Respiratory Syncytial Virus: Immunisation and Prophylaxis


Respiratory syncytial virus (RSV) is the second most common cause of mortality in infants worldwide after malaria and the leading cause of hospitalisation in infants in many countries. It is also associated with high levels of morbidity and mortality in older adults (those over 60 years of age). These high levels of healthcare utilisation result in huge associated healthcare costs. As such, the development of an RSV vaccine is listed as a leading global priority by the World Health Organization (WHO). There is a monoclonal antibody (palivizumab) licensed to prevent RSV infection, but it is only used in high‐income countries for the most high‐risk infants owing to its very high cost. The development of an RSV vaccine/prophylactic agent has been hampered by an incomplete understanding of the immunopathogenesis of RSV infection, although many are currently undergoing clinical trials. Adding a new vaccine to the existing vaccine schedules will also present many challenges.

Key Concepts

  • Respiratory syncytial virus (RSV) is a leading cause of morbidity and mortality worldwide in infants, children and older adults.
  • Agents to prevent severe RSV infection are needed to reduce this burden of disease.
  • The immunopathogenesis of RSV infection is incompletely understood, hampering the development of a vaccine.
  • Palivizumab, a monoclonal antibody, is licensed for use in high‐risk infants, but is extremely expensive, and thus newer agents are required.
  • Many RSV vaccines and novel prophylactic monoclonal antibodies are in development, although a licensed product is likely to still be many years away.
  • After a vaccine becomes licensed, there is still a need to ensure that it can be incorporated into the existing vaccine schedules.

Keywords: respiratory syncytial virus; palivizumab; ribavirin; infants; older adults

Figure 1. The host immune response to RSV (respiratory syncytial virus) infection. Reproduced with permission from Rossi and Colin © ERS 2015.


Bentley A, Filipovic I, Gooch K, et al. (2013) A cost‐effectiveness analysis of respiratory syncytial virus (RSV) prophylaxis in infants in the United Kingdom. Health Economics Review 3: 18. DOI: 10.1186/2191-1991-3-18.

Blair W and Cox C (2016) Current landscape of antiviral drug discovery. F1000Research 5: 202. DOI: 10.12688/f1000research.7665.1.

Blanken MO, Rovers MM, Molenaar JM, et al. (2013) Respiratory syncytial virus and recurrent wheeze in healthy preterm infants. New England Journal of Medicine 368: 1791–1799. DOI: 10.1056/NEJMoa1211917.

Carbonell‐Estrany X, Simões EA, Dagan R, et al. (2010) Motavizumab for prophylaxis of respiratory syncytial virus in high‐risk children: a noninferiority trial. Pediatrics 125: e35–e51.

Carbonell‐Estrany X, Pérez‐Yarza EG, García LS, et al. (2015) Long‐term burden and respiratory effects of respiratory syncytial virus hospitalization in preterm infants‐The SPRING study. PLoS One 10: 1–16. DOI: 10.1371/journal.pone.0125422.

Cromer D, van Hoek AJ, Newall AT, et al. (2017) Burden of paediatric respiratory syncytial virus disease and potential effect of different immunisation strategies: a modelling and cost‐effectiveness analysis for England. Lancet Public Health 2: e367–e374. DOI: 10.1016/S2468-2667(17)30103-2.

Drysdale SB, Sande CJ, Green CA, et al. (2016) RSV vaccine use – the missing data. Expert Review of Vaccines 15: 149–152. DOI: 10.1586/14760584.2016.1114419.

Falsey AR and Walsh EE (2000) F. Respiratory syncytial virus infection in adults. Clinical Microbiology Reviews 13: 371–384.

Falsey A, Hennessey P, Formica M, et al. (2005) Respiratory syncytial virus infection in elderly and high risk adults. New England Journal of Medicine 352: 1749–1759. DOI: 10.1056/NEJMoa043951.

Feltes TF, Cabalka AK, Meissner HC, et al. (2003) Palivizumab prophylaxis reduces hospitalization due to respiratory syncytial virus in young children with hemodynamically significant congenital heart disease. Journal of Pediatrics 143: 532–540. DOI: 10.1067/S0022-3476(03)00454-2.

Fleming DM, Taylor RJ, Lustig RL, et al. (2015) Modelling estimates of the burden of Respiratory Syncytial virus infection in adults and the elderly in the United Kingdom. BMC Infectious Diseases 15: 443. DOI: 10.1186/s12879-015-1218-z.

de Fontbrune FS, Robin M, Porcher R, et al. (2007) Palivizumab treatment of respiratory syncytial virus infection after allogeneic hematopoietic stem cell transplantation. Clinical Infectious Diseases 45: 1019–1024. DOI: 10.1086/521912.

Glenn GM, Fries LF, Thomas DN, et al. (2015) A randomized, blinded, controlled, dose‐ranging study of a respiratory syncytial virus recombinant fusion (F) nanoparticle vaccine in healthy women of childbearing age. Journal of Infectious Diseases 213 (3): 411–422.

Glezen WP, Taber LH, Frank AL, et al. (1986) Risk of primary infection and reinfection with respiratory syncytial virus. American Journal of Diseases of Children 140: 543–546.

Green CA, Yeates D, Goldacre A, et al. (2016) Admission to hospital for bronchiolitis in England: trends over five decades, geographical variation and association with perinatal characteristics and subsequent asthma. Archives of Disease in Childhood 101: 140–146. DOI: 10.1136/archdischild-2015-308723.

Han LL, Alexander JP and Anderson LJ (1999) Respiratory syncytial virus pneumonia among the elderly: An assessment of disease burden. Journal of Infectious Diseases 179: 25–30.

Hardelid P, Pebody R and Andrews N (2013) Mortality caused by influenza and respiratory syncytial virus by age group in England and Wales 1999–2010. Influenza and Other Respiratory Viruses 7: 35–45. DOI: 10.1111/j.1750-2659.2012.00345.x.

Ka R, Oa O and Ij S (2012) Palivizumab for prophylaxis against respiratory syncytial virus infection in children with cystic fibrosis. Cochrane Database of Systematic Reviews 2: CD007743. DOI: 10.1002/

Kapikian AZ, Mitchell RH, Chanock RM, et al. (1969) An epidemiologic study of altered clinical reactivity to respiratory syncytial (RS) virus infection in children previously vaccinated with an inactivated RS virus vaccine. American Journal of Epidemiology 89: 405–421.

Kassis C, Champlin RE, Hachem RY, et al. (2010) Detection and control of a nosocomial respiratory syncytial virus outbreak in a stem cell transplantation unit: the role of palivizumab. Biology of Blood and Marrow Transplantation 16: 1265–1271. DOI: 10.1016/j.bbmt.2010.03.011.

Kim HW, Canchola JG, Brandt CD, et al. (1969) Respiratory syncytial virus disease in infants despite prior administration of antigenic inactivated vaccine. American Journal of Epidemiology 89: 422–434.

Lambert L, Sagfors AM, Openshaw PJM, et al. (2014) Immunity to RSV in early‐life. Frontiers in Immunology 5: 1–14. DOI: 10.3389/fimmu.2014.00466.

Lozano R, Naghavi M, Foreman K, et al. (2012) Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 380: 2095–2128. DOI: 10.1016/S0140-6736(12)61728-0.

Mazur NI, Martinón‐Torres F, Baraldi E, et al. (2015) Lower respiratory tract infection caused by respiratory syncytial virus: current management and new therapeutics. The Lancet Respiratory Medicine 3: 888–900.

MedImmune (2010) MedImmune Discontinues Development of Motavizumab for RSV Prophylaxis Indication.‐us/media/medimmune‐discontinues‐development‐of‐motavizumab‐for‐rsv‐prophylaxis‐indication‐20101221.html#! (accessed 12 Nov 2017).

Meijboom MJ, Pouwels KB, Luytjes W, et al. (2013) RSV vaccine in development: assessing the potential cost‐effectiveness in the Dutch elderly population. Vaccine 31: 6254–6260. DOI: 10.1016/j.vaccine.2013.10.023.

Nair H, Nokes DJ, Gessner BD, et al. (2010) Global burden of acute lower respiratory infections due to respiratory syncytial virus in young children: a systematic review and meta‐analysis. Lancet 375: 1173–1181. DOI: 10.1016/S0140-6736(09)62100-0.

National Institute for Health and Care Excellence (2015) Bronchiolitis: Diagnosis and Management of Bronchiolitis in Children. Clinical Guideline NG 9. London: National Institute for Health and Care Excellence.

Novovax (2016) Novavax Announces Topline RSV F Vaccine Data from Two Clinical Trials in Older Adults.‐releases/news‐release‐details/novavax‐announces‐topline‐rsv‐f‐vaccine‐data‐two‐clinical‐trials (accessed 12 Nov 2017).

O'Brien KL, Chandran A, Weatherholtz R, et al. (2015) Efficacy of motavizumab for the prevention of respiratory syncytial virus disease in healthy Native American infants: a phase 3 randomised double‐blind placebo‐controlled trial. Lancet Infectious Diseases 15: 1398–1408. DOI: 10.1016/S1473-3099(15)00247-9.

Openshaw PJM, Culley FJ and Olszewska W (2001) Immunopathogenesis of vaccine‐enhanced RSV disease. Vaccine 20: 27–31. DOI: 10.1016/S0264-410X(01)00301-2.

Openshaw PJM, Chiu C, Culley FJ, et al. (2017) Protective and harmful immunity to RSV infection. Annual Review of Immunology 35: 501–532. DOI: 10.1146/annurev-immunol.

PATH (2015) PATH RSV Vaccine Snapshot, September 2017.

PATH (2017) RSV Vaccine and mAb Snapshot. (accessed 7 Feb 2017).

Prescott W and Hutchinson D (2011) Respiratory syncytial virus prophylaxis in special populations: is it something worth considering in cystic fibrosis and immunosuppression? Journal of Pediatric Pharmacology and Therapeutics 16: 77–86.

Public Health England (2015) Immunisation Against Infectious Disease. ‘The Green Book’.

Ralston SL, Lieberthal AS, Meissner HC, et al. (2014) Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics 134: e1474–e1502. DOI: 10.1542/peds.2014-2742.

Régnier S and Huels J (2013) Association between respiratory syncytial virus hospitalizations in infants and respiratory sequelae. Pediatric Infectious Disease Journal 32: 1. DOI: 10.1097/INF.0b013e31829061e8.

Rossi GA and Colin AA (2015) Infantile respiratory syncytial virus and human rhinovirus infections: respective role in inception and persistence of wheezing. European Respiratory Journal 45: 774–789. DOI: 10.1183/09031936.00062714.

Shay DK, Holman RC, Newman RD, et al. (1999) Bronchiolitis‐associated hospitalizations among US children, 1980‐1996. JAMA 282: 1440–1446. DOI: 10.1001/jama.282.15.1440.

Shi T, Balsells E, Wastnedge E, et al. (2015) Risk factors for respiratory syncytial virus associated with acute lower respiratory infection in children under five years: systematic review and meta‐analysis. Journal of Global Health 5: 20416. DOI: 10.7189/jogh.05.020416.

Shi T, McAllister DA, O'Brien KL, et al. (2017) Global, regional, and national disease burden estimates of acute lower respiratory infections due to respiratory syncytial virus in young children in 2015: a systematic review and modelling study. Lancet 390: 946–958. DOI: 10.1016/S0140-6736(17)30938-8.

The IMpact‐RSV study Group (1998) Palivizumab, a humanized respiratory syncytial virus monoclonal antibody, reduces hospitalization from respiratory syncytial virus infection in high‐risk infants. Pediatrics 102: 531–537. DOI: 10.1542/peds.102.3.531.

Wang D, Cummins C, Bayliss S, et al. (2008) Immunoprophylaxis against respiratory syncytial virus (RSV) with palivizumab in children: a systematic review and economic evaluation. Health Technology Assessment 12: iii, ix–x, 1–86.

Wegzyn C, Toh LK, Notario G, et al. (2014) Safety and effectiveness of palivizumab in children at high risk of serious disease due to respiratory syncytial virus infection: a systematic review. Infectious Disease and Therapy 3: 133–158. DOI: 10.1007/s40121-014-0046-6.

Weisman LE (2003) Populations at risk for developing respiratory syncytial virus and risk factors for respiratory syncytial virus severity: infants with predisposing conditions. Pediatric Infectious Disease Journal 22: S33–S37; discussion S37–9. DOI: 10.1097/00006454-200302001-00005.

Welliver RC (2007) Temperature, humidity, and ultraviolet B radiation predict community respiratory syncytial virus activity. Pediatric Infectious Disease Journal 26: S29–S35. DOI: 10.1097/INF.0b013e318157da59.

Widmer K, Zhu Y, Williams JV, et al. (2012) Rates of hospitalizations for respiratory syncytial virus, human metapneumovirus, and influenza virus in older adults. Journal of Infectious Diseases 206: 56–62. DOI: 10.1093/infdis/jis309.

World Health Organization (2014) Principles and Considerations for Adding a Vaccine to a National Immunization Programme‐From Decision to Implementation and Monitoring. (accessed 12 Nov 2017).

World Health Organization (2017) RSV Vaccine Research and Development Technical Roadmap and WHO Preferred Product Characteristics. (accessed 12 Nov 2017).

Zomer‐Kooijker K, Van Der Ent CK, Ermers MJJ, et al. (2014) Increased risk of wheeze and decreased lung function after respiratory syncytial virus infection. PLoS One 9: 3–8. DOI: 10.1371/journal.pone.0087162.

Further Reading

Caballero MT, Polack FP and Stein RT (2017) Viral bronchiolitis in young infants: new perspectives for management and treatment. Jornal de Pediatria. pii: S0021‐7557(17)30658‐7.

Graham BS (2017 Apr) Vaccine development for respiratory syncytial virus. Current Opinion in Virology 23: 107–112.

Karron RA and Zar HJ (2017) Determining the outcomes of interventions to prevent respiratory syncytial virus disease in children: what to measure? The Lancet Respiratory Medicine. pii: S2213‐2600(17)30303‐X.

Rossey I, McLellan JS, Saelens X and Schepens B (2017) Clinical potential of prefusion RSV F‐specific antibodies. Trends in Microbiology. pii: S0966‐842X(17)30214‐7. doi: 10.1016/j.tim.2017.09.009.

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Barr, Rachael, and Drysdale, Simon B(Feb 2018) Respiratory Syncytial Virus: Immunisation and Prophylaxis. In: eLS. John Wiley & Sons Ltd, Chichester. [doi: 10.1002/9780470015902.a0027784]