Review of Respiratory Medicine - Volumen 25, N�mero 1 - March 2025

Original Articles

Respiratory Syncytial Virus: a Pathogen Diagnosed in the Physician’s Office

Virus sincitial respiratorio: un patógeno que se diagnostica en el consultorio

ABSTRACT

Background: The respiratory syncytial virus (RSV) is a public health challenge, since it is the leading cause of pneumonia in children and older adults. Its impact grew after the SARS-CoV-2 pandemic, as changes in contingency measures and the return to in-person activities can influence the increase in infections caused by RSV and other viruses.

Objective: To develop a comprehensive and standardized approach for the diagnosis, prevention, and treatment of RSV in primary healthcare with the aim of enhancing the quality of care and reducing the disease burden in the population, while raising awareness among the medical community about the importance of timely and differential diagnosis.

Materials and methods: A multidisciplinary panel of 7 specialists with extensive experi­ence in research and infectious diseases was assembled to analyze available scientific literature and establish the variables for RSV diagnosis and management. A real-time Delphi methodology was applied to reach a consensus. The consensus was considered achieved when an agreement of 80% or higher was reached.

Results: Unanimous consensus was reached on the importance of accurate diagnostic tests and symptomatic treatment for mild patients. The relevance of rapid diagnostic tests and expanded access in primary care was emphasized. Specific recommendations are presented in Table 1.

Conclusions: Rapid diagnostic tests are recommended, especially during seasonal periods, to achieve early and accurate RSV detection. This comprehensive approach results in better therapeutic decision-making, reduction in the use of unnecessary medi­cation, and the provision of preventive recommendations to patients.

Key words: Respiratory syncytial virus, Consensus, Diagnosis, Primary care

RESUMEN

Introducción: El virus sincitial respiratorio (VSR) es un desafío de salud pública pues es la causa principal de neumonía en niños y adultos mayores. Su impacto se acentuó después de la pandemia de SARS-CoV-2, pues los cambios en las medidas de contin­gencia como el regreso a la presencialidad pueden influir en el aumento de infecciones por VSR y otros virus.

Objetivo: Desarrollar un enfoque integral y estandarizado para el diagnóstico, pre­vención y tratamiento del VSR en la medicina primaria, con el objetivo de mejorar la calidad de la atención y reducir la carga de enfermedad en la población, mientras se hace conciencia sobre la importancia de un diagnóstico oportuno y diferencial entre la comunidad médica.

Materiales y métodos: Se integró un panel multidisciplinario compuesto por 7 espe­cialistas con amplia experiencia en infectología e investigación, para analizar literatura científica disponible y establecer las variables de diagnóstico y manejo del VSR. Se aplicó una metodología Delphi en tiempo real con el fin de alcanzar un consenso, el cual se consideró cuando hubo un acuerdo del 80%.

Resultados: Hubo consenso por unanimidad en la importancia de las pruebas diag­nósticas precisas y el tratamiento sintomático para pacientes leves. Se destacó la relevancia de las pruebas de diagnóstico rápido y la ampliación del acceso en atención primaria. Se sugiere utilizar las recomendaciones específicas expuestas en la tabla 1.

Conclusiones: Se sugiere utilizar pruebas de diagnóstico rápido, sobre todo durante los periodos estacionales, para lograr una detección temprana y precisa del VSR. Este enfoque integral se traduce en una mejor toma de decisiones terapéuticas, la reducción del uso injustificado de medicamentos y la oferta de recomendaciones preventivas a los pacientes.

Palabras clave: Virus sincitial respiratorio, Consenso, Diagnóstico, Atención primaria

Received: 10/29/2024

Accepted: 12/27/2024

INTRODUCTION

RSV represents a public health challenge, as it is one of the leading causes of community-acquired pneumonia in both children and older adults. De­spite the fact that it has been documented since the 1950s, an increase in the vulnerability and severity of cases has been observed following the SARS-CoV-2 pandemic.^1-4

In Mexico, constant monitoring is essential due to changes in contingency measures, the post-pandemic dynamics, and the return to in-person activities. All those factors could significantly increase infections caused by the RSV and other viruses. In this context, rapid viral detection tests are crucial for timely diagnosis, for adopting ap­propriate measures, and also for reducing the unnecessary use of medication.^1,5,6

This consensus summarizes the work of a multi­disciplinary group of experts, carried out in Mexico City on September 12, 2023, to establish strategies for detecting the RSV at the primary care level.

The main objectives were:

• To develop diagnostic strategies specifi­cally for Mexico by establishing guidelines adapted to the local population and epidemio­logical conditions.

• To promote medical awareness of the im­portance of timely and differential diag­nosis of RSV. This has to do with highlighting clinical implications and the need to avoid the unnecessary use of antibiotics and steroids in viral infections.

MATERIALS AND METHODS

A team of seven specialists in Pediatrics, Infectious Disea­ses, and Neonatology was assembled to conduct this study. The selection of these experts followed the criteria of Webler and collaborators,⁷ which include extensive experience in infectious diseases and remarkable scientific contributions.

The group conducted a review of the scientific litera­ture related to the RSV. Sources such as PubMed and the Cochrane Library were consulted, using descriptors like “respiratory syncytial virus,” “diagnosis,” “treatment,” and “epidemiology.” Initially, approximately 250 articles were identified in both databases. Exclusion criteria were applied, including duplicate articles, studies in languages other than English or Spanish, publications older than 10 years, studies involving non-human populations, reviews without meta-analyses, and reviews without full-text access. After this selection process, 22 studies were included which met the established criteria and provided relevant evidence for analysis.

Measurement scales

Thirty questions were developed and presented, distributed across four categories: epidemiology, clinical presentation, diagnosis, and treatment. The questionnaire included Likert scales and open-ended questions to encourage discussion.⁷

Consensus strategy

A real-time variant of the Delphi method was applied, based on the approach of Gnatzy et al,⁸ in which experts met in person but remained anonymous through an individual response platform. Consensus was defined as the agree­ment between 80% or more participants. Two rounds of interactive questions were conducted, allowing experts to provide written justifications for their responses.

The event was recorded on video, following the approach suggested by Webler et al⁷ for further analysis. The real-time Delphi survey results were presented in the form of graphs and subjected to quantitative analysis of structured responses. Additionally, a qualitative analysis of all discus­sions was conducted in order to identify common themes.

RESULTS

A majority consensus was reached on key aspects related to RSV infection (Table 1). The essential role of rapid diagnostic tests for early RSV detec­tion was highlighted. Symptomatic treatment is recommended for pediatric and adult patients that don’t have severe symptoms, while supportive measures should be applied in severe cases or cases with comorbidities. Hygiene measures and social distancing are also recommended to control the spread. These findings underscore the importance of accurate diagnostic tests and specific approaches in managing RSV infection.

Epidemiology

With regard to populations more prone to risk of complications from RSV infection, a hierarchy of risk was identified. The consensus was unanimous in that the most vulnerable are infants younger than 3–6 months at the start of an epidemic, fol­lowed by infants with chronic lung disease and congenital heart disease. Premature infants are particularly vulnerable, as they face significant risks of illness and various complications. In terms of viral load, the age group with the highest RSV load was unanimously identified as infants aged 1 to 23 months.^1-5

There was a lack of consensus on long-term immunity following RSV infection. While some experts highlighted the importance of components such as lactoferrin and IgA in breast milk for infant immune protection,⁹ it was suggested that this could provide protection rather than true immunity.

The seasonal nature of RSV infection is con­sidered a key factor in planning prevention and diagnostic strategies.² This has become even more relevant in the context of the SARS-CoV-2 pandemic, highlighting the need for continuous surveillance throughout the year to effectively manage RSV infections. In this regard, vacci­nation plays a fundamental role in preventing severe diseases. This emphasizes the need to integrate preventive strategies that include vaccination as a crucial measure to reduce the burden of RSV.¹⁰

Clinical presentation

The panel unanimously agrees that RSV infection symptoms are nonspecific and primarily affect the lower respiratory tract, potentially leading to pneumonia and respiratory failure.^1-6

It is essential to underline the fact that respi­ratory infections caused by different viruses may present with a similar clinical presentation.¹¹ Therefore, the participants emphasize the impor­tance of developing virological studies in order to accurately identify the causal agent and make ap­propriate therapeutic decisions. The panel reached unanimous consensus on the fact that multiple tests are necessary to determine the causal agent of respiratory infections and ensure appropriate treatment.

Diagnosis

With unanimous support from the panel, it was established that RSV rapid testing should be per­formed only during seasonal outbreaks (fall and winter) to avoid false positives. These tests play a crucial role in timely RSV identification and treat­ment guidance.^1,2,5

The panel aligns with the existing literature, which identifies the nasopharyngeal swab as the ideal sample for RSV detection.¹² Additionally, 85% of the panel reached a consensus on the validity of using rapid tests, particularly due to their sensitivity and specificity. For optimal point-of-care (POC) testing, unanimous agreement was reached that these tests should be highly sensitive, easy to use, and cost-effective, and should facilitate informed decision-making.

On the other hand, the importance of diag­nostic tests providing clear results was empha­sized, as faint lines in antigen tests may lead to diagnostic uncertainty. Speed is a key factor in these tests, with the goal of obtaining results in less than 30 minutes. In this context, the BD Veritor Plus has proven useful for rapid RSV detection, particularly in pediatric settings, due to its high specificity. However, its moderate sen­sitivity suggests that a negative result does not completely rule out the RSV, and in some cases, confirmation with more sensitive tests such as RT-PCR (reverse transcription polymerase chain reaction) may be necessary. Compared to other rapid detection systems, such as the Sofia, the BD Veritor Plus has somewhat lower sensitivity (71.15% compared to Sofia’s 80.77%), but both share 100% specificity.^13,14,15

With regard to the diagnostic tests, accord­ing to the literature, the RT-PCR is consid­ered the most sensitive, with a sensitivity that is higher than rapid antigen detection tests (RADTs), viral cultures, and other tech­niques.^13,14 However, rapid antigen tests, such as the BD Veritor, have high specificity (100%), making them useful for confirming infections when the result is positive, although their lim­ited sensitivity should be considered, especially in adults. The sensitivity of RADT tests var­ies, showing better results in children (81%) compared to adults (29%).¹³ As for rapid mo­lecular tests, these are also an attractive option due to their high sensitivity and specificity, with sensitivity values up to 73.08% and 90% specificity. Finally, direct fluorescent antibody (DFA) tests and viral cultures have 83% and 86% sensitivity, respectively (CHUCK).

100% of the attendees agree on the importance of the routine use of RSV diagnostic tests in pa­tients with respiratory symptoms. It is proposed that rapid tests be conducted at the first point of contact using devices like the BD Veritor System RSV to detect common respiratory viruses.16 Ad­ditionally, the RT-PCR is classified as the best diagnostic test in the clinical setting and is the most widely used in Mexico.¹²

Treatment

Unanimously, the proposal for managing patients with a confirmed RSV infection is to promote hygiene measures and social distancing so as to control the spread and manage close contacts.^1,2,5 The use of isolation as a preventive measure is not supported; instead, emphasis is placed on symptom observation, even in vulnerable populations.

On the other hand, symptomatic treatment is recommended for patients with mild RSV infec­tion.^1-5 In patients with comorbidities and severe symptoms, supportive measures must be taken and additional infections shall be ruled out. ^4,17

Access

The expert panel unanimously agrees that the availability and access to rapid diagnostic tests for RSV detection should be expanded in primary care centers. This would be achieved through the implementation of continuous medical education strategies to raise awareness about the importance of having the appropriate equipment for such tests in primary care settings and teaching hospitals.^18,19

The main characteristic that is to be expected from rapid diagnostic systems is the ability to provide accurate and specific results to ensure a reliable detection of the infection and support clinical decision-making. In situations where the simultaneous evaluation of different respiratory vi­ruses is required, 100% of the panel agrees that the ideal approach would be to obtain multiple results with a single test strip. However, it is important to underline the fact that the choice of a viral panel may depend on the population in question, as the etiology of respiratory infections varies between adults and children. In general, viral panels show higher sensitivity in children, making them the preferred option for this population. Adults tend to have lower sensitivity, although they maintain high specificity. This difference highlights the im­portance of selecting the appropriate panel based on the population and clinical situation. The abil­ity to obtain multiple simultaneous results with a single panel can be beneficial by providing an accurate diagnosis, guiding appropriate treatment, and expediting clinical management.^19-21

DISCUSSION

This article addresses fundamental aspects of managing RSV infection in primary care, always taking into account the health policies of each country. The primary care level and training of healthcare personnel may depend on the socioeco­nomic context, that is why it is very important to adapt the diagnostic, prevention, and treatment strategies to local particularities. RSV infection presents a wide range of clinical manifestations, ranging from mild symptoms to severe respiratory infections.^5,6 In this regard, several aspects related to its diagnosis, prevention, and treatment need to be considered.

First, it is essential to establish an accurate RSV diagnosis in patients presenting respiratory symptoms.^5,6 RSV symptoms are similar to those of other respiratory viruses, thus making diagnosis challenging.²² Therefore, the access to rapid tests at the first point of contact gains relevance. These tests allow for early identification and appropriate treatment while reducing virus transmission.^17,22

Additionally, prevention strategies should be taken into account for high-risk populations, such as premature newborns and patients with underly­ing medical conditions like heart or lung diseases, who are more susceptible to developing severe RSV infections. Screening and the implementation of preventive measures, including vaccination, are essential in primary care.^1-6,10

RSV poses a challenge in primary care due to its broad spectrum of clinical manifestations and the need for accurate diagnostic tests. Prevention, particularly in high-risk populations, is a vital component of RSV management. Despite advances in diagnosis and prevention, more research is necessary.

CONCLUSIONS

This article provides guidance for the diagnosis and symptomatic management of patients with RSV infection at the first point of contact. These guidelines will be important tools for healthcare professionals at this level of care, facilitating a deeper understanding of disease progression, potential complications, and effectiveness of in­terventions.

This initiative aligns with best practices in infec­tious disease care and represents a significant step forward in improving the management of patients with RSV infection, aiming to reduce complications and contribute to public health.

Acknowledgement

To Becton Dickinson México for the funding of the Real- Time Delphi platform. To Miramar Descience for developing the consensus and Maria Conchita Hernández and Paula Heatley for writing this article.

Conflict of interest

There are no conflicts of interest.

Funding

This work has been partially funded by Becton Dickinson México.

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