What is the recommended prophylaxis for Respiratory Syncytial Virus (RSV) in adults, particularly those with underlying health conditions or immunocompromised individuals?

RSV Prophylaxis in Adults

All adults aged ≥75 years should receive a single lifetime dose of RSV vaccine, and adults aged 60-74 years with any chronic medical condition or immunocompromise should also be vaccinated. 1

Age-Based Vaccination Strategy

Universal Vaccination (Age ≥75 Years)

• Every adult ≥75 years requires RSV vaccination regardless of health status or comorbidities, as this age group faces significantly elevated rates of hospitalization, severe disease, and mortality from RSV. 1, 2
• Age alone is sufficient indication—do not delay vaccination while waiting for documentation of risk factors. 2

Risk-Based Vaccination (Ages 60-74 Years)

Adults in this age range should receive RSV vaccination if they have any of the following conditions:

Respiratory conditions:

• Chronic obstructive pulmonary disease (COPD) 1, 3
• Asthma 1, 3
• Bronchiectasis 1
• Interstitial lung disease 1
• Chronic respiratory failure 1

Cardiovascular conditions:

• Chronic heart failure 1, 3
• Coronary artery disease 3

Metabolic and organ dysfunction:

• Diabetes mellitus (particularly with complications) 1, 3
• Chronic kidney disease, especially end-stage renal disease 1, 3
• Chronic liver disease 1, 3

Neurological conditions:

• Chronic neurological or neuromuscular diseases 1
• Frailty or dementia 1

Other risk factors:

• Severe obesity (BMI ≥40 kg/m²) 1
• Residence in nursing homes or long-term care facilities 1, 2

Immunocompromised Adults (Critical Population)

All immunocompromised adults aged ≥60 years require RSV vaccination, including: 1, 2

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

For adults aged 50-59 years with risk factors (including immunocompromise), RSVPreF3 (Arexvy) is the only FDA-approved vaccine option. 1, 3

Dosing and Administration

Single Lifetime Dose

• Only one dose of RSV vaccine is recommended for a lifetime—adults who have already received any RSV vaccine should not receive another dose. 1, 3, 2
• Current evidence demonstrates protection lasting through at least two consecutive RSV seasons, with some data showing efficacy for three seasons. 1, 3
• The need for future booster doses will be evaluated as more long-term data become available. 1

Optimal Timing

• Administer between September and November (late summer to early fall), before or early in the RSV season, to maximize protection during peak transmission months. 1, 3, 2
• Eligible adults who have not been vaccinated may receive the vaccine at any time of year, though benefit is greatest when given before RSV season. 1

Co-Administration with Other Vaccines

• RSV vaccine can be co-administered with seasonal influenza vaccine at different injection sites. 1, 3, 2
• Some studies show numerically lower antibody titers for both RSV and influenza when co-administered, though the clinical significance remains unknown. 3
• Data on co-administration with pneumococcal, herpes zoster, and COVID-19 vaccines are currently lacking. 1, 3

Clinical Implementation Considerations

Documentation Requirements

• Patient attestation alone is sufficient evidence of risk factors—extensive medical documentation should not be required and should not delay vaccination. 1, 3, 2
• For adults ≥75 years, do not withhold vaccination while waiting for medical records, as age alone is sufficient indication. 1, 2

Vaccine Supply Prioritization

If vaccine supply is limited, prioritize in this order: 1, 3

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

Common Pitfall to Avoid

• Do not withhold vaccination based on previous RSV infection—natural RSV infection does not confer long-lasting immunity, reinfections are common due to short-lived immune responses, and previous infection does not contraindicate vaccination. 1, 3

Rationale for Vaccination

RSV accounts for 10.6% of hospitalizations for pneumonia and 11.4% for COPD exacerbations in older adults, yet the burden has been historically underrecognized. 1 Immunosenescence (age-related immune decline) is a recognized risk factor for severe RSV disease, with comorbidities further increasing susceptibility. 1 The estimated RSV-associated hospitalizations, ICU admissions, and deaths preventable per 1 million vaccine doses administered exceed the estimated numbers of potential vaccine-attributable Guillain-Barré syndrome cases. 2