RSV Surges Through Hospitals Amidst Early Fall Season

• Respiratory syncytial virus (RSV) is a common seasonal virus circulating in the colder months. 
• RSV is associated with significant morbidity and mortality, causing over 3 million hospital admissions and greater than 100,000 deaths in children a year. 
• In an ideal world, those with cold-like symptoms should not interact with children at substantial risk for RSV.
  

What Is RSV?

Respiratory syncytial virus (RSV) is a common seasonal virus circulating in the colder months when the population remains indoors more often, allowing accessible transmission in the cold, dry air which may weaken resistance.  

When dealing with the spread of RSV and similar viruses, hand washing is a primary method of prevention. 

Yet, despite our best efforts, infectious viruses that cause respiratory illnesses in vulnerable age populations persist.  

Seasonal RSV often begins with fever and cold symptoms that can lead to lower respiratory tract infections (LRTI), bronchiolitis, pneumonia, asthma, apnea, respiratory failure, and death. Children’s hospitals nationwide are experiencing a surge in infections with a distinct seasonality of early fall.  

RSV Virology

Masking and sheltering during the pandemic years may have limited pregnant individuals from passing immunity to their children, leaving the youngest and most recent born of our population unprepared to fight the current upsurge of RSV.  

Across the globe, RSV is associated with significant morbidity and mortality, causing over 3 million hospital admissions and greater than 100,000 deaths in children a year. In the older population, 200,000 hospitalizations and 15,000 deaths occur in those over the age of sixty-five. Those infected with RSV are contagious for three to eight days and often present with bronchiolitis in young children. 

Babies and the immunocompromised can spread RSV for up to four weeks. Premature infants and those with bronchopulmonary dysplasia, congenital heart disease, and Down syndrome have predisposed risk factors for high mortality and prolonged morbidity after an RSV infection. Even a healthy full-term child infected with RSV may need hospitalization and can experience severe sequelae or death. 

Often the characteristics of an RSV infection beyond bronchiolitis includes mucosal and submucosal edema, and asthma secondary to the development of pathogenic inflammation. The prevalence of developing asthma later in a child’s life is higher amongst children hospitalized with an RSV in infancy or early childhood. 

An RSV Case Study

A healthy full-term 3-year-old boy with no history of asthma or pneumonia arrived at the pediatric ED with several days of fever and illness in late September. He is the younger sibling of a 5-year-old healthy girl.

The parents gave Motrin and Tylenol to the youngest child for a fever of 39.1 °C with the onset of symptoms several days ago. Following the fever, the child developed shortness of breath, a paroxysmal cough, and a decrease in appetite.

On the third day of illness, the parents reported an increased fever to 104 °F with wheezing and persistent phlegm. The parents became concerned when the child developed a notable increase in shortness of breath and lethargy accompanied by a rash. Upon arrival, the ED staff worked to stabilize the patient.  

While awaiting a PICU bed, the patient had an abrupt respiratory decline. The patient’s weak and irregular breathing required prompt intubation. Blood-gas analysis showed metabolic acidosis. Comprehensive lab work suggests a bacterial infection. Radiologic studies, including a head CT, showed extensive cerebral swelling and a chest x-ray identified coarse bilateral lung markings and a diagnosis of pneumonia.

Initial supportive treatment included antibiotics to control the infection and immunoglobulin (1 g/kg) for immune support. Fourteen hours later, on the sixth day of illness, the patient experienced multiple organ failure, and despite heroic efforts, the patient passed.

Treatment for RSV

The best treatment for RSV and many seasonal viruses may lie in prevention. Basic infection control: washing your hands, avoiding close contact, and covering your coughs and sneezes can limit some transmission.  

Though an individual decision, getting a flu shot and a COVID-19 booster for your child may limit potentially fatal outcomes related to accompanying seasonal viruses.  

The only prescription medication to prevent serious sequela caused by an RSV infection in high-risk infants is palivizumab, an intramuscular monoclonal antibody administered once a month during the prevalent season.  

Effective therapy often requires five doses with the first dose of 15mg/kg administered intramuscularly (IM) prior to the onset of RSV season and the remaining doses administered monthly.  

Synagis (palivizumab) is not a vaccine but can help prevent serious lung disease. The administration of palivizumab is not a cure and does not treat children infected with the virus.  

The Bottom Line

In an ideal world, those with cold-like symptoms should not interact with children at substantial risk for RSV.

For parents with small, vulnerable children and healthcare professionals the awareness of symptoms including: a runny nose, cough, sneezing, wheezing and an increased breathing pattern that affects feeding are paramount. Parents of children having severe breathing problems should not hesitate to go to an emergency department or call 911.

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