Primary prevention

Primary prevention consists of meticulous infection control. Hand washing and washing of shared toys will reduce the spread of viral infection.

The American Academy of Pediatrics (AAP) recommends that clinicians counsel carers about infant tobacco smoke exposure when assessing a child for bronchiolitis.[44]

Vaccines

No effective vaccine for respiratory syncytial virus (RSV) currently exists for infants.[45]​ However, there is a bivalent RSV prefusion F (RSVpreF) protein-based vaccine (commercially known as Abrysvo®) available for pregnant women to provide passive protection to infants from birth to age 6 months who are born during the RSV season.[46][47]

The Advisory Committee on Immunization Practices (ACIP) recommends the vaccine in pregnant women between 32 and 36 weeks’ gestation whose infants are expected to be born during the RSV season (during September through to the end of January in most of the continental US).[46]

Maternal vaccination is an alternative to immunoprophylaxis of infants (see below); both are not required for most infants. The Centers for Disease Control and Prevention (CDC) advocates providing information about both methods of protection to women who are pregnant during the RSV season. CDC: RSV in infants and young children Opens in new window

Immunoprophylaxis

Palivizumab and nirsevimab are monoclonal antibodies that are directed at targets on the RSV F protein and are approved for RSV immunoprophylaxis in infants and children. Palivizumab must be given monthly because of its shorter half-life in order to maintain protective levels. Nirsevimab has been engineered to be longer acting, with a prolonged half-life and a more potent action. It binds to the prefusion F1 and F2 subunits of the RSV F protein and blocks viral infection of the host cell.[48]​ Nirsevimab has the advantage of only requiring a single intramuscular dose (compared to 5 doses with palivizumab).

Palivizumab

Palivizumab was the first monoclonal antibody recommended for the passive immunisation of high-risk infants and children. Guidelines in the US and Europe currently recommend eligible infants receive palivizumab only if nirsevimab is not available.[47][49]​ Due to the cost and labour associated with this therapy, clinical guidelines recommend a maximum of 5 monthly doses of palivizumab during the RSV season to be given to only high-risk infants. Prophylaxis should be discontinued in any child who experiences a breakthrough RSV hospitalisation.

Nirsevimab

The AAP recommends nirsevimab over palivizumab because of its efficacy, duration of effect and convenience. The AAP and ACIP recommend a single dose of nirsevimab for:[49][50]

  • Infants aged <8 months, born during or entering their first RSV season whose mother did not receive RSVpreF vaccine, whose mother’s vaccine status is unknown, or who were born less than 14 days after their mother’s RSVpreF vaccination

  • Infants and children aged 8-19 months, entering their second RSV season and at increased risk of severe RSV disease regardless of mother’s prior immunisation status, including infants and children:

    • with chronic lung disease of prematurity requiring ongoing medical therapies within 6 months of the onset of the RSV season

    • with severe immunodeficiencies

    • with cystic fibrosis and severe lung disease (prior hospitalisation for pulmonary exacerbation, persistent chest radiographical abnormalities) or weight-for-length <10ᵗʰ percentile

    • who are Indigenous people (American Indian and Alaska Natives)

The APP also recommends nirsevimab in the following instances in which both forms of protection (passive immunoprophylaxis and active maternal vaccination) might be considered:[49]

  • Vaccinated parent who might not have mounted an adequate immune response to vaccination (i.e., because of an immunodeficiency) or have conditions associated with reduced transplacental antibody transfer (like HIV infection)

  • Infants who experienced loss of transplacentally acquired antibodies (i.e., after extracorporeal membrane oxygenation)

  • Infants at substantially higher risk for severe disease (e.g., haemodynamically significant congenital heart disease)

A single dose of nirsevimab at the start of the RSV season was shown to reduce the number of medically attended RSV-associated acute lower respiratory infections (ALRIs) by 70.1% (95% CI 52.3 to 81.2) versus placebo, and RSV-related hospitalizations by 78.4% (95% CI 51.9 to 90.3) among healthy preterm infants throughout 150 days following drug administration.[51]​ A single dose of nirsevimab given to late-preterm and full-term infants before an RSV season has shown significant reductions in medically attended RSV-associated ALRIs and RSV-related hospitalisations in the treated group versus placebo.[52]​ A real-world trial conducted across Europe among >8000 infants 12 months or younger of gestational age 29 weeks or greater demonstrated an 83.2% (95% CI 67.8 to 92.0) reduction in RSV-related hospitalisation in those treated versus those who did not receive immunoprophylaxis, and a reduction in very severe RSV hospitalisation, defined as a need for supplemental oxygen during hospitalisation, of 75.7% (95% CI 32.8 to 92.9) among those infants treated.[53]

Secondary prevention

Family members should practise good hand-washing techniques to avoid passing viral infection on to other family members.

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