Incidence of RSV-Acute Respiratory Infection in Adults 18-64 years with High-Risk Conditions: A Prospective Community-based Surveillance Study

Abstract Background Data on respiratory syncytial virus (RSV) acute respiratory infection (ARI) among community-dwelling U.S. adults aged 18-64 years, particularly those with high-risk conditions (HRC), remain limited. This study estimated incidence and attack rates of RSV-ARI and RSV lower respiratory tract disease (LRTD) in adults with and without HRCs. Methods A multi-state, community-based prospective cohort of adults aged 18–64 years with and without HRCs was followed from October 2022 to September 2024. Incidence rates and annual attack rates of RSV-ARI and RSV-LRTD were calculated by HRC presence and age group. Results Of 3,375 adults with at least one HRC, the RSV-ARI incidence rate was 17.9 per 1,000 person-years (attack rates: year-1, 1.87%; year-2, 1.56%), compared with 14.8 per 1,000 person-years (year-1, 1.33%; year-2, 1.50%) among adults without HRCs. RSV-LRTD incidence was 10.0 per 1,000 person-years in adults with HRCs versus 5.7 per 1,000 person-years in those without. Asthma, congenital immunodeficiency, and immunosuppressive medication use were associated with increased incidence of RSV-ARI and RSV-LRTD; while adults with solid organ transplant and chronic kidney disease had a significantly higher incidence rate of RSV-LRTD compared to those without these conditions. Adults aged 18–49 years with HRCs had significantly higher RSV-LRTD incidence (9.6 vs. 4.3 per 1,000 person-years). After adjustment for age and sex, having ≥1 HRC was associated with a 62% increased RSV-LRTD risk, rising to 117% among adults aged 18–49 years. Conclusions Adults with HRCs—particularly asthma, congenital immunodeficiency, chronic kidney disease, immunosuppressive medication use, and solid organ transplant—experienced higher RSV-ARI and RSV-LRTD incidence. The elevated RSV-LRTD burden was most pronounced in adults aged 18–49 years with HRCs.