Editor's Note
April 15, 2024
RSV Vaccination—The Juice Is Worth the Squeeze
Tracy Y. Wang
JAMA Intern Med. 2024;184(6):611. doi:10.1001/jamainternmed.2024.0219
In this issue of JAMA Internal Medicine, Woodruff et al1 present a cross-sectional study of patients 50 years and older who were hospitalized and tested positive for respiratory syncytial virus (RSV), reporting that 22% experienced an acute cardiac event, including acute exacerbation of heart failure or myocardial injury. The already high in-hospital mortality rate of 5% for older adults with RSV-associated hospitalizations was doubled among those experiencing a concurrent acute cardiac event.
This report confirms for RSV a similar severity of cardiovascular adverse outcomes observed with other acute respiratory pathogens, such as influenza and SARS-CoV-2, that stem from infection-related metabolic and myocardial stress at the very least, but may also implicate other, more direct pathogen-mediated effects. Older adults are particularly vulnerable due to greater prevalence of preexisting cardiopulmonary comorbidities and lower functional reserve. In the RSV infection surge last year, the Centers for Disease Control and Prevention reported up to 10 000 deaths in adults older than 60 years, with highest risk of severe RSV infections among patients living in long-term care facilities, as well as those with preexisting lung, heart, or kidney disease or immunosuppression.2
What may make a difference is the recent approval of 2 vaccines that are effective in preventing severe RSV infections in adults 60 years or older. Yet vaccine uptake has been very low—much lower compared with influenza vaccination—in part due to the relative lack of knowledge of RSV as well as inconvenient access to vaccination. Prior RSV-related efforts have focused on infants and young children, with many clinicians and patients still unaware of RSV burden of disease and prognosis in older adults. Systemwide quality-management approaches, such as Healthcare Effectiveness Data and Information Set measures, may help make RSV vaccination recommendations more routine in the older adult population. RSV vaccines are inconsistently covered by insurers for patients aged 60 to 64 years and, for those with Medicare coverage, are only covered under Part D, in contrast with the influenza vaccine, which is covered under Part B. This coverage difference means that many clinic offices need to refer patients to pharmacies for vaccination, and out-of-pocket costs may be necessary for vaccination.
Woodruff et al1 focused on a broader older adult population, including those aged 50 to 59 years who are not currently recommended for vaccination. Preliminary data suggest similar immune response and safety of the RSV vaccine in these patients compared with those older than 60 years, and label expansion is being considered.3However, vaccine fatigue and access barriers among currently eligible persons need to be addressed to enhance uptake by those who stand to benefit.
