Understanding RSV in Older Adults: Risks, Symptoms, and Barriers to Vaccination

In an interview with Pharmacy Times®, Derek Webb, PharmD, member of the Virginia Board of Pharmacy and pharmacy manager at Food City, explained that respiratory syncytial virus (RSV) in older adults often begins with cold-like symptoms but progresses to lower respiratory tract illness, which differentiates it from influenza and COVID-19. He noted that adults over 75 are automatically considered high risk due to immune decline, while those aged 50 to 74 qualify if they have chronic conditions such as heart, lung, kidney, or liver disease, as well as diabetes or obesity. Webb also highlighted barriers to vaccination, including low awareness of RSV risk, initial confusion over eligibility guidelines, and increased vaccine hesitancy and fatigue since the COVID-19 pandemic.

Pharmacy Times: Can you describe the typical clinical presentation of RSV in older adults and how it might differ from influenza or COVID-19?

Derek Webb, PharmD: I think it's important to note that respiratory syncytial virus, or RSV, has been around for decades. It's not something new. We have patients who present to the pharmacy with a runny or stuffy nose, coughing, and common cold-type symptoms. As RSV advances, it becomes more of a lower respiratory tract infection, leading to difficulty breathing and shortness of breath.

It’s difficult to differentiate RSV upfront, but as the disease progresses, it becomes easier to distinguish from the flu or COVID-19. Typically, patients with flu or COVID-19 present with upper respiratory symptoms initially, along with fever, body aches, chills, and similar complaints. With RSV, as the illness progresses, the symptoms are mostly lower respiratory tract related.

Pharmacy Times: What are the risk factors that place older adults at higher risk of severe RSV disease?

Webb: First and foremost, as we age, our immune systems decline to some degree. For RSV, the main indication based on age is 75 and up. We assume that anyone 75 or older has a declining or compromised immune system, which automatically qualifies them for an RSV vaccine because they are high risk.

For adults ages 50 to 64, it is more complicated. This group qualifies if they also have risk factors. The main risk factors for severe RSV are chronic heart disease, such as congestive heart failure; chronic lung disease, such as COPD or emphysema; chronic kidney or liver disease; severe obesity; or diabetes. These conditions make patients ages 50 to 74 eligible for vaccination.

Pharmacy Times: What have been some of the biggest barriers so far to RSV vaccine uptake in older adults?

Webb: There are definitely barriers. To start with some statistics: in the 75 and older population, only about 40% to 45% have been vaccinated with the recommended RSV vaccine dose. In the 50 to 64 age group, only about 30% of eligible individuals have been vaccinated. Clearly, uptake is an issue, and we can do a better job as healthcare providers in getting more people vaccinated.

The biggest barriers include low awareness of RSV risk. Many adults don’t associate RSV with being significant in their age group, since it was long thought of as a childhood disease. But RSV actually affects both ends of the spectrum—the very young and the elderly—who are highly susceptible to severe illness.

Another barrier is confusion about eligibility when the vaccine was first released in 2023. The CDC and ACFP recommended shared clinical decision-making for adults 60 and older, which caused uncertainty among healthcare providers and patients about who qualified.

Finally, since the COVID-19 pandemic, vaccine hesitancy and vaccine fatigue have increased. Many people are apprehensive about adding another vaccine to the schedule. There is a sense of burnout, but as healthcare providers, we need to remind people that the RSV vaccine is important and that they should not give up on protecting themselves.