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

Clinical Indications for RSV Vaccination in the Elderly

Primary Age-Based Recommendations

All adults aged ≥75 years should receive a single dose of RSV vaccine regardless of comorbidities or risk factors. 1, 2, 3 This universal recommendation reflects the significantly elevated rates of RSV-associated hospitalization, severe disease, and mortality in this age group, with 54.1% of RSV hospitalizations occurring in adults ≥75 years. 4

Adults aged 60-74 years should receive RSV vaccination if they have any chronic medical conditions or risk factors for severe RSV disease. 1, 2, 5 The CDC's Advisory Committee on Immunization Practices (ACIP) updated guidance in 2024 emphasizes that patient attestation alone is sufficient evidence of risk factors—extensive medical documentation should not be required to avoid barriers to vaccination. 1, 3

Specific Risk Factors for Adults Aged 60-74 Years

Respiratory Conditions

• Chronic obstructive pulmonary disease (COPD) is a major risk factor, accounting for 11.4% of COPD exacerbations in older adults. 2, 5
• Asthma, bronchiectasis, interstitial lung disease, and chronic respiratory failure all qualify for vaccination. 1, 3, 5

Cardiovascular Conditions

• Heart failure and coronary artery disease are high-risk conditions, with congestive heart failure being one of the most common comorbidities in RSV-hospitalized patients. 1, 2, 4
• Recent real-world data show vaccine effectiveness is lower in patients with cardiovascular disease (56%) compared to those without (80%), making vaccination particularly important in this population. 6

Metabolic and Renal Conditions

• Diabetes mellitus, particularly with complications requiring insulin or SGLT2 inhibitors, qualifies for vaccination. 1, 2, 5
• Chronic kidney disease, especially end-stage renal disease, is a recognized risk factor. 1, 3, 5

Other Medical Conditions

• Chronic liver disease (e.g., cirrhosis) 1, 3, 5
• Chronic hematologic conditions (e.g., sickle cell disease, thalassemia) 1
• Neurologic or neuromuscular conditions causing impaired airway clearance or respiratory muscle weakness (e.g., post-stroke dysphagia, amyotrophic lateral sclerosis, muscular dystrophy) 1, 3
• Severe obesity (BMI ≥40 kg/m²) 1, 3, 5

Immunocompromised Status

• Moderate or severe immunocompromise, including solid organ transplant recipients, hematopoietic stem cell transplant recipients, patients with malignancies, and those on immunosuppressive medications. 1, 3, 5
• Important caveat: Vaccine effectiveness is significantly lower in immunocompromised adults (30%) compared to immunocompetent adults (67%), but vaccination is still recommended. 6

Living Situation and Frailty

• Residence in a nursing home or long-term care facility—17.2% of all RSV hospitalizations occur in long-term care facility residents. 1, 3, 4
• Frailty, defined by the Fried frailty phenotype (≥3 of: unintentional weight loss, exhaustion, weakness, slow walking speed, low physical activity). 1, 5
• Dementia 3, 5

Provider Discretion

• Healthcare providers may recommend vaccination for adults aged 60-74 years with other chronic conditions or risk factors that would increase risk for severe disease, including situations where providers have concern for undiagnosed chronic conditions or residence in remote/rural communities where transport for escalation of care is challenging. 1

Special Population: Adults Aged 50-59 Years

For adults aged 50-59 years with risk factors for severe RSV disease, RSVPreF3 (Arexvy) is the only vaccine currently approved. 2, 3, 5 The same risk factors listed above apply to this age group.

Administration Guidelines

Dosing Schedule

• A single lifetime dose of RSV vaccine is currently recommended—adults who have already received any RSV vaccine should not receive another dose. 1, 2, 3
• A single dose provides protection for at least two consecutive RSV seasons. 1, 2
• Real-world effectiveness data show vaccine effectiveness of 69% for same-season vaccination versus 48% for prior-season vaccination, though this difference did not reach statistical significance (P = 0.06). 6

Optimal Timing

• Vaccination should preferably occur in late summer or early fall (August-October in most of the continental United States), just before RSV season begins. 1, 2, 5
• Eligible adults may be vaccinated at any time of year, but vaccination will have the most benefit if administered before RSV season. 1, 3

Coadministration

• RSV vaccine can be co-administered with seasonal influenza vaccine at different injection sites. 1, 2, 5
• Some studies show numerically lower antibody titers for both RSV and influenza when co-administered, though clinical significance remains unknown. 2

Prioritization if Vaccine Supply is Limited

If resources are constrained, prioritize in this order: 1, 2, 5

1. Adults aged ≥75 years
2. Adults aged 60-74 years with multiple comorbidities
3. Residents of long-term care facilities

Important Clinical Considerations

• Previous RSV infection does not confer long-lasting immunity and does not contraindicate vaccination—reinfections are common due to short-lived immune responses. 2, 5
• RSV accounts for 10.6% of hospitalizations for pneumonia and 11.4% for COPD exacerbations in older adults, yet remains underrecognized. 2, 3
• Among hospitalized older adults with RSV, 17.0% require ICU admission, 4.8% require mechanical ventilation, and 4.7% die. 4
• Postlicensure surveillance suggests a potential increased risk for Guillain-Barré syndrome (GBS) after protein subunit RSV vaccination, which should be discussed with patients. 1, 5
• Phase 3 trials demonstrated vaccine efficacy of 82.6% against RSV-related lower respiratory tract disease and 94.1% against severe disease. 7