FormalPara Key Summary Points

Why carry out this study?

Respiratory syncytial virus (RSV) is a frequent pathogen that can significantly affect respiratory health during early childhood, leading to considerable utilisation of healthcare resources.

The effects of the infection not only pertain the child itself but also daily family life, yet comprehensive scientific understanding of its overall impact including health-related quality of life and associated dimensions remains limited.

What was learned from the study?

Asking affected parents during the 2022–2023 RSV season across Europe, the study aimed to investigate the overall burden of RSV-induced pediatric hospitalisation on families.

RSV-related hospitalisations in young children impose a significant and diverse burden on the entire family with profound consequences for both personal and professional aspects of life.

(Standardised) holistic strategies that tackle both direct and structural obstacles to effective disease management are needed.

Introduction

Respiratory syncytial virus (RSV) is a frequent, highly contagious virus affecting both children and adults [1]. Typically, it is accompanied by symptoms resembling a common cold with an uncomplicated disease course. However, predominantly infants and younger children may experience more severe disease outcomes which are not restricted to those with underlying medical conditions [2, 3]. In such cases, what would usually be a mild cold-like illness can rapidly become a serious health threat, necessitating hospitalisation. Globally, in 2019 about 33 million cases of acute lower respiratory tract infections (LRTI) resulted in more than three million hospitalisations in children below the age of 5 years, with the need for (invasive) supportive care measures such as supplemental oxygen, fluid replacement, mechanical ventilation or intubation [4, 5].

In recent years, there has been a notable surge in severe pediatric RSV infections following the cessation of preventive measures implemented during the COVID-19 pandemic [6, 7]. In parallel, awareness of the disease and its potential impact has developed to a less rapid scale [8]. Thus, many lack the knowledge of what consequences an RSV infection can have not only for the affected child itself but for the entire family. Particularly parents and caregivers may undergo a decline in their health-related quality of life, extending to the manifestation of post-traumatic stress symptoms, when family dynamics suddenly face an unexpected shift due to a child’s hospitalisation [9]. Published research is still scarce on appropriate caregiver-specific patient-reported outcome measures (PROMs) that precisely capture the comprehensive impact of a child’s RSV-induced hospitalisation on the quality of life of parents [10,11,12,13]. With the aim of filling existing research gaps, the ResQ Family project was initiated [14].

The main objective of the study was to investigate the overall burden of RSV-induced hospitalisation of children on affected families. By examining the child’s health status and its potential effects on various aspects of family life, we aimed to elucidate the consequences for parental health-related quality of life (HRQoL) and family functioning, both during the acute infection phase and 6 weeks later. This investigation included dimensions such as feelings of stress and worry, alongside assessing work productivity loss, parental disease awareness as well as existing support structures. Additionally, we aimed to uncover potential country-specific disparities across Europe.

Methods

Detailed information regarding the study’s methodology can be found in a recently published study protocol [14]. Main important points are briefly summarised below.

Study Population and Design

This international observational cross-sectional study was performed using a web-based, online questionnaire. During the 2022–2023 RSV season (between September 2022 and May 2023) in Germany, France, Italy and Sweden parents and caregivers of children (< 24 months of age) with an RSV-induced hospitalisation were recruited to share their perspective into family life throughout the course of the disease episode.

Participants were primarily recruited through social media outreach efforts of the European Foundation for the Care of Newborn Infants (EFCNI). Additionally, the established network of national parent organisations (SOS Préma, Bundesverband das frühgeborene Kind e.V., Svenska Prematurförbundet, Vivere Onlus) as well as partnering healthcare professionals and healthcare societies (European Society for Paediatric Research (ESPR), Union of European Neonatal & Perinatal Societies (UENPS) and the Respiratory Syncytial Virus Foundation (ReSViNET)) played a crucial role in supporting the recruitment by sharing the survey-link through both their hospital networks and various social media channels.

Participants were planned to be first approached within a time span of 4 weeks starting on the day of the RSV-induced hospitalisation of the child (t0). Upon finishing the initial questionnaire at time t0, parents were contacted via e-mail and invited to contribute to a follow-up survey 6 weeks later (t1). Participants who did not respond to our initial request received up to four reminder emails, spaced at an average interval of 21 days.

Questionnaire

To facilitate a participatory research approach, the study was designed by a multidisciplinary working group comprising researchers from EFCNI’s scientific affairs and research department as well as external experts from all four participating countries. Researchers specialised in the field of respiratory diseases and/or PROMs with a particular focus on HRQoL built an external scientific advisory board (ESAB) counselling the process of survey development. A project expert group (PEG) including pediatric and neonatal healthcare professionals as well as parent and patient representatives critically reviewed and gave feedback on the draft questionnaire, helped with the translation and carried out pre-tests, prior to being transferred to an online survey tool (SurveyMonkey).

The final version of the initial questionnaire consisted of 84 single- and multiple-choice closed and one open question, whereas the follow-up survey counted a reduced set of items (23 single- and multiple-choice closed and one open question). Both questionnaires comprised a combination of validated and self-developed items collecting data on the participating parent/caregiver and the affected child. The questions included were summarised in several topics: (1) background information (including child’s comorbidities), (2) RSV symptoms and healthcare resource utilisation, (3) parental worry and feelings, (4) parental HRQoL and family functioning, (5) loss of work productivity, (6) RSV awareness and support structures as well as (6) overall burden of the families during the acute infection phase and 6 weeks later (follow-up). The standardised and caregiver specific, self-report questionnaire Pediatrics Quality of Life Family Impact Module 2.0 (PedsQL FIM) served as the primary PROM instrument assessing the impact of RSV on parental HRQoL and family functioning [15,16,17]. Comprising 36 Likert-scaled items representing various dimensions (physical, emotional, social and cognitive functioning, communication, worry, family daily activities and family relationships), the PedsQL FIM generates three sum scores ranging from 0 to 100: the total score, the parent HRQoL summary score and the family functioning summary score, with higher scores indicating better parental HRQoL and/or family functioning [15]. The English version of the initial as well as the follow-up questionnaire is provided in the Supplementary Material.

Statistical Analysis

Elaborating on the burden of RSV infections in everyday family life, statistical analysis was conducted by descriptive evaluations of all parameters included in the data set. Categorical variables were illustrated using absolute numbers and percentages, while continuous variables were described with medians and interquartile ranges. Subgroup analysis aimed to further elucidate how the participating countries differed with regards to the perceived burden of the affected families. Pearson’s chi-square/Fisher’s exact test for categorical variables and analysis of variance (ANOVA) test (or a non-parametric alternative if normal distribution was not given) for continuous variables were used to examine potential differences between the subcategories. Responses to multiple-choice questions were analysed as sum of answers per answer option, n (%), allowing the total to exceed 100%.

Having a special focus on the overall burden of affected families, a change over the observation period with regard to the subjectively perceived general health status of the parents before, during (t0) and after (t1) the infection as well as parental HRQoL and family functioning (PedsQL FIM sum scores) during (t0) and after (t1) the infection were calculated by applying the Friedmann test and paired t tests (pre–post effects), respectively.

All analyses were conducted using the statistical software R (R version 4.2.2) (R Core Team (2022). R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. URL https://www.R-project.org/). Statistical significance was determined with a threshold of p values below 0.05 and all missing values were excluded from the primary analysis.

Ethics and Privacy

Prior to initiating recruitment of the study, the Ethics Committee of the University of Maastricht in the Netherlands officially waived the requirement for ethics approval (reference number METC 2022-3307). Following the confirmation of ethical exemption, the study was registered on clinicaltrials.gov (NCT05550545). Data collection, processing, and storage adhered to the General Data Protection Regulation and the Declaration of Helsinki. The study itself followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline for cohort studies. Informed consent was secured from all participants through a confirmation box checked before starting the questionnaire. Participants were informed about the potential for distressing reactions regarding their personal situations or experiences and were given the opportunity to cease participation at any point during the survey. No financial incentives were provided to study participants.

Results

In total, 138 participants from four European countries with complete information in the initial questionnaire were included in the study. Of these, 59 also responded to the follow-up survey. A flow chart of inclusion is shown in Fig. 1. Baseline characteristics for the total set of the study sample and broken down by country can be found in Table 1 and the Supplementary Table S1. In short, most of the participants filling out the questionnaire were mothers (n = 134, 97.1%; fathers n = 3, 2.2%; “other” n = 1, 0.7%), had a median age of 32.5 (range 22–45 years) and had a higher level of education (university degree n = 79, 57.7%). When examining the children affected, 78.3% had an older sibling and half of them were exclusively breastfed until they were hospitalised. Respiratory comorbidities such as previous hyperresponsiveness of the airways, previous bronchiolitis, other previous respiratory diseases (frequent respiratory infections, frequent coughing, abnormal breathing patterns etc.) or previous pneumonia were present in 33.6%, 33.1%, 29.4% and 6.6%, of the surveyed population, respectively. Further pre-existing conditions, e.g. affecting the heart or other organs, were prevalent in 3.6%. In a country comparison, significantly more parents of preterm-born babies showing substantial higher levels of respiratory comorbidities participated from France (Table 1a). Similarly, the compliance with general immunisation recommendations for children displayed significant cross-country variations with France demonstrating the highest willingness to vaccinate (p < 0.001).

Fig. 1
figure 1

Flow chart of questionnaire respondents

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Table 1 Key characteristics of the main study population (n = 138) at time t0
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RSV Symptoms and Healthcare Resource Utilisation

Except for Italy, most of the RSV cases were diagnosed in hospital and confirmed by test (79.6% and 84.8% of the total population, respectively). The average time spent in hospital was 6 days with 35.5% of the affected children being treated at a neonatal or pediatric intensive care unit. All symptoms related to the RSV infection along with the respective duration reported are displayed in Tables 1b and S1b. Parents across all four participating countries, but in particular evident for France, reported that their children experienced cough, dyspnoea, wheezing and reduced appetite for more than 7 days. Regarding the clinical manifestations of RSV, 76.1% of affected children experienced bronchiolitis with significant differences between countries (p < 0.001) indicating higher occurrence in France and Italy within our study sample. Pneumonia was specified in 19.6% of the patients, with similar rates across all countries. During hospitalisation most of the children were supported by additional oxygen (80.4%).

Parental Worry and Feelings

The majority of all parents (91%) felt quite or very worried about their child’s overall health status with the occurrence of dyspnoea (fast breathing, retractions of the chest) being the symptom that worried parents the most in all participating countries equally (Table 1c). Further, apnoea (breathing pauses) was also deemed a concerning symptom, particularly reported by German and Swedish parents (p = 0.03).

Several negative emotions related to the child’s health status emerged during the hospitalisation. At country level significant differences were shown, particularly regarding the feeling of guilt towards the separation from other family members at home (e.g. siblings) and the feeling of loneliness with parents from France and Italy being the most impacted (p = 0.001 and p = 0.03 respectively). French participants were also significantly more likely to feel guilty for not having prevented the RSV infection, which was less evident in the remaining countries (p = 0.04).

Parental HRQoL and Family Functioning

The average scores for the PedsQL FIM measured during the acute infection phase (t0) were as follows: 55.6 for the total score, 52.5 for the parent HRQoL summary score and 59.4 for the family functioning summary score (country-specific results can be found in Table 1d). Across all countries and at the dimension level, “daily activities” emerged as the most impacted aspect relative to the other factors, while “family relationships” demonstrated the highest score. All remaining dimensions differed significantly between the subgroups with the French population consistently exhibiting the lowest scores and participants from Germany and Italy showing relatively higher quality of life (Table 1d).

Loss of Work Productivity

While the majority of the population surveyed was (still) on parental leave (55.5%), 31.3% stated that they were full-time or part-time employed with a median of 35 working hours per week at time t0. Of these, 40.5% indicated that their job productivity was “very much” influenced by the RSV-induced hospitalisation of their child. Between the outbreak of the disease until the completion of the initial survey, parents reported missing an average of 29 working hours. Additional barriers when visiting the child in hospital such as additional costs, conflicts with the care of siblings or other family members and long distance were reported by 30.2%, 25.6% and 20.9% of the working population respectively. German and Italian participants were thereby significantly more affected by overlaps in care as compared to France and Sweden (p = 0.008; Table 1e).

RSV Awareness and Support Structures

About one-quarter (21.7%) of the population surveyed had not been aware of RSV and its possible complications for the child prior to this hospitalisation. Moreover, 48.6% reported that they were not aware of the consequences for the whole family, 28.3% lacked the information about measures for preventing RSV and 24.8% did not know where to find support for managing mental health problems like stress during this period. On country level, participants from France and Sweden showed significantly higher levels of disease awareness and knowledge of prevention measures as compared to Germany and Italy (Table 1f).

Before discharge from hospital, 40% of the participants did not receive any information or did not feel adequately informed about how to protect the child (and their family) from reinfection with the virus. Similarly, 71.1% stated that during the child’s hospitalisation no or no adequate information about mental health support was offered. Significant cross-country differences were shown in both categories with Germany offering the fewest support structures (p  < 0.001 and p = 0.025 respectively).

Overall Burden of Families During Acute Infection Phase and 6 Weeks Later (Follow-up)

Fifty-nine participants of the total set (n = 138) also responded to the follow-up survey (t1) which was carried out about 6 weeks after completion of the initial questionnaire (t0). Across all countries RSV-related symptoms of cough, reduced appetite, wheezing and dyspnoea were still present for more than 7 days in 55.9%, 22.0%, 16.9% and 15.3% of the affected children, respectively, with 32.2% of the parents still feeling quite or very worried about their child’s overall health status.

When examining the overall burden of the surveyed population, significant differences were shown in the subjectively perceived general health before, during and after the child’s RSV-induced hospitalisation with parents demonstrating the worst scores at the time of the acute infection phase (p < 0.001; Fig. 2). Comparing PedsQL FIM results at time t0 and t1, participants reported a significant improvement in the total score (t(58) = 4.13, p < 0.001, d = 0.54), the parent HRQoL summary score (t(58) = 5.13, p < 0.001, d = 0.67) and the family functioning summary score (t(58) = 2.56, p = 0.007, d = 0.33) 6 weeks after the acute infection phase (Table 2 and Fig. 3). According to Cohen, these effects were medium for both quality-of-life summary scores and small for the family functioning summary score. At subscale level, caregivers of RSV-infected children showed no significant differences from t0 to t1 for “cognitive functioning,” “communication” and “family relationships”, while the remaining dimensions—similar to the three sum scores—demonstrated significantly higher scores at the time of the follow-up survey.

Fig. 2
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Subjectively perceived general health from 10 (excellent) to 1 (very bad) for each participant before, during and approximately 6 weeks after the RSV infection (n = 58)

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Table 2 Key characteristics of the main study population 6 weeks after the acute infection phase (t1, follow-up survey)
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Fig. 3
figure 3

Country-specific PedsQL FIM sum scores at t0 and t1. The shape of each violin plot represents the density estimate of each variable. The line dividing the box in each violin plot into two parts represents the median of the data. The ends of the box show the upper (Q3) and lower (Q1) quartiles

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Overall, 27.1% of the caregivers stated that the child’s hospitalisation for RSV is still affecting them “often” or “always” 6 weeks after the acute infection phase. Also, 20% of the employed participants who conducted the follow-up survey reported a lasting impact on their job productivity with an average of 13.5 missed working hours since the child’s discharge from hospital. No major country-differences were identified in the results of the follow-up survey (Table 2).

Discussion

To our knowledge, this is the first multicountry study in Europe evaluating the multifaceted burden of severe pediatric RSV infections with hospitalisation on parents and the family with a special focus on the involvement of affected caregivers in the research process. Our results show that a severe RSV infection is not restricted to those with pre-existing comorbidities but also affected healthy term-born infants, with a significant impact on parents and caregivers across both their private and professional lives. Especially during the acute infection phase, the subjectively perceived general health of parents and parental HRQoL was shown to be negatively influenced by the child’s RSV infection. Considerable differences were demonstrated across Europe with France and Sweden exhibiting significantly higher disease awareness and support structures like offering mental health support.

In line with our findings, Mitchell et al. analysed the burden of RSV hospitalisations among Canadian infants not to be considered at risk for the condition and identified significant parental work impairment with an average of 24.7 missed working hours, a job productivity loss of 51.4% as well as further barriers such as additional expenses and a substantial time burden when visiting the child in hospital [18]. The study group also reported a significant amount of parental stress, which—along with the feeling of guilt—emerged as one of the most common feelings reported by our study population [18]. High levels of stress in parents of RSV-affected children were also described by Leidy and colleagues who analysed the impact of severe RSV infections within a population of former preterm-born children on the family during hospitalisation in the USA [11]. Gates et al. conducted a systematic review on parent experiences related to bronchiolitis and observed that many affected parents felt guilty and anxious in relation to the child’s disease (course) [19].

All of these factors may interact as potential stressors with a (collective) influence on the general health and (health-related) quality of life of those affected [20]. Compared to a community sample of healthy children (means of the total score = 70.8, the parent HRQoL summary score = 69.4 and the family functioning summary score = 65.5), our study participants reported substantially lower sum scores, indicating a negative impact of RSV-associated hospitalisation in young children on parental quality of life in general and with a special focus on “daily activities” as the most impacted part of family life across all countries [17]. This assumption is consistent with previously published literature, describing a significant deterioration in parental quality of life—especially regarding parents’ concerns, emotions and feelings as well as usual, family and self-care activities—from RSV (hospitalisation) in children [10, 21].

On the country level, considerable differences were shown with regard to RSV symptom duration/severity and clinical manifestations as well as parental worry, feelings, QoL and disease awareness. Participants from France reported more severe disease courses in their children with a greater impact on their feelings—especially guilt and loneliness—and HRQoL (dimensions). Simultaneously, French participants demonstrated greater awareness towards the disease and its (potential) consequences prior to the child’s hospitalisation. This might be attributed to the significant higher participation of parents from France with preterm-born (and often comorbid) children, who were on the one hand more likely to already be experiencing a negative impact on their QoL due to the (consequences of) preterm birth but on the other hand also more aware of possible health conditions in early childhood [22, 23]. Considerable differences between the countries were also demonstrated in relation to the professional status of the parent completing the questionnaire. Thus, significantly more Swedish participants were (still) on parental leave, which may have had an impact on the general health status and quality of life of affected parents. In general, an improved legal framework ensuring a flexible, mostly part-time, and/or more generous parental leave could potentially contribute to an increase in parents’ work–life balance and general life satisfaction [24, 25]. This in turn may increase the parents’ resilience and ability to cope with having a sick child.

When looking at the course of the effects RSV had on the burden of affected families, it was evident that both the health of the affected children—especially with regard to respiratory symptoms—and the parents’ quality of life were still compromised 6 weeks after the acute phase. Although the subjectively perceived general health, the HRQoL and family functioning were significantly more impaired during the acute RSV infection phase, a certain number of parents reported a persistent burden on their private, emotional and professional lives. Prolonged disease effects which pertained beyond the critical infectious stage were also shown in previous literature. A systematic review on long-term respiratory morbidity associated with RSV infection in early childhood identified growing evidence for long-term wheezing, asthma and impaired lung function after RSV LRTI in toddlerhood [26]. Same patterns are shown in relation to long-term consequences of pediatric RSV infection on parental HRQoL as analysed, for instance, by Diez-Gandia and colleagues, Leidy et al. as well as Glaser et al. [10, 11, 21, 27]. As a result, a significant long-term healthcare-resource utilisation burden occurs [28].

Within our study’s framework, it is furthermore particularly significant that, despite 75.4% of the surveyed parents being informed about and aware of RSV prior to their children’s infections, the efforts to protect them from the virus were not successful. This finding contrasts with another study featuring a much larger sample size, where only 35% of participants reported having a basic or good level of knowledge about RSV [8]. Besides enhanced public health campaigns and educational efforts by healthcare providers as well as the advent of social media allowing parents to rapidly access and share experiences and knowledge about RSV more easily than ever before, a potential contributing factor to this discrepancy may be the higher educational level present in our sample, with 57% holding university degrees and 28.5% having college education. The implementation of hygiene measures proves particularly challenging in households with young children and toddlers (78.3% had older and 7.2% younger siblings), more so when one person, typically the mother, is predominantly responsible for childcare. Overall, our findings indicate the necessity for interventions that extend beyond the private sphere, suggesting that policies similar to those for other communicable diseases in childcare settings could be beneficial (e.g. inform parents of the presence of an RSV case, enabling them to make informed decisions about their younger children’s exposure etc.). Hence, it is crucial to foster measures that directly target affected families and mitigate both the immediate and secondary effects of the disease, while also considering the broader perspective of public health. Various innovative approaches to shield all infants from contracting RSV are currently being adopted worldwide. These initiatives include the administration of long-acting monoclonal antibodies to infants and the introduction of maternal vaccination [29]. Even though our study shows an increased awareness about RSV among the participants, not all parents have been reached, additionally indicating the need for further efforts to engage all educational backgrounds and parental groups to ensure comprehensive awareness and protection against RSV.

In case a (severe) infection cannot be avoided, healthcare professionals can play a crucial role in providing or facilitating enhanced support services such as mental health support and maintaining a good relationship with affected parents to mitigate stress-related challenges, thus fostering healthier family functioning [30]. In many hospitals, psychosocial support, including psychological counselling, is part of the standard services offered to parents of intensive care patients, although the availability and extent of this support depend on the resources of the specific hospital or health system. Regarding RSV, we found that parents are not routinely provided with support offers; 71.1% of our cohort did not have access to psychological support services during hospitalisation. This is particularly concerning because, weeks later, parents remain emotionally distressed. Possible reasons include the healthcare staff’s underestimation of RSV’s emotional consequences for the family, which could be attributed to the perception that children are hospitalised for relatively short periods from the healthcare personnel’s viewpoint (compared, for example, to preterm-born infants), potentially overlooking the significant emotional and psychological impact on the families involved. Country differences in terms of available support services can furthermore provide valuable insights for examining preventive methods and strategies adopted in France and Sweden or the broader Nordic countries area.

Strengths and Limitations

To our knowledge, the ResQ Family project is the first study to utilise a validated, caregiver-specific instrument for assessing the overall burden of parents/caregivers of children hospitalised for RSV [10, 11, 13, 15, 31]. By integrating additional items derived from existing literature and an ongoing collaboration with a diverse working group including affected parents, we facilitated participatory research while ensuring a high level of expertise. This approach comprehensively covers essential key aspects in family life and enhances transparency throughout the study cohort. By giving voice to relevant stakeholders such as parents, healthcare professionals and researchers, we have identified the burden of RSV on the entire family and detected potential supportive factors such as good information and mental health support during hospitalisation. This enables us to promote prevention and support structures for families with a young child, including those who already contracted RSV, and disseminate this knowledge among healthcare professionals, patient representatives, decision-makers and the general public.

However, certain limitations need to be mentioned. The small sample size, in particular with regard to cross-country comparisons, may have weakened the analysis’s robustness within the individual countries. From the Swedish region, only 18 parents participated, while France demonstrated the highest participation rate (n = 60), which may have had an influence on the reported differences across Europe. Also, the diminished response rate in the follow-up survey may have had an impact on the overall burden analysis in terms of long-term effects on child and family as well as the comparison of the subjectively perceived general health, parental HRQoL and family functioning in t0 and t1. A subsequent participation might have potentially attracted either parents whose children were still experiencing symptoms or those whose children had fully recovered and were therefore more able to respond. Thus, in both cases we cannot rule out an over- or underestimation of the results 6 weeks after hospitalisation. The observational cohort design of the study also limits our findings to the extent that no causal relationships can be revealed since direct effects cannot be estimated without a control group. Nevertheless, as compared to scores 6 weeks after the acute infection phase as well as scores of the community sample mentioned above, it can be assumed that an RSV-associated hospitalisation of children has a negative impact on parental health and quality of life [17]. Moreover, recruitment of participants via social media channels may have induced sampling bias by following a voluntary response procedure. Benedict and colleagues, who compared different recruitment strategies (hospital-based vs. social media), found that social media recruitment resulted in higher patient enrolment with fewer study resources. However, the study also highlighted issues with participants reporting significantly higher levels of negative mood and more negative illness perceptions, leading to a limited generalisability of the results [32]. In addition, the assessment of this survey was based on a self-report of the parents, which may have led to recall biases and difficulties in understanding, especially in connection with dates (date of admission, etc.) and medical information [33].

Conclusion

The ResQ Family study provides convincing evidence that RSV-associated hospitalisations in children across Europe generate a high and multifaced burden for the entire family with far-reaching implications for private and professional life. Our results furthermore emphasize the necessity to enhance parental health literacy while acknowledging the socio-medical intricacies involved in preventing infectious diseases in children. We advocate for holistic strategies that tackle both direct and structural obstacles to effective disease management and prevention to guarantee every newborn the best possible start into life. This involves integrating interventions at societal, educational and policy levels to shield vulnerable groups more effectively and reduce the worldwide annual burden of RSV cases.