What are the contraindications to RSV (Respiratory Syncytial Virus) vaccine in elderly patients?

Contraindications to RSV Vaccine in Elderly Patients

The only absolute contraindication to RSV vaccination in elderly patients is a history of severe allergic reaction (e.g., anaphylaxis) to any component of the RSV vaccine or after a previous dose of RSV vaccine. 1

Absolute Contraindications

• Severe allergic reaction (anaphylaxis) to any vaccine component is the sole absolute contraindication to RSV vaccination 1
• Previous severe allergic reaction to an RSV vaccine dose contraindicates further vaccination 1

Important Clinical Context: What Are NOT Contraindications

The guidelines explicitly clarify several conditions that clinicians might mistakenly consider contraindications:

Age is NOT a Contraindication

• All adults aged ≥75 years should receive RSV vaccination regardless of health status or comorbidities 1
• Adults aged 60-74 years with risk factors should receive vaccination 1
• Advanced age with multiple comorbidities is an indication, not a contraindication 1

Immunocompromised Status is NOT a Contraindication

• Moderate or severe immunocompromise is actually an indication for vaccination in adults aged 60-74 years 1
• Solid organ transplant recipients, hematopoietic stem cell transplant recipients, and patients on immunosuppressive medications should receive RSV vaccine 2
• Recent real-world data shows vaccine effectiveness of 67-73% in immunocompromised patients aged ≥60 years, though slightly lower than immunocompetent individuals 3

Chronic Medical Conditions are NOT Contraindications

• COPD, asthma, heart failure, coronary artery disease, diabetes, chronic kidney disease, and chronic liver disease are all indications for vaccination, not contraindications 1
• Frailty, dementia, and nursing home residence are indications for vaccination 1

Previous RSV Infection is NOT a Contraindication

• Prior RSV infection does not confer long-lasting immunity and does not contraindicate vaccination 2, 4
• Reinfections are common due to short-lived immune responses 5

Precautions (Not Contraindications)

Guillain-Barré Syndrome (GBS) History

• History of GBS is a precaution, not an absolute contraindication 1
• For protein subunit RSV vaccines, patients should be informed of the potential risk for GBS 1
• Real-world data shows an excess of 5.2 cases per 1,000 doses for RSVPreF3+AS01 and 18.2 cases per 1,000 doses for RSVPreF, though the absolute risk remains small 3
• Clinical judgment should guide decision-making in patients with GBS history, weighing the small GBS risk against substantial benefits of preventing severe RSV disease 3

Moderate or Severe Acute Illness

• Vaccination should generally be deferred in patients with moderate or severe acute illness with or without fever 1
• This is a temporary precaution, not a permanent contraindication 1

Common Clinical Pitfalls to Avoid

Do Not Require Extensive Medical Documentation

• Patient attestation alone is sufficient evidence of risk factors 1, 2
• Vaccinators should not deny RSV vaccination due to lack of medical documentation 1
• Adults aged ≥75 years should not have vaccination delayed while waiting for documentation, as age alone is sufficient indication 4

Do Not Withhold Vaccine Based on Lack of Risk Factor Documentation

• For adults aged 60-74 years who attest to having risk factors, vaccination should not be withheld even without formal medical records 4
• Providers should have flexibility in offering RSV vaccine to patients they assess to be at increased risk for severe disease, even if they do not fall into an explicitly named risk category 1

Previous RSV Vaccination is NOT a Contraindication But IS a Reason to Withhold

• Adults who have already received any RSV vaccine should not receive another dose 1, 2
• A single dose provides protection for at least two RSV seasons 1
• This is not technically a contraindication but rather reflects current dosing recommendations 1

Summary Algorithm for RSV Vaccination Decision

1. Check for severe allergic reaction history to vaccine components or previous RSV vaccine dose → If YES, do not vaccinate 1
2. Check if patient already received RSV vaccine → If YES, do not give another dose 1
3. Check for moderate/severe acute illness → If YES, defer vaccination temporarily 1
4. Check for GBS history → If YES, discuss risks/benefits and use clinical judgment 1, 3
5. If none of the above apply → Proceed with vaccination based on age and risk factors 1