upper respiratory infection symptoms, may reflect the insensitivity of current viral diagnostic tests. In summary, RSV infection has been documented as a cause of serious disease in a number of adult populations which include the elderly and adults with chronic heart and lung diseases.
The first comprehensive report of RSV infection in the immunocompromised host was published by Hall et al. Since , numerous studies have shown RSV to be a cause of serious disease in immunocompromised adults as well 13 , 25 , 26 , 34 , 53 , 89 , 97 , , , , , — These studies include a variety of conditions such as leukemia, bone marrow transplantation BMT , and solid organ transplants. In a 3-year period at the M. Anderson Hospital, respiratory viruses were isolated in illness episodes.
It is presumed that virus is introduced by ill visitors or staff members, and in the outbreak in BMT patients reported by Harrington et al. RSV infection in the immunocompromised host is associated with significant morbidity and mortality, particularly BMT patients prior to marrow engraftment. Recipients of solid organ transplants and BMT patients postengraftment appear to have a better prognosis 34 , In general, the clinical presentation of RSV in human immunodeficiency virus HIV -infected persons is similar to its presentation in individuals without HIV infection, although occasional severe disease has been described Prolonged viral shedding has been documented in children up to 90 days , but similar data are not available for adults.
Nosocomial RSV infections have been clearly demonstrated on pediatric wards and in nurseries since the s but more recently have also been shown to be a problem in adult patients in the hospital and LTCF Outbreaks of RSV have also been documented in adult medical wards, medical and surgical intensive care units, oncology wards, and BMT units 34 , 49 , 53 , 74 , , , Because of the high morbidity and mortality associated with RSV in cancer patients, this problem has been the focus of significant attention However, nosocomial spread of RSV in other groups of adult patients is likely underrecognized.
Takimoto described 11 patients with RSV on an adult medical ward during one winter season Two of these patients, both of whom developed pneumonia, had onset of symptoms 7 days after admission.
Guidry reported RSV infections among intubated patients in a medical intensive care unit between the months of January and March A physician who also had symptomatic RSV infection was considered a possible source. Lastly, an outbreak of RSV infections has been reported in a cardiothoracic intensive care unit in which 21 of 46 adults sampled had positive RSV antigen tests during a community outbreak The mean time after admission to diagnosis was All patients had fever and abnormal chest X-rays, seven had prolonged respiratory failure, and four died.
With these few but compelling reports, it seems likely that RSV is present on adult wards much more frequently than is recognized. Reinfection with RSV is common throughout adult life and is generally limited to the upper respiratory tract Early studies in healthy young adults, using both experimental challenge and observation of natural infection, indicated that infections produced only very mild upper respiratory tract symptoms 84 , , , However, a study of 10 healthy hospital staff with natural RSV infections demonstrated more significant symptoms, although none had serious complications All had nasal congestion, fever, and an irritating nonproductive cough, and 8 of 10 missed work for an average of 6 days.
Two subjects had transient wheezing, and all had persistent fatigue and intermittent shortness of breath at 4 weeks postillness. Exaggerated airway reactivity was demonstrated on pulmonary function tests for up to 8 weeks. The clinical manifestations of RSV infection in the older adult are quite variable, with symptoms ranging from a mild cold to severe respiratory distress It should be noted that these studies involved frail elderly persons with many chronic medical conditions and that the clinical features of RSV in healthy older persons have not been fully elucidated.
The manifestations of RSV may be difficult to distinguish from those influenza virus or other respiratory viruses; however, there are a few helpful clues which suggest RSV. The typical RSV illness begins with nasal congestion and discharge, and these symptoms help distinguish RSV from influenza The presence of wheezing by report or on exam is another feature which helps differentiate RSV from other infections.
In a study by Dowell et al. Constitutional symptoms, such as myalgias and malaise, are more common in influenza than RSV infection, as are gastrointestinal complaints Chest radiographs generally do not distinguish RSV pneumonia from bacterial infection and most commonly demonstrate bilateral alveolar opacities but may also show interstitial changes The role of bacterial infection with RSV has not been well studied.
Since the adequacy of specimens was not addressed, the significance of these findings is uncertain. RSV has occasionally been reported in association with syndromes other than respiratory illness, such as cardiac arrhythmia and neurological disorders, although a definitive causal relationship has not been proven 61 , The clinical progression of RSV infection in immunocompromised adults appears to follow a similar pattern as in immunocompetent hosts with upper respiratory infection preceding lower respiratory tract disease and acute lung injury Clinical or radiographic sinusitis appears to be a particularly helpful clue to RSV in the compromised adult, since it may be present even in patients without upper respiratory symptoms 34 , The usual pattern is bilateral interstitial infiltrates which become increasingly alveolar, with lobar involvement with time 34 , Although RSV infection in the immunocompromised adult is associated with significant morbidity and mortality, the severity of clinical manifestations depends on the magnitude of the immunosuppression.
Recipients of solid organ transplants generally are not as ill as persons with hematologic malignancies, but again, the severity of RSV depends on the level of immunosuppression Those infected preengraftment are at highest risk for pneumonia and death 89 , In another report of 46 adult BMT patients with documented RSV, the risk of pneumonia and death was closely related to time after transplant Histopathology from autopsied cases shows diffuse alveolar damage and, in some cases, severe squamous metaplasia 89 , The pathogenesis of severe RSV disease in older adults has not been well studied.
Lower respiratory tract disease in infants, which is manifested as bronchiolitis and pneumonia, is believed to be due to a combination of small airways and waning maternal immunity In addition, immunologic mechanisms such as production of inflammatory cytokines may contribute to the pathogenesis of disease in babies with bronchiolitis 2.
Giant-cell pneumonia with abundant viral inclusions has been described in immunosuppressed children and adults dying from overwhelming RSV infection; however, the mechanisms which make the elderly at risk for severe disease are not known 89 , It is presumed that the presence of underlying heart and lung disease, a declining immune system, and an aging respiratory tract may all play a role. Very little is available in the way of pathologic specimens from immunocompetent elderly persons dying of RSV complications with the exception of one case of giant-cell pneumonia that was documented at autopsy Links with this icon indicate that you are leaving the CDC website.
Linking to a non-federal website does not constitute an endorsement by CDC or any of its employees of the sponsors or the information and products presented on the website. You will be subject to the destination website's privacy policy when you follow the link. CDC is not responsible for Section compliance accessibility on other federal or private website. The British Lung Foundation says respiratory syncytial virus RSV could rebound in January after few cases last winter - but numbers are currently low.
As with Covid, most children have mild symptoms but a small number need hospital treatment. Many more coughs and viruses are circulating this winter than last. In a normal year, RSV is responsible for 20, hospital admissions in the under-ones - but most parents had not heard of it, the charity said. During the pandemic, with lockdowns and little mixing, RSV virtually disappeared. But it returned last summer, out of season, and contributed to emergency departments becoming overwhelmed with children , before another rise in cases in the autumn.
The numbers of children affected in the last week of December "had gone right down" and were "a lot lower than feared", she said. But it could start to affect more children once they had been mixing at school for a couple of weeks.
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