“RSV—along with COVID-19 and influenza—form the current ‘tripledemic’ found across the United States this fall and winter,” said Simon Haeder, PhD, the study’s author. “While the elderly, as well as the very young and those with chronic health conditions, typically are affected more than others, the good news is that vaccines now are available for all three of these respiratory viruses.”

The study, one of the first to address seniors and RSV, was published in Health Affairs Scholar. It asked 1,345 Americans over the age of 60 about their current RSV vaccination status and their intention to get the vaccine. Although RSV usually causes mild, cold-like symptoms that last a week or two, it can also lead to serious illness. According to the Centers for Disease Control and Prevention (CDC), 60,000 to 160,000 seniors in the United States are hospitalized with RSV each year, and 6,000 to 10,000 ultimately die from the infection.

The study found that men were more likely to be vaccinated against RSV than women, and that those who were vaccinated had higher levels of concern about the disease, believed they were at greater risk for getting the disease, believed that vaccines were safe and important, and had higher levels of trust in health institutions.

Of the 91 percent of seniors who were unvaccinated against RSV, 42 percent said they planned to get the vaccination. Respondents who were vaccine hesitant reported that they did not need the vaccine, lacked information about the vaccine and had concerns about its side effects and safety.

“Although the vaccines are 83 percent to 89 percent effective in preventing lung infections, the CDC did not officially recommend them this year, which may have also been a factor,” Haeder said. “In addition, vaccine hesitancy is growing worldwide in response to COVID-19.”

The likely results will be more illnesses, hospitalizations and deaths among the vaccine hesitant, especially among the very young, elderly and those who have chronic health conditions, Haeder said.

Haeder’s study is the latest in a series of studies assessing vaccination hesitancy in the United States. Previous studies have looked at parents’ intention to seek out vaccinations against COVID-19, influenza and RSV for their children, as well as adults’ intention to seek out vaccinations against COVID-19. Haeder also previously assessed vaccination hesitancy amongst pet owners.

Haeder said vaccine hesitancy could be addressed through policies that focus on the potential benefits of vaccination and the potential risks of not being vaccinated, along with programs—especially those tailored for women—that debunk misleading claims about RSV and its vaccines.

“Not only will the unvaccinated place a great burden on the health care system, but their illnesses could have been prevented or mitigated by vaccinations,” Haeder said. “The costs to society will be large and will affect society as a whole.”

By Ann Kellett, Texas A&M University School of Public Health

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A high level of RSV vaccination would not only potentially reduce millions of dollars in annual outpatient and hospitalization costs but would also produce an economy of scale with individual shots being delivered at a relatively modest cost of between $117 and $245 per dose, the study said.

The vaccines are currently covered by most private insurers without a patient copay because they are recommended by the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices. Some Medicare beneficiaries can also obtain the shots at no cost, but only if they are enrolled in Part D of the program, which deals with drug benefits.

“RSV causes substantial morbidity and mortality among the elderly in the U.S. and globally, but this is the first time that RSV vaccines have been available,” said senior author Alison Galvani, the Burnett and Stender Families Professor of Epidemiology (Microbial Diseases) at the Yale School of Public Health. “We wanted to understand the potential impact of RSV vaccination in terms of averting illness, medical costs, hospitalizations, and deaths.”

RSV is a common respiratory virus that causes mild cold-like symptoms in most people, who usually recover in one or two weeks. But older adults and infants are more likely to develop serious RSV, which can be life-threatening. The current study looked only at the potential impact and cost of RSV vaccines for older adults.

Two RSV vaccines, Arexy and Abrysvo, were approved by the U.S. Food and Drug Administration earlier this year. RSV disease causes an estimated 60,000 to160,000 hospitalizations and 6,000 to 10,000 deaths annually in adults 65 and older, according to the Centers for Disease Control and Prevention (CDC). As of Dec. 1, just 14.8% of people 60 or older in the U.S. said they had obtained an RSV vaccine, CDC records show.

In conducting their study, the researchers created a model for RSV outcomes based on characteristics of the U.S. population 60 or older. Measured outcomes included the annual incidence of cases per 100,000 people requiring outpatient, inpatient, and intensive care, and the death rate for hospitalized patients. The researchers then calculated the medical care costs for these outcomes and lost productivity.

The researchers analyzed how these outcomes would be reduced if 66% of adults 60 and older received an RSV vaccine. That is the typical influenza vaccination coverage for adults 65 years or older in the U.S.

“It would be great if we could achieve even higher levels,” said Galvani, who also serves as the director of Yale’s Center for Infectious Disease Modeling and Analysis. “But if we can achieve that for flu, it makes sense that would be feasible for RSV vaccination as well.”

For comparison, the researchers also analyzed the impact of 100% RSV vaccination coverage. In each scenario, they factored in the efficacy of the vaccine at preventing the need for medical care and death. They looked at the impact of these levels of RSV vaccination over one year and then over two years.

They found that 66% vaccination coverage in the first year reduced outpatient care by 41.4% to 53.6%, hospitalizations by 57.6% to 60.5%, and RSV-related deaths by 58.5% to 60.4%.

Increasing vaccination coverage to 100% reduced outpatient care by 62.9% to 81.2%, hospitalizations by 87.4% to 91.7%, and deaths by 87.6% to 91.3%.

Based on these numbers, the maximum cost-effective price per dose for one season at 66% coverage was $118 to $127. The difference was small — $1 to $3 — for 100% coverage.

With the annual cost savings achieved from vaccination, a program where 66% of adults 60 and older are vaccinated for RSV would cost the U.S. health care system $6.4 to $7.1 billion for one season, and $9.7 to $10.7 billion at 100% vaccination, the researchers found.

The vaccines are intended to protect people over two RSV seasons, as clinical trials for the vaccine showed efficacy for that time. But the researchers felt that until real-world efficacy data are available, a one-season analysis was more appropriate.

“Within the next year or two years, as these vaccines are rolled out, we will get a lot of data on effectiveness and better analysis,” said Seyed Moghadas, the paper’s first author and professor of applied mathematics and computational epidemiology at York University. “This new data will help us better inform vaccination strategies for improved impact against RSV disease.”

If real-world data show strong efficacy over two seasons, Arexvy could be cost effective up to $235 per dose and Abrysvo up to $245 per dose, the researchers found.

These are important issues to understand, Galvani said. Some private insurers have not decided if they will cover the vaccines, and whether Medicare does depends on the plan, she said. People 60 to 64 are not eligible for Medicare and may not have health coverage, she added.

“Accessibility and cost are definitely concerns in the American health care system,” she said. “We hope that our results will inform decision-makers about the health and economic benefits of vaccination, as our results demonstrate the importance of making these vaccines accessible to everyone over 60 years to realize their full benefit.”

The research was published Nov. 30 in Clinical Infectious Diseases.

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A new study found that nearly one in ten of all deceased infants under 6 months old were infected with Respiratory Syncytial Virus (RSV). Two-thirds of infant fatalities from RSV occurred in the community and would have been excluded from mortality estimates based on hospital data.

RSV is a common virus that produces cold-like symptoms and is merely a nuisance for the vast majority of people who contract it. But for babies — especially infants in low- and middle-income countries who lack adequate access to medical care — the virus can be fatal.

Prior research has estimated that about 120,000 infants die from RSV each year, but this figure is based on modeling conducted in hospital-based settings and does not account for RSV deaths that occur in the community, which are not captured in hospital-based surveillance.

Now, a new study led by Boston University School of Public Health (BUSPH) researchers has found that the true burden of RSV infant mortality is substantially higher than what was previously believed.

Published in the journal The Lancet Global Health, the study used systematic surveillance to measure the presence of RSV among infants who died in medical facilities or in the community and found that the virus was present in 7 to 9 percent of infants under 6 months old and was primarily concentrated in infants under 3 months old.

Notably, two-thirds of these deaths occurred in the community — i.e., among infants who never received medical care in a hospital and were overlooked in previous facility-based surveillance.

“The concentration of deaths in young infants less than 3 months old(<3m) is important for two main reasons,” says study principal investigator Dr. Christopher Gill, associate professor of global health at BUSPH. “First, it is a reminder that these very young infants with very small airways are at particular risk of RSV infections anatomically. Second, both of the proposed new tools to prevent RSV infections — maternal vaccinations and infant monoclonal antibodies — will be most effective immediately after birth and could wane after.”

The findings are part of, conclude the three-year Zambia Pertussis RSV Infant Mortality Estimation (ZPRIME) study, which was conducted among infants at one of the busiest morgues in Lusaka, Zambia. The study is the largest post-mortem RSV surveillance study of its kind and the first to directly measure RSV infant deaths in the community, rather than rely on modeling estimates.

For the project, Gill and colleagues partnered with local mortuary staff to obtain consent for a nasal swab and PCR test of infants from families who lost a child between the ages of four days and six months. The researchers enrolled 2,286 deceased infants, representing almost 80 percent of infant deaths in Lusaka from August 2017 to August 2020, with the exception of a brief suspension of enrollment during the first wave of the COVID-19 pandemic in 2020.

RSV was detected in at least 7 percent of deceased infants, and closer to 9 percent of deceased infants during the time periods with uninterrupted data. The virus was found in 9 percent of deaths that occurred in the community, compared to 4 percent of deaths that occurred within 48 hours at a medical facility, and 5 percent of deaths that occurred after 48 hours in a medical setting. About 72 percent of the deaths occurred in infants under 3 months old.

The study showed that RSV directly caused at least 2.8 percent of all infant deaths, and 4.7 percent of all infant deaths outside of hospitals. The majority of these deaths were seasonal, occurring in the first half of the year, and were concentrated in the most impoverished areas of Lusaka.

“Our prior work has shown that delays to seeking and accessing appropriate care is the rule rather than the exception in many impoverished countries,” says study co-author Rachel Pieciak, a research fellow in the Department of Global Health at BUSPH. “Managing RSV infections tends to rely heavily on supportive care such as supplemental oxygen and suction, but we suspect that the majority of the young infants in our study are dying before accessing even basic care. While no small feat, public health interventions aimed at addressing common barriers to care could have the potential to prevent these infant deaths.”

Preventative measures such as RSV vaccination of mothers who could pass on antibodies to her baby would also effectively be the most effective strategy to reduce infant mortality from the virus, the researchers say. There is currently no approved vaccine for RSV, but trials are underway.

“Our findings build upon our previous work in the Pneumonia Etiology Research for Child Health Study, which showed that RSV was the most frequent and most lethal respiratory infection in children under 5, and especially in infants, in the eight low- and middle-income countries that we studied,” says study team member Dr. Donald Thea, professor of global health at BUSPH. “Many of the young infants who develop RSV require very specialized facilities-based care, which is in short supply in these low and middle-income countries. By far the best approach to dealing with this problem is to effectively vaccinate mothers late in pregnancy so that her ample antibodies cross the placenta and ‘fill the infant’s tank’ to provide good protection during the critical first 6 months of life.”

Journal Reference:

1. Christopher J Gill, Lawrence Mwananyanda, William B MacLeod, Geoffrey Kwenda, Rachel Pieciak, Zachariah Mupila, Caitriona Murphy, Chilufya Chikoti, Leah Forman, Flora Berklein, Rotem Lapidot, Charles Chimoga, Benard Ngoma, Anna Larson, James Lungu, Ruth Nakazwe, Diana Nzara, Lillian Pemba, Baron Yankonde, Angel Chirwa, Magda Mwale, Donald M Thea. Infant deaths from respiratory syncytial virus in Lusaka, Zambia from the ZPRIME study: a 3-year, systematic, post-mortem surveillance project. The Lancet Global Health, 2022; 10 (2): e269 DOI: 10.1016/S2214-109X(21)00518-0

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