What are the current recommendations for respiratory syncytial virus (RSV) prophylaxis and vaccination, including dosing frequency, for high‑risk infants and for adults aged 60 years and older?

RSV Vaccine Recommendations and Frequency

All adults aged ≥75 years should receive a single dose of RSV vaccine, and adults aged 60-74 years with chronic medical conditions (COPD, asthma, heart disease, diabetes, chronic kidney disease, or severe obesity) should receive a single dose using shared clinical decision-making. 1

Adults Aged ≥60 Years

The 2024 ACIP updated recommendations represent a shift from the 2023 shared clinical decision-making approach to more targeted guidance 1:

Strong Recommendations (Age-Based):

• Adults ≥75 years: Single dose of RSV vaccine (either GSK Arexvy or Pfizer Abrysvo)
• This age group shows the highest preventable disease burden, with approximately 4,000+ RSV-associated outcomes preventable per 1 million doses 1

Risk-Based Recommendations (Ages 60-74):

• Adults 60-74 years with ≥1 chronic medical condition should receive a single dose
• Chronic conditions include: COPD, asthma, coronary artery disease, diabetes mellitus, chronic kidney disease, or severe obesity (BMI ≥40)
• This group shows approximately 2,500-2,800 preventable outcomes per 1 million doses 1

Lower Priority (Ages 60-74 without risk factors):

• Adults 60-74 years without chronic conditions show substantially lower benefit (only ~400-450 preventable outcomes per 1 million doses) 1
• May consider on individual basis, but not routinely recommended

Dosing Frequency:

Single dose only - no booster doses are currently recommended 1, 2. The vaccines provide protection over at least two RSV seasons, though long-term duration and need for future boosters remain under surveillance 3, 4.

Important Safety Consideration:

There is a small increased risk of Guillain-Barré syndrome (GBS), with approximately 3-16 vaccine-attributable GBS cases per 1 million doses depending on the product 1. However, the benefit-risk ratio strongly favors vaccination in the recommended age and risk groups, with thousands of preventable hospitalizations and ICU admissions outweighing this rare risk.

Expanded High-Risk Groups (2026 Updates):

Recent guidance expands recommendations to include 3:

• Adults ≥18 years residing in chronic care facilities
• Adults who received lung or hematopoietic stem cell transplant
• Adults receiving home or chronic oxygen therapy
• Adults receiving dialysis

Infants and High-Risk Children

Maternal Immunization Strategy:

Pregnant individuals should receive a single dose of RSVpreF (Abrysvo) between 32-36 weeks of gestation, typically administered September through January 5, 6. This provides passive protection to infants through maternal antibody transfer during their first RSV season.

Infant Immunization (Alternative to Maternal Vaccination):

All infants <8 months born during or entering their first RSV season should receive immunization (typically with nirsevimab, a long-acting monoclonal antibody), unless the mother received RSV vaccine during pregnancy 6, 4.

High-Risk Infants and Children Requiring Prophylaxis:

The following groups may receive palivizumab (maximum 5 doses per season, given monthly) 7:

First RSV Season:

• Infants with chronic lung disease (CLD) requiring medical therapy within 6 months before RSV season
• Infants born <29 weeks gestation and <12 months old at season start
• Infants born 29-31 weeks gestation and <6 months old at season start
• Infants with hemodynamically significant congenital heart disease
• Infants with significant airway abnormalities or neuromuscular disease compromising secretion handling

Second RSV Season:

• Infants and children 8-19 months at high risk of severe RSV disease entering their second season 6
• Children <24 months with CLD requiring ongoing therapy
• Children <24 months with hemodynamically significant heart disease

Dosing Schedule for Palivizumab:

The number of doses depends on birth month and gestational age 7:

• Infants born ≤28 weeks 6 days gestation: up to 5 doses regardless of birth month
• Infants born 29-31 weeks: up to 5 doses if born May-November; 0 doses if born earlier (will be >6 months at season start)
• Infants born 32-34 weeks with risk factors: 1-3 doses depending on birth month (only until 90 days of age)

Key Clinical Pitfalls:

• Do not give both maternal vaccine and infant immunization - this represents unnecessary duplication 6
• RSV season typically runs November through March in most regions; adjust timing accordingly
• Infants discharged from hospital during RSV season may require fewer than 5 doses of palivizumab
• Keep high-risk infants away from crowds and group childcare during RSV season 7