Should a patient get the RSV (Respiratory Syncytial Virus) vaccination?

RSV Vaccination Recommendation

All adults aged ≥75 years should receive a single dose of RSV vaccine, and adults aged 60-74 years should receive it if they have any chronic medical conditions or risk factors for severe disease. 1

Age-Based Vaccination Algorithm

Adults ≥75 Years

• Universal vaccination is recommended regardless of health status or comorbidities due to significantly elevated rates of RSV-associated hospitalization, severe disease, and mortality in this age group 2, 3
• No additional risk stratification is needed—age alone is sufficient indication 2
• Patient attestation alone is sufficient; do not delay vaccination while waiting for medical documentation 1, 2

Adults 60-74 Years

Vaccinate if ANY of the following risk factors are present: 1

Respiratory conditions:

• Chronic obstructive pulmonary disease (COPD) 1
• Asthma 1
• Bronchiectasis 2
• Interstitial lung disease 1
• Cystic fibrosis 1

Cardiovascular conditions:

• Heart failure 1
• Coronary artery disease 1
• Congenital heart disease (excluding isolated hypertension) 1

Metabolic and renal conditions:

• Diabetes mellitus complicated by chronic kidney disease, neuropathy, retinopathy, or other end-organ damage, OR requiring insulin or SGLT2 inhibitor 1
• End-stage renal disease or dependence on hemodialysis 1

Other chronic conditions:

• Chronic liver disease (e.g., cirrhosis) 1
• Chronic hematologic conditions (e.g., sickle cell disease, thalassemia) 1
• Neurologic or neuromuscular conditions causing impaired airway clearance or respiratory muscle weakness (e.g., poststroke dysphagia, ALS, muscular dystrophy) 1
• Severe obesity (BMI ≥40 kg/m²) 1

Immunocompromised status:

• Moderate or severe immune compromise 1
• Solid organ transplant recipients 2
• Hematopoietic stem cell transplant recipients 2
• Patients with solid tumors or hematological malignancies 2
• Patients on immunosuppressive medications 2
• HIV-positive individuals 2

Living situation:

• Residence in a nursing home or long-term care facility 1

Clinical judgment factors:

• Frailty (defined as ≥3 of: unintentional 10 lb weight loss in past year, self-reported exhaustion, weakness, slow walking speed, or low physical activity) 1
• Residence in remote or rural community where transportation for escalation of care is challenging 1
• Provider concern for undiagnosed chronic medical conditions 1

Adults 50-59 Years

• Only RSVPreF3 (Arexvy) is FDA-approved for this age group 1, 2
• Vaccination may be considered for those with risk factors listed above, but ACIP has not yet made a formal recommendation pending additional safety data 1

Critical Evidence Considerations

The 2024 ACIP update represents a significant policy shift: The previous 2023 recommendation used "shared clinical decision-making" for all adults ≥60 years, but ACIP concluded that benefits did not clearly outweigh potential harms in adults aged 60-74 years without risk factors 1. This led to the current risk-stratified approach.

Safety concern—Guillain-Barré Syndrome (GBS): Postlicensure surveillance suggests a potential increased risk of GBS after protein subunit RSV vaccination (GSK Arexvy and Pfizer Abrysvo) 1. Recent real-world data show an excess of 5.2 cases per 1,000 doses for RSVPreF3+AS01 (Arexvy) and 18.2 cases per 1,000 doses for RSVPreF (Abrysvo) 4. Patients should be informed of this potential risk, particularly for protein subunit vaccines 1.

Practical Administration Guidelines

Dosing:

• Only a single lifetime dose is currently recommended—adults who have already received any RSV vaccine should not receive another dose 1, 2
• A single dose provides protection for at least two consecutive RSV seasons 1, 2

Timing:

• Optimal timing is late summer or early fall (August-October in most of the continental United States), just before RSV season begins 1, 2
• Eligible adults may be vaccinated at any time of year if not previously vaccinated 1

Co-administration:

• RSV vaccine can be co-administered with seasonal influenza vaccine at different injection sites 1, 2
• Co-administration is acceptable with other adult vaccines 1

Vaccine Effectiveness

Real-world effectiveness data from the 2023-2024 season: 4

• Overall vaccine effectiveness was 75.1% (95% CI, 73.6%-76.4%) against RSV-associated acute respiratory infection
• Similar effectiveness for ages 60-74 years and ≥75 years
• Immunocompromised patients had moderately reduced effectiveness: 67.0%-73.1% for most immunocompromised patients, but only 29.4%-44.4% for stem cell transplant recipients 4

Common Pitfalls to Avoid

Do not require extensive medical documentation: Patient attestation is sufficient evidence of the presence of a risk factor—vaccinators should not deny RSV vaccination due to lack of medical documentation 1, 2

Do not withhold vaccination from adults ≥75 years while assessing risk factors: Age alone is sufficient indication; no risk stratification is needed 2

Do not administer repeat doses: Only one lifetime dose is currently recommended; adults who received RSV vaccine in 2023 should not receive another dose 1, 2

Do not overlook immunocompromised patients: While vaccine effectiveness is somewhat reduced in immunocompromised individuals, they remain at high risk for severe RSV disease and should still be vaccinated 2, 4