A Pharmacist's Role in Protecting Older Adults From RSV: A Conversation With Marilyn Bulloch, PharmD, BCPS, FCCM

Respiratory syncytial virus (RSV) poses a significant threat to older adults, whose weakened immune systems and underlying health conditions increase their risk for severe illness. With new vaccines now available, pharmacists are uniquely positioned to educate, guide, and support patients in preventing RSV and its complications. In this conversation with Pharmacy Times, Marilyn Bulloch, PharmD, BCPS, FCCPFCCM, shares insights on RSV risks, vaccine options, and pharmacists’ critical role in protecting older adults during respiratory virus season.

Q: What makes older adults especially vulnerable to severe RSV infections compared with younger populations?

A: As people age, both their innate and adaptive immune system function declines. This makes it harder for them to battle any infection. It also makes it harder to recover when they get an infection. RSV tends to spread to the lower respiratory system in older adults, which can lead to more severe illnesses that are even harder to recover from. This by itself would make our older patients more vulnerable, but many also have decreased lung function. This can be a matter of age—some people have decreased respiratory muscle strength, and others may have decreased lung compliance. RSV can be particularly difficult in patients with these issues. This is all before considering that RSV is known to exacerbate chronic conditions that many geriatric patients have, [such as] COPD [chronic obstructive pulmonary disease] or heart failure.

Q: What key symptoms should pharmacists advise older adults and caregivers to watch for when it comes regarding RSV?

A: I think it is fair to say that healthier older adults could have symptoms similar to younger adults that present like a mild cold: cough, sore throat, headache, and runny nose. Some may have a fever and not feel like eating. Some patients may wheeze. Those with chronic conditions that already impact the lungs, [such as] COPD [chronic obstructive pulmonary disease], can have difficulty breathing. If the virus spreads to the lower respiratory tract, it can cause viral pneumonia or inflammation of the small airways (a condition called bronchiolitis). Viral pneumonia is not exactly the same as a pneumonia caused by bacteria (which most people are more familiar with). When this happens, the fever is higher and the cough is more severe. Viral pneumonia tends to be a much more severe infection with more complications. 

Q: What role do pharmacists play in educating patients about RSV prevention, including vaccines and infection control practices?

A: Pharmacists in general have a reputation for providing fair, objective, and unbiased information that is evidence-based. Just as we would with any other medication, we need to stay up to date on the studies and literature so that we can make sure we optimize the use of these vaccines. We can not only educate our patients, but [also] other health care providers. Helping them understand the nuances of the different vaccines can help them in their own patient education and vaccine selection strategies.

Q: With new RSV vaccines available, how can pharmacists help older adults understand their options and make informed decisions?

A: Vaccines are like any other medication; there may not always be a one-size-fits-all approach. There are 3 different RSV vaccines available. While all 3 are effective, there are some slight, subtle differences (aside from efficacy) that, in very select patients, may make one better to use than another or make a patient more receptive to being vaccinated. Presenting this information and reasoning to patients helps them feel like the immunization recommendation is not a generic statement but intentionally tailored to them as an individual. For some patients, just knowing that they have options and allowing that shared decision-making can be a big benefit in helping them decide to get vaccinated.

It is important to refrain from being judgmental. We can still be firm and clear in our recommendations for vaccinations while being respectful of our patients’ autonomy. When there is mutual respect, there is a greater opportunity for patients to actually take those recommendations.

Q: What challenges do you see in improving RSV vaccination rates among older adults, and how can pharmacists help overcome them?

A: Many older adults simply do not know that the vaccines even exist, much less that they would benefit from receiving one. Awareness itself is a big challenge. Another challenge is that people forget that many older adults can no longer get out into the community by themselves anymore. This is true for patients who live at home, but we have to remember older adults living in nursing facilities and group homes as well. They cannot always go to the pharmacy or to a clinic to get the vaccine. Medicare has a program to pay for in-home vaccination administration for some vaccines, but unfortunately, RSV is not currently on the list.

Q: How can pharmacists work with physicians, nurses, and other health care providers to create a comprehensive RSV prevention strategy for older adults?

A: Collaboration is key. It is important for health care providers, particularly those in the same community, to deliver a similar message to patients. Mixed messages about who should get the RSV vaccine, when they should get it, and which one they should receive decreases the likelihood that the patient will actually get the vaccine. Many pharmacies carry the vaccine, which can offload work from busy clinical and physician practices. However, there are some primary care providers who prefer to administer their own vaccinations. If that is the case, understanding and respect can help facilitate that interprofessional collaboration. If a patient does receive the vaccine at the pharmacy, it improves collaboration and continuity of care [by notifying] the patient’s primary care physician and other providers so that the patient’s records can be consistent and up to date.

Q: What communication strategies can be most effective when discussing RSV risks and vaccines with older adult patients?

A: Be patient and honest. Try to avoid a parent-like approach when talking to the patient. Sometimes it can be useful to relate vaccines to other medications that they already take. This can be particularly helpful when you are trying to communicate how the vaccines prevent infection, how they have been studied and monitored, and that no medication (including vaccines) can ever prevent 100% of issues. Many patients with heart failure and COPD understand this. Taking their medications as instructed helps [control] their disease and its progression, but they can still have exacerbations.

Q: How do you see the pharmacist’s role in RSV prevention fitting into the broader public health landscape, especially during respiratory virus season?

A: Any infection in the lungs weakens them and can make patients more vulnerable to another lung infection. Although everyone thinks of the colder months as peak time for viruses, infections from other pathogens (most commonly bacteria) are also circulating. One infection is hard enough, but multiple infections from different types of organisms can have a significant negative impact on the body. By encouraging older adults who have not yet had the RSV vaccine but who qualify (ie, those older than 75 or those aged 50 and older who are at high risk) to get vaccinated in the late summer, we can help provide protection before RSV and other pathogens begin circulating in depth. 

Q: What advancements or changes do you hope to see in RSV prevention and management for older adults?

A: Vaccines are the best way to prevent RSV, but we all know patients who cannot receive certain vaccines for legitimate medical reasons. We also have patients who are unable to mount a full immune response to a vaccine. I would love to see an effective antiviral developed for these patients that can help significantly reduce complications of RSV in our vulnerable older population.