RSV

Respiratory Syncytial Virus (RSV) is a highly infectious virus that can lead to serious disease in children.  The virus emerges each year roughly at the time school starts in the fall and subsides later in the spring.  Midsummer RSV is unusual.  Last year we did not see the typical rise in RSV, but this year the RSV surge started much earlier and is of much greater magnitude than normal.  Our COVD-19 response has unintentionally increased children’s risk from RSV infection.

Lock downs, social distancing, and masking, whether voluntary or mandated, changed the rhythm of upper respiratory infections like RSV and Flu.  Flu has yet to return; the last infection diagnosed in my practice was in May, 2020, at the tail of the 2019-2020 season.  But RSV has returned with a vengeance, all over the world.  To illustrate, look at this graph of RSV infections in Tokyo for the years 2017-2021.  And this year’s cases are more severe than before.   According to CDC, “Due to the reduced circulation of RSV during the winter months of 2020–2021, older infants and toddlers might now be at increased risk of severe RSV-associated illness since they have likely not had typical levels of exposure to RSV during the past 15 months.”  You read that right.  Anti-COVID measures, regardless how well-intentioned or how necessary, will cause more severe RSV disease in our children this year.

Just how severe is RSV?  RSV is a major viral cause of death in children 5 years of age and younger, with mortality rates estimated between 0.5 and 1.7% in healthy U.S. children, but devastatingly higher in immunosuppressed children and in the children of the developing world.  By comparison, the mortality risk for infants and children infected by SARS-CoV-2 is under 0.03%.  RSV is a more serious risk to our kids than COVID.

There is no vaccine for RSV, and there is no treatment other than supportive care.  Severe cases require ventilator support in a pediatric ICU.  Most patients survive.  According to the American Academy of Pediatrics Red Book, most kids are exposed to RSV by the age of 2, and reinfection is common. 

Which brings us to the point.  Even though RSV can cause a serious and deadly viral respiratory illness, the virus circulates among children.  Children live with this virus.  RSV prevention measures are targeted toward those at highest risk of death from the virus.  Eradication of RSV is not the objective, and, as our experience in 2020 and 2021 suggests, may not even be desirable. The disruption of the seasonal viral pattern by implementation of COVID-19 precautions has increased the risk of sickness and death by RSV this year.  Children derive benefits from natural exposure to RSV that may be important to their future survival.

We need to be aware that our actions during this pandemic can have consequences beyond what is in view.  Homelessness, suicide, drug overdose, and now increased RSV–all unintended consequences of our public health policies.  With this in mind, and the possibility of other unknown variables, we need to target our prevention efforts toward those at greatest danger. We must agree on a clear, sensible, and attainable objective.  We must learn to live with the virus.