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Prioritizing RSV in Older Adults
Prioritizing RSV in Older Adults: Strategies to Promote RSV Awareness and Vaccine Uptake

Released: November 15, 2023

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Key Takeaways
  • Limited testing availability and the lack of education among patients and healthcare professionals has led to an underestimation of the burden of RSV in older adults.
  • To help increase RSV vaccine uptake, consider sharing information about RSV in the context of other respiratory viruses, such as influenza, to make it clear that RSV is a major threat with a similar burden.

The following is a recap of key questions from healthcare professionals (HCPs) during a program featuring Angela Branche, MD; Pamela Rockwell, DO, FAAFP; and Richard Zimmerman, MD, MPH, discussing the burden of respiratory syncytial virus (RSV) and clinical implementation of RSV vaccines in older adults.

Do you think HCPs and patients underestimate the incidence and burden of RSV in adults, and if so, why?

Richard Zimmerman, MD, MPH:
I certainly do. At my health center, we do not routinely test for RSV in all care settings. In the outpatient setting, we have a combination test with SARS-CoV-2 and influenza available, but not a specific RSV test. However, our urgent cares have a quad test that includes RSV, influenza A/B, and SARS-CoV-2, which has helped us identify a lot of RSV cases that we did not expect.

How do we raise awareness about RSV?

Pamela Rockwell, DO, FAAFP:
I agree that many underestimate RSV. If we do not test, we are never going to know, so we must think about testing and how to better improve testing availability.

However, I think the issue of why this is the case goes beyond the lack of testing. I found it interesting that new medical students I interacted with during their clinical rotations were surprised when the RSV vaccine was approved for adults. This was not shocking to hear based on how RSV in adults has been perceived. I was raised with the idea that RSV is an infection for little babies only and that it is just a cold in adults. I think we need to do a better job of educating our learners, as well as our practicing HCPs.

Richard Zimmerman, MD, MPH:
Public health education is another way to raise RSV awareness. There are many issues with health literacy, or the lack thereof, in many of our patient populations. I suspect that prior to the advent of the ads for RSV vaccines, most of my patients did not know about RSV unless they worked in healthcare.

Angela Branche, MD:
I agree. The other day, I had a patient in my office whom I was trying to convince to get the RSV vaccine. She had never heard about RSV and was not sure if she wanted it or needed to be vaccinated.

I think we need to have conversations about RSV disease in the context of influenza and COVID-19, because those are viruses that are well known to patients. Once we make it clear that RSV is a real threat, and it is one we have known about for years, then I think that will help a lot.

Pamela Rockwell, DO, FAAFP:
I do think the threat of hospitalization and death really works, and older adults are very savvy to know they need to get the influenza and COVID-19 vaccines. When you tell them RSV is just as common as influenza, or in certain people can cause higher rates of morbidity and mortality than influenza, I think they are more likely to get vaccinated.

How effective are the RSV vaccines?

Richard Zimmerman, MD, MPH:
In clinical trials, the RSV vaccines have demonstrated greater than 80% effectiveness in preventing lower respiratory tract disease. At this time, we do not know the duration of protection because the studies were started nearly 2 years ago.

If you have a 62-year-old patient in front of you, and they are willing to receive only 1 vaccine (influenza, RSV, or COVID-19), which would you recommend?

Pamela Rockwell, DO, FAAFP:
It depends on the 62 year old. We should be making individualized decisions based on risk factors that predispose them to severe RSV disease. For example, if they have a history of congestive heart failure with recurrent exacerbations and possibly chronic obstructive pulmonary disease, I would push them toward RSV vs influenza if they are going to get only 1 vaccine.

Although, in my experience, I find that if somebody is open to hearing more about the vaccines, I have been successful in having RSV and influenza being given at the same time. However, if they want to divide them out by 2 weeks, we try to elicit a promise from them that they will go to their local pharmacy or come back to our office for the second vaccine and possibly receive the updated COVID-19 vaccine.

Richard Zimmerman, MD, MPH:
I would look at the epidemiology of my community and see what is happening. Right now, we have almost no influenza in Pittsburgh, but RSV and SARS-CoV-2 are circulating. At present, I would personally prioritize the RSV and COVID-19 vaccines, although I like to get my patients vaccinated against influenza before Thanksgiving. If they will receive only 1 vaccine, I would pick between the RSV and COVID-19 vaccines.

Angela Branche, MD:
It is an impossible question to answer in Rochester. We have SARS-CoV-2 and RSV circulating, and in 1 month, we will have influenza cases start to appear. Most of our patients will not come back again to see their primary care providers during the winter season.

An RSV vaccine may be beneficial for those with congestive heart failure class III or IV, coronary artery disease, and/or chronic obstructive pulmonary disease. For adults who are 75 years of age and older, regardless of if they have chronic cardiopulmonary comorbidities, I would recommend administering the RSV vaccine and then prioritizing the COVID-19 vaccine. Then, I am going to remind them to get their influenza vaccine before the end of the year.

Fortunately, we do have pharmacy partners that can help with vaccinating. In my community, approximately three fourths of vaccines are being administered in pharmacies right now, so I think we need to strengthen our partnerships with pharmacies to promote vaccine update.

Do vaccines against other respiratory viruses provide any protection against RSV?

Angela Branche, MD:
Influenza vaccines will not provide protection against RSV, and neither will they provide protection against COVID-19; they are all completely different viruses. Also, the antigens and proteins used to make these vaccines are structurally different.

For the 3 big respiratory viruses we are covering this year (COVID-19, influenza, and RSV), you need each vaccine to protect against each virus.

What resources are available to help cover the cost of RSV vaccines? Do major insurance companies cover the RSV vaccine?

Pamela Rockwell, DO, FAAFP:
I know a lot of my patients are concerned about cost. Because of the Affordable Care Act, and now the Inflation Reduction Act, patients are covered to receive the RSV vaccine because it is an official recommendation by the CDC Advisory Committee on Immunization Practices.

For those who had issues with patients getting vaccine coverage, the CDC has done a remarkable job updating their online resource in almost real time with new recommendations that come in past their official publication of the immunization schedules, so insurance companies can no longer use that as a reason to deny coverage.

Richard Zimmerman, MD, MPH:
That is an excellent point. We are so fortunate to have the Affordable Care Act and Inflation Reduction Act; Medicare (under Part D) and Medicaid are covering the RSV vaccine. From my understanding, health plans should provide coverage without charging a copayment or cost sharing for immunizations recommended by the Advisory Committee on Immunization Practices. They may have up to 1 year to implement new recommendations.

Your Thoughts?
In which patients do you plan to discuss the RSV vaccine? What strategies have you used to overcome vaccine hesitancy? Join the conversation by posting a comment.