What are the current RSV vaccination and prophylaxis recommendations for adults ≥60 years, pregnant individuals, immunocompromised patients, and high‑risk infants?

RSV Vaccination and Prophylaxis Recommendations

All adults ≥75 years should receive a single dose of RSV vaccine, and adults 60-74 years with chronic medical conditions, immunocompromise, or nursing home residence should also be vaccinated. 1

Adults ≥60 Years

The 2024 ACIP guidelines represent a shift from shared clinical decision-making to clear age-based and risk-based recommendations 1:

Who Should Be Vaccinated:

• All adults ≥75 years: Universal recommendation for single dose
• Adults 60-74 years at increased risk, including:
  • Chronic medical conditions (COPD, asthma, cardiovascular disease, diabetes)
  • Moderate or severe immunocompromise
  • Nursing home residents

Vaccine Options:

Any FDA-approved RSV vaccine is acceptable 1:

• Arexvy (GSK)
• Abrysvo (Pfizer)
• mResvia (Moderna)

Key Implementation Points:

• One dose only - adults who previously received RSV vaccine should not receive another dose 1
• Qualified vaccinators (pharmacists, nurse practitioners) may determine eligibility based on clinical assessment without requiring medical documentation 1
• Patient attestation of risk factors is acceptable 1

Efficacy vs. Risk Balance:

The vaccines prevent substantial morbidity. Per 1 million doses in adults ≥75 years 1:

• Preventable outcomes: 4,283 RSV-associated hospitalizations (GSK) or 3,817 (Pfizer)
• Preventable ICU admissions: 630 (GSK) or 561 (Pfizer)
• Risk: 3-16 cases of Guillain-Barré syndrome per million doses

This represents an 80% reduction in RSV lower respiratory disease 2, with recent evidence showing 70% reduction in RSV-associated hospitalization among immunocompromised adults 3.

Pregnant Individuals

Pregnant patients between 32-36 weeks gestation should receive RSV vaccination if delivering during RSV season (typically September-January) and not planning nirsevimab for their infant. 4

Rationale:

• Maternal vaccination provides passive immunity to infants through transplacental antibody transfer 4
• Peak infant hospitalization occurs at 2-3 months of age, when infants are most vulnerable 5, 4
• The FDA-approved Abrysvo (Pfizer) for maternal immunization protects infants via maternal antibody transfer 6

Important Caveat:

This is an either/or decision - either maternal vaccination OR infant nirsevimab prophylaxis, not both 4. The choice depends on timing, access, and shared decision-making.

Immunocompromised Patients

Immunocompromised adults and adolescents should receive age-appropriate RSV vaccination, with timing individualized based on their specific condition. 3

Strong Evidence Base:

Recent 2025 IDSA guidelines provide a strong recommendation for RSV vaccination in immunocompromised populations based on 3:

• 70% reduction in RSV-associated hospitalization (95% CI: 66-73%)
• 81% effectiveness against critical illness (95% CI: 52-92%)
• Comparable serious adverse events to non-immunocompromised populations

Timing Considerations:

Vaccination should be coordinated around 3:

• Chemotherapy cycles
• Transplant status (pre- vs. post-transplant)
• B-cell depleting therapies (ideally before initiation or after B-cell recovery)

Household Protection:

All eligible household members should receive RSV vaccination to provide indirect protection 3.

Pediatric Immunocompromised (<18 years):

Use shared decision-making as direct evidence is limited 3.

High-Risk Infants

All infants should receive nirsevimab (monoclonal antibody) during their first RSV season, regardless of risk status. 4

Key Points:

• This represents passive immunization with long-acting monoclonal antibody
• CDC's ACIP and American Academy of Pediatrics endorse universal infant prophylaxis 4
• Major innovation reducing need for multiple injections in high-risk infants 2

Alternative Strategy:

If maternal vaccination was given at 32-36 weeks gestation, infant nirsevimab may not be needed - this should be discussed with pediatrics 4.

Common Pitfalls to Avoid

1. Don't revaccinate: Adults who received RSV vaccine previously should not get another dose 1
2. Don't double-protect infants: Choose either maternal vaccination OR infant nirsevimab, not both 4
3. Don't delay in immunocompromised: Despite theoretical concerns, vaccination is strongly recommended with individualized timing 3
4. Don't require extensive documentation: Provider assessment and patient attestation are sufficient for determining risk status 1

Coadministration

RSV vaccines can be given simultaneously with influenza and COVID-19 vaccines 3, which is particularly important for optimizing protection during respiratory virus season.