Should adults aged 65 years and older be recommended to receive the respiratory syncytial virus (RSV) vaccine, and which dosing regimen is appropriate?

RSV Vaccine Recommendation for Adults 65 and Older

All adults aged 75 years and older should receive a single dose of RSV vaccine, and adults aged 65-74 years should receive the vaccine if they have chronic medical conditions, are immunocompromised, or reside in nursing homes. 1

Age-Stratified Recommendations

Adults ≥75 Years

• Universal vaccination is recommended with a single dose of any FDA-approved RSV vaccine (Arexvy, Abrysvo, or mResvia) 1, 2
• No shared clinical decision-making required—this is a routine recommendation
• The yellow designation in the 2025 immunization schedule indicates universal recommendation for this age group 2

Adults 65-74 Years

Vaccination is recommended for those with:

• Chronic medical conditions including:
  • Chronic obstructive pulmonary disease (COPD)
  • Asthma
  • Chronic heart failure
  • Diabetes
  • Chronic kidney disease
  • Chronic liver disease 1
• Moderate or severe immunocompromise
• Residence in nursing homes or long-term care facilities 1

Adults 60-64 Years

While not specifically addressed in your question about "65 and older," current ACIP guidance extends to age 60-74 with the same risk-based criteria 1

Dosing Regimen

Single dose only—adults who have previously received RSV vaccine should not receive another dose 1

The evidence shows that:

• One dose provides efficacy of 67.2% against RSV-LRTD over two seasons 3
• Revaccination at one year did not provide additional benefit in clinical trials 3
• Duration of protection extends beyond a single season, making annual vaccination unnecessary with current evidence

Clinical Implementation

Eligibility determination can be made by any qualified vaccinator (pharmacists, nurse practitioners, physicians) based on clinical assessment, even without formal medical documentation 1. Patient self-report of risk conditions is acceptable, reducing implementation barriers from the previous shared clinical decision-making approach.

Vaccine Options

Three FDA-approved vaccines are available:

• Arexvy (GSK) - protein subunit vaccine
• Abrysvo (Pfizer) - protein subunit vaccine
• mResvia (Moderna) - mRNA vaccine 1

All three are considered equivalent in the ACIP recommendations, with no preferential recommendation among them.

Benefits vs. Risks

The benefit-risk profile strongly favors vaccination in the recommended populations:

Preventable outcomes per 1 million doses in adults ≥75 years:

• 4,283 RSV-associated hospitalizations
• 630 ICU admissions
• 605 deaths 1

Safety considerations:

• Guillain-Barré syndrome (GBS) risk is approximately 3 cases per 1 million doses for protein subunit vaccines 1
• This rare risk is substantially outweighed by prevented morbidity and mortality
• Postlicensure monitoring through the 2023-2024 season confirmed favorable safety profiles 1

Common Pitfalls to Avoid

1. Don't apply shared clinical decision-making—the 2024 update specifically removed this requirement to increase uptake in high-risk populations 1

2. Don't revaccinate—unlike influenza, RSV vaccine is a one-time dose with current evidence 1

3. Don't require extensive documentation—patient attestation of risk factors is sufficient for eligibility determination 1

4. Don't delay vaccination in adults ≥75 years waiting for risk assessment—vaccination is universally recommended regardless of health status 1

The 2024 ACIP update represents a significant shift from the previous permissive "may receive" recommendation to a clear directive that maximizes coverage among those most likely to benefit from RSV vaccination, particularly given that RSV causes substantial respiratory illness, hospitalizations, and deaths in older adults during fall and winter months 1.