What are the contraindications for the Respiratory Syncytial Virus (RSV) vaccine in elderly individuals?

Contraindications to RSV Vaccination in the Elderly

The primary contraindication to RSV vaccination in elderly individuals is a history of severe allergic reaction (such as anaphylaxis) to any component of the RSV vaccine. 1

General Considerations for RSV Vaccination

RSV vaccination is currently recommended for:

• All adults aged ≥75 years, regardless of health status 1, 2
• Adults aged 60-74 years with risk factors for severe RSV disease 1
• In some countries, adults aged ≥50 years with specific risk factors 1

Specific Contraindications and Precautions

Absolute Contraindications:

• History of severe allergic reaction (anaphylaxis) to any component of the RSV vaccine 1
• Previous severe allergic reaction to a prior dose of the same RSV vaccine 2

Precautions (Require Clinical Assessment):

• Moderate or severe acute illness with or without fever - vaccination should be deferred until the acute illness resolves 1
• History of Guillain-Barré Syndrome (GBS) - protein subunit RSV vaccines have shown a potential increased risk for GBS in post-licensure surveillance 1, 3
  • The risk varies by vaccine type: approximately 5.2 cases per million doses for RSVPreF3+AS01 and 18.2 cases per million doses for RSVPreF 3

Special Populations Requiring Careful Consideration

Immunocompromised Patients:

• No absolute contraindication exists for immunocompromised patients 1, 2
• Vaccine effectiveness may be reduced in this population:
  • Overall VE in immunocompromised patients: 67.0-73.1% 3
  • Lowest effectiveness in stem cell transplant recipients: 29.4-44.4% 3

Patients with Acute Illness:

• Vaccination should be deferred in patients with moderate to severe acute illness 1
• Mild illness with or without low-grade fever is not a contraindication 2

Clinical Decision-Making Algorithm

1. Assess patient age:

   • ≥75 years: Recommend vaccination unless contraindicated 1, 2
   • 60-74 years: Assess for risk factors 1
   • 50-59 years: In some countries, assess for specific risk factors 1

2. Screen for contraindications:

   • History of severe allergic reaction to vaccine components 1
   • Current moderate/severe acute illness 1

3. Consider precautions:

   • History of GBS (discuss risks/benefits) 1, 3
   • Immunocompromised status (discuss potentially reduced effectiveness) 3

4. Administer vaccine if indicated:

   • Single lifetime dose only 1, 2
   • Preferably between September and November before RSV season 1, 2
   • Can be co-administered with influenza vaccine at different injection sites 1, 2

Important Clinical Pitfalls to Avoid

• Do not administer multiple doses of RSV vaccine - only a single lifetime dose is currently recommended 1, 2
• Do not delay vaccination for adults ≥75 years while waiting for medical documentation of risk factors - age alone is sufficient indication 1, 2
• Do not deny vaccination based on lack of medical documentation for risk factors - patient attestation is sufficient 1
• Do not assume immunocompromised patients cannot receive the vaccine - they can, but should be informed about potentially reduced effectiveness 2, 3
• Do not confuse RSV vaccination recommendations with those for other respiratory vaccines (influenza, pneumococcal, COVID-19) 1