Review: Respiratory syncytial virus (RSV)

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Respiratory syncytial virus (RSV) can be particularly unpleasant, causing infected cells in the lung and respiratory tract to fuse creating multinucleated ‘syncytia’.¹ Often RSV causes mild symptoms or people are completely asymptomatic.

However, people who are immunosuppressed, infants and the elderly could experience more severe disease.¹ So, in February this year, the Government accepted the advice of the Joint Committee on Vaccination and Immunisation to extend eligibility for RSV vaccination.

From April 1 this year the NHS in England will offer RSV vaccination to people aged 80 years and over as well as all residents in care homes for older adults. These groups add to the current programme, which currently offers RSV vaccination to adults turning 75 years, those aged 75 to 79 years, and pregnant women to protect newborn babies.

Meanwhile, recent studies suggest that RSV vaccination should reduce cardiorespiratory risk and so help stem the tide of antibiotic resistance.

Cardiorespiratory risk examined

Researchers from Pfizer examined the medical records of 11,887 patients with RSV-related hospitalisation. Participants’ mean age was 69.4 years and 61.4 per cent were females.²

During the first seven days of hospitalisation, RSV patients were nine times (incidence rate ratio [IRR] 8.7) more likely to experience a myocardial infarction (MI) and showed a seven-fold (IRR 7.4) increased stroke risk compared with RSV-free controls. During the first seven days of hospitalisation, RSV patients were also 23.1, 16.5 and 12.5 times more likely to experience worsening of chronic obstructive pulmonary disease, arrhythmia and congestive heart failure exacerbations respectively.²

The increased risk from RSV persisted during days 15–21 for MI (IRR 2.6), stroke (IRR 3.7), COPD exacerbation (IRR 1.3), arrhythmia (IRR 1.6) and CHF exacerbations (IRR 2.4). Indeed, the risk remained significantly raised following RSV-related hospitalisation for up to 63 days for MI (IRR 1.8) and stroke (IRR 1.8), and up to 84 days for CHF exacerbations (IRR 1.5). The authors comment that “the findings … highlight the extended RSV disease burden and the need to increase RSV immunisation in adults.”²

Antibiotics typically not needed

RSV infections presenting in primary care are typically self-limiting and most antibiotic prescriptions are anticipated to be unnecessary.³ But distinguishing viral from bacterial infections in primary care can be difficult. As a result, RSV infection may account for 1 in 50 (2.1%) of antibiotic prescriptions issued by GPs in England. That is equivalent to, on average, 640,000 antibiotic prescriptions annually.³

Computer models examined associations between general practice antibiotic prescriptions and laboratory-confirmed respiratory infections from 2015 to 2018. In people with RSV, adults aged 75 years and older used the greatest volume (23.3% of the total) of antibiotics, with an annual average of 149,078 prescriptions.

Infants aged 6–23 months had the highest average annual rate of antibiotic use: 6,580 prescriptions per 100,000 individuals. Penicillins, macrolides or tetracyclines accounted for most antibiotic prescriptions attributable to RSV. People aged 65 years and over received antibiotics from a wider range of classes compared to younger patients.³

Jabs will drive down infections

“To tackle antibiotic resistance we need to ensure antibiotics are used only when necessary,” said study author Dr Lucy Miller from the UK Health Security Agency (UKHSA). “But we also need to drive down infections to reduce the need for antibiotics in the first place. This study highlights that the introduction of the new RSV vaccine programme could not only help reduce the risk of infections in vulnerable individuals, but also contribute towards a reduction in antibiotic prescribing and antibiotic resistance in the population overall.”

Increasing the number and range of vaccinations delivered in pharmacies should help further protect vulnerable people and reduce pressure on general practice. In October 2024, 50 pharmacies in Essex and Suffolk started offering RSV vaccines. Following findings from these early adopters, NHS England commissioned up to 200 additional pharmacies to offer RSV and pertussis vaccinations.⁴

Vaccination is a fertile area for service growth: RSV and pertussis, not to mention flu and Covid‑19, exemplify pharmacists’ potential to deliver immunisation programmes at scale. It is a role pharmacy should continue to embrace.