What are the guidelines for RSV (Respiratory Syncytial Virus) vaccination?

RSV Vaccine Guidelines

Primary Age-Based Recommendations

All adults aged ≥75 years should receive a single lifetime dose of RSV vaccine regardless of comorbidities, due to significantly elevated rates of hospitalization, severe disease, and mortality in this population. 1

• Adults aged 60-74 years should receive RSV vaccination if they have any risk factors for severe RSV disease 1, 2
• Adults aged 50-59 years with risk factors should receive RSVPreF3 (Arexvy), which is the only vaccine currently approved for this younger age group 1, 2

Risk Factors for Severe RSV Disease (Ages 50-74)

Respiratory Conditions

• Chronic obstructive pulmonary disease (COPD) 1, 2
• Asthma 1, 2
• Bronchiectasis 3
• Interstitial lung disease 3

Cardiovascular Conditions

• Heart failure 1, 2
• Coronary artery disease 1, 2

Metabolic and Organ Dysfunction

• Diabetes mellitus 1, 2
• Chronic kidney disease, especially end-stage renal disease 1, 3
• Chronic liver disease 1, 3
• Severe obesity (BMI ≥40 kg/m²) 1

Neurological and Immunological Conditions

• Neurologic or neuromuscular conditions affecting airway clearance 1
• Moderate or severe immunocompromise, including solid organ transplant recipients, hematopoietic stem cell transplant recipients, patients with malignancies, and those on immunosuppressive medications 3

Geriatric Syndromes and Living Situations

• Frailty 1
• Dementia 1
• Residence in nursing homes or long-term care facilities 3

Available RSV Vaccines for Adults

• Arexvy (RSVPreF3): Recombinant RSV pre-fusion F protein adjuvanted with AS01E, approved for adults ≥50 years 1
• Abrysvo (RSVpreF): Recombinant bivalent RSV-A and RSV-B pre-fusion F protein, approved for adults ≥60 years 1
• mRESVIA (mRNA-1345): mRNA vaccine, approved for adults ≥60 years 1

Dosing and Administration

A single lifetime dose of RSV vaccine is currently recommended, with no booster doses indicated at this time. 1, 2, 3

• The vaccine should preferably be administered between September and November (August-October in some regions), before or early in the RSV season, to maximize protection during peak transmission months 1, 2, 3
• RSV vaccine can be co-administered with seasonal influenza vaccine at different injection sites 1, 2
• Adults who have previously received any RSV vaccine should not receive another dose 3
• Current evidence demonstrates protection lasting through at least two consecutive RSV seasons 3

Important Caveats on Co-Administration

• Co-administration with influenza vaccines may result in numerically lower antibody titers for both RSV and influenza, though the clinical significance remains unknown 1
• Data on co-administration with COVID-19, pneumococcal, and herpes zoster vaccines are currently lacking 1

Prioritization if Vaccine Supply is Limited

• Adults aged ≥75 years should receive highest priority 1, 2
• Adults aged ≥50 years with multiple comorbidities should be prioritized next 1
• Residents of long-term care facilities should be prioritized 3

Critical Clinical Implementation Points

• Patient attestation alone is sufficient evidence of risk factors; extensive medical documentation should not be required to avoid barriers to vaccination 1, 2, 3
• Previous RSV infection does not confer long-lasting immunity and does not contraindicate vaccination, as reinfections are common due to short-lived immune responses 1, 2, 3
• 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, 3

Safety Considerations

• Postlicensure surveillance suggests a potential increased risk for Guillain-Barré syndrome (GBS) after protein subunit RSV vaccination (Abrysvo and Arexvy), which informed updated recommendations 1
• RSVPreF3 is more reactogenic than placebo, with injection-site pain and fatigue being most common 1
• Serious adverse event rates are similar between vaccine and placebo groups for both RSVPreF3 (4.4% vs 4.3%) and RSVpreF (4.3% vs 4.1%) 1

Special Populations

Cancer Patients

• The RSV vaccine is FDA-approved and available for those ≥60 years, but its effectiveness in patients with cancer is unknown 4
• Consultation with infectious disease specialists is recommended for cancer patients considering RSV vaccination 4

Inflammatory Bowel Disease

• All adult patients with inflammatory bowel disease (IBD) aged ≥60 years should receive RSV vaccine, as they have a 30% higher risk of hospitalization due to RSV compared with non-IBD controls 1

Pediatric RSV Prevention

Monoclonal Antibody (Nirsevimab)

• The long-acting RSV monoclonal antibody nirsevimab is approved for infants <24 months of age to prevent RSV infection 4
• Provides protection through one RSV season with a single dose 3
• Infants aged 8-19 months at increased risk entering their second RSV season require another dose 3

Palivizumab (Synagis)

• Indicated for prevention of serious lower respiratory tract disease caused by RSV in pediatric patients with: 5
  • History of premature birth (≤35 weeks gestational age) and who are ≤6 months of age at the beginning of RSV season
  • Bronchopulmonary dysplasia (BPD) requiring medical treatment within the previous 6 months and who are ≤24 months of age
  • Hemodynamically significant congenital heart disease (CHD) and who are ≤24 months of age
• Dosing: 15 mg/kg monthly by intramuscular injection throughout RSV season 5
• Children undergoing cardiopulmonary bypass should receive an additional dose as soon as possible after the procedure 5

Maternal Vaccination

• Abrysvo is the only vaccine indicated for use in pregnancy (weeks 28-36, preferably 32-36) to prevent RSV-LRTD in infants from birth to 6 months of age 3, 6
• Protection conferred through maternal vaccination likely wanes after 3 months 3
• At least 14 days are required after maternal vaccination for adequate antibody development and transplacental transfer 3