Which patients require the Respiratory Syncytial Virus (RSV) vaccine?

RSV Vaccination Requirements

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 failure, coronary artery disease, diabetes, chronic kidney disease, chronic liver disease, immunocompromise, frailty, dementia, or nursing home residence) should also be vaccinated. 1

Age-Based Vaccination Criteria

Adults ≥75 Years

• Universal vaccination is recommended for all adults aged ≥75 years regardless of comorbidities, due to significantly elevated rates of hospitalization, severe disease, and mortality in this age group 2, 3
• This population should be prioritized if vaccine supply is limited 1, 4

Adults 60-74 Years

• Vaccination is recommended for adults in this age range who have any of the following risk factors 1, 2:
  • Chronic respiratory conditions: COPD, asthma, bronchiectasis, interstitial lung disease, chronic respiratory failure 1, 4
  • Cardiovascular disease: Heart failure, coronary artery disease, other chronic cardiovascular conditions 1, 2
  • Metabolic conditions: Diabetes mellitus (particularly with complications), severe obesity (BMI ≥40 kg/m²) 1, 4
  • Renal disease: Chronic kidney disease, especially end-stage renal disease 1, 4
  • Hepatic disease: Chronic liver disease 1, 4
  • Neurological conditions: Chronic neurological or neuromuscular diseases, dementia 1, 4
  • Immunocompromise: Solid organ transplant recipients, hematopoietic stem cell transplant recipients, patients with malignancies, those on immunosuppressive medications, HIV-positive individuals 4
  • Living situation: Residence in nursing homes or long-term care facilities 1, 4
  • Frailty 1, 4

Adults 50-59 Years

• RSVPreF3 (Arexvy) is the only vaccine approved for adults aged 50-59 years with risk factors for severe RSV disease 1, 2, 4
• The same risk factors listed above apply to this age group 1

Dosing and Administration Guidelines

Single Lifetime Dose

• Only a single lifetime dose of RSV vaccine is recommended—adults who have previously received any RSV vaccine should not receive another dose 4, 3
• Current evidence demonstrates protection lasting through at least two consecutive RSV seasons 4

Optimal Timing

• The vaccine should preferably be administered between September and November, before or early in the RSV season, to maximize protection 1, 2, 3
• Vaccination can occur at any time of year for eligible adults who have not been previously vaccinated 4

Co-administration

• RSV vaccine can be co-administered with seasonal influenza vaccine at different injection sites 1, 2, 3
• Data on co-administration with other vaccines (pneumococcal, herpes zoster, COVID-19) are currently lacking 1

Clinical Implementation Considerations

Documentation Requirements

• Patient attestation is sufficient evidence of risk factors—extensive medical documentation should not be required 2, 3
• This approach facilitates timely vaccination without creating administrative barriers 3

Previous RSV Infection

• Previous RSV infection does not confer long-lasting immunity and does not contraindicate vaccination 2, 4
• Reinfections are common due to short-lived immune responses 1

Supply Prioritization

• If vaccine supply is limited, prioritize in this order 1, 4:
  1. Adults aged ≥75 years
  2. Adults aged ≥50 years with multiple comorbidities
  3. Residents of long-term care facilities

Common Pitfalls to Avoid

• Do not administer multiple doses—only one lifetime dose is currently recommended, even if the patient develops RSV infection after vaccination 4, 3
• Do not delay vaccination for adults ≥75 years while waiting for medical documentation—age alone is sufficient indication 3
• Do not confuse adult RSV vaccines with pediatric RSV prophylaxis (palivizumab/Synagis), which is indicated only for high-risk infants and young children up to 24 months of age 5
• Do not require extensive workup to document risk factors in adults aged 60-74 years—patient report is adequate 2, 3

Rationale for Recommendations

The burden of RSV in older adults has been historically underrecognized, accounting for 10.6% of hospitalizations for pneumonia and 11.4% for COPD exacerbations 2, 4. Advanced age (≥75 years) is associated with higher incidence of RSV infection, increased hospitalization rates and duration, greater clinical severity, and higher mortality 1. Given that no specific treatments exist for RSV-associated disease, vaccination represents a critical opportunity to prevent infection and reduce burden on both patients and the healthcare system 1.