Why a new jab to beat virus that’s as risky as flu is a good idea for over-65s

FEW of us may have heard of this virus, but now leading scientists warn that RSV (respiratory syncytial virus) poses a significant threat to some people’s health. Until now, RSV, a common respiratory winter illness, has mainly been associated with young children.

Nearly all children will have it by the time they turn two, and for many it is mistaken for a cold.

However, for some infants it can cause inflammation of the small airways and significant breathing difficulties, and it results in 20 to 30 deaths a year in the under-fives.

But another group of patients is also at risk from the virus, according to scientists. RSV is increasingly identified as causing serious and sometimes lethal respiratory illness in older people, particularly those with heart or lung problems or who are physically frail.

In Europe, RSV causes an estimated 250,000 hospitalisations and 17,000 inhospital deaths every year in people over the age of 65.

Adults with underlying co-morbidities, including chronic obstructive pulmonary disease (COPD), asthma, diabetes, and chronic heart failure are at high risk for severe RSV disease.

Harish Nair, a professor of paediatric diseases and global health at Edinburgh University, says some mathematical studies even estimate that RSV may cause the same annual increase in hospitalisations and deaths as flu.

Yet the viral infection is underdiagnosed and undertreated, not least because its symptoms are not fully recognised and can be mistaken for colds, flu or even neurological conditions.

Andrew Pollard, professor of infection and immunity at Oxford University, told Good Health that the risk from repeat RSV infections increases with age and can make chronic conditions worse.

‘In adulthood, every three or four years we catch a “cold” that is actually RSV,’ he explains. ‘And as we get older, we’re at increased chance of getting other conditions that make us more vulnerable to RSV.

‘Once we’re over 65, an increasing proportion of the population has medical conditions that can worsen with an RSV infection.

‘If you have heart failure and you get a respiratory infection, then it makes your heart failure symptoms much worse. It’s the same for people with chronic lung disease.’

TYPICALLY, the RSV season starts in October, peaking in December and dropping off by March. The majority of people infected have only mild illness, usually showing symptoms within four to six days of becoming infected: a runny nose, a drop in appetite, coughing, sneezing, wheezing and fever.

But some estimate that it may cause as many hospitalisations and deaths per year as flu, because it can cause lifethreatening symptoms in people who are frail or vulnerable, particularly older people.

A 2012 study by the UK Health Protection Agency concluded that the virus causes 1,200 deaths a year in those aged 45 to 74, and 4,000 deaths in over-75s in England and Wales alone. In Ireland, RSV led to over 800 hospitalisations in those aged 60 and older last winter.

But the JCVI says these figures may be an underestimate — and better surveillance is needed.

Professor Nair told Good Health that these figures may be at least 250 per cent too low.

RSV is usually diagnosed using samples of nasal mucus. But Professor Nair says thanks to immune defences dwindling with advancing years, ‘older people shed very little RSV in their nasal mucus — so their results often come back negative. You need to test their lung sputum [mucus samples from the lung] and their spit.

‘When you combine nasal mucus, lung sputum and spit tests, you get at least two-anda-half times more positive results. You should get even more positive results if you test people’s blood as well.’

Another reason why so many RSV infections are missed, he says, is because ‘we still don’t understand the full range of symptoms’.

As he explains, although RSV is known as a respiratory tract infection, it can affect older people in other much less obvious ways.

‘They may come into hospital suffering from confusion, from lethargy and falls. They get tested for neurological problems, but in fact their problems are caused by RSV infection.’

This is because the infection can cause weakness in older people, raising the risk of falls; it can also cause fever, which can make them confused.

‘Only after we implement the vaccination programme will we understand the true burden of this infection, by comparing hospitalisations and deaths before and after the programme’s introduction,’ says Professor Nair.

Another reason why RSV cases are undercounted is that there was, until now, no preventive treatment for it, says Christopher Chiu, a professor of infectious diseases at Imperial College London, so testing for it wasn’t considered important.

In November, the National Immunisation Advisory Committee (NIAC) recommended to the Government that all infants and older people should be immunised against RSV.

It said people aged 65 years and older should be vaccinated with one of the two available products - either Abrysvo, made by Pfizer, or Arexvy, made by GSK.

ACCORDING to NIAC, both options are similar in safety and efficacy but further analysis is needed to see which is the more cost effective and a better fit with the vaccine programme. (The new jabs are effective for at least two years.)

‘I think we’re going to be quite surprised by how much RSV infection there is in older adults,’ says Professor Pollard.

‘The virus is a really cheeky one. It has ways of switching off our immune system’s defence systems so that we never get complete immunity from it.’

He believes that a vaccination campaign will prove highly cost-effective if it helps to keep older people out of hospitals during winter.

‘The health system suffers huge winter pressures which are driven by the seasonal increase in respiratory viruses,’ he says. ‘As well as flu, other respiratory infections hospitalise older and frail people — and RSV is top of the list.’

To older people concerned at the prospect of another jab on top of Covid, flu and shingles, Professor Pollard says: ‘There is no concern about over-vaccinating older immune systems. Our immune defences are under a daily onslaught of viruses and bacteria. The RSV vaccine gives a most trivial dose compared with that.’

He’s also reassuring about potential side-effects: headache, pain at the injection site, tiredness and joint or muscle aches or pain.

‘The regulators have no concerns from the trial evidence and there is very robust safety monitoring,’ he says.

The Health Information Quality Authority (HIQA) is assessing if the vaccines would reduce the burden on health services from RSV, and as of yet there is no date for an immunisation rollout in Ireland.

For now, HSE advice is very much around prevention, recognising symptoms and seeking medical help if a person with the condition deteriorates.

‘Most cases of RSV and flu can be cared for at home, and usually clears between two to three weeks without treatment. Stay home from crèche, school or work and ask your pharmacist for advice on medicines,’ advises Dr Greg Martin, National Clinical Lead for Health Protection Surveillance. ‘However, parents and caregivers should be vigilant of symptoms, trust their instincts and always contact their GP if they are worried, especially if the symptoms get worse quickly.’