What are the RSV (Respiratory Syncytial Virus) vaccine recommendations for high-risk individuals, including young children under 2 years old with premature birth or underlying health conditions like heart disease or lung disease, and older adults with chronic health conditions?

RSV Vaccination Recommendations

All adults aged ≥75 years should receive a single lifetime dose of RSV vaccine, and adults aged 60-74 years should receive it if they have chronic medical conditions including COPD, asthma, heart failure, coronary artery disease, diabetes, chronic kidney disease, chronic liver disease, immunocompromise, frailty, dementia, or nursing home residence. 1, 2

Adult Vaccination Guidelines

Age-Based Recommendations

Universal vaccination is recommended for all adults ≥75 years 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

For adults aged 60-74 years, vaccination is recommended if they have any of the following risk factors: 1, 2, 3

• Chronic respiratory conditions: COPD, asthma, bronchiectasis, interstitial lung disease, chronic respiratory failure 2
• Cardiovascular disease: Heart failure, coronary artery disease, other chronic cardiovascular conditions 1, 2
• Metabolic conditions: Diabetes (particularly with complications) 1, 2
• Renal disease: Chronic kidney disease, especially end-stage renal disease 2
• Hepatic disease: Chronic liver disease 1, 2
• Neurological conditions: Chronic neurological or neuromuscular diseases 2
• Immunocompromise: Solid organ transplant recipients, hematopoietic stem cell transplant recipients, patients with solid tumors or hematological malignancies, patients on immunosuppressive medications, HIV-positive individuals 2
• Living situation: Residence in nursing homes or long-term care facilities 1, 2
• Other conditions: Frailty, dementia, severe obesity (BMI ≥40 kg/m²) 2

For adults aged 50-59 years with risk factors, RSVPreF3 (Arexvy) is the only vaccine currently approved. 1, 2, 4

Dosing and Administration

Only a single lifetime dose of RSV vaccine is recommended. Adults who have previously received any RSV vaccine should not receive another dose. 2, 3 Current evidence demonstrates that one dose provides protection lasting through at least two RSV seasons. 2

The vaccine should preferably be administered between September and November, before or early in the RSV season, to maximize protection during peak transmission months. 1, 4, 3 However, eligible adults who have not been vaccinated may receive the vaccine at any time of year. 2

RSV vaccine can be co-administered with seasonal influenza vaccine at different injection sites. 1, 4, 3 Data on co-administration with other vaccines such as pneumococcal, herpes zoster, and COVID-19 are currently lacking. 1

Clinical Implementation Considerations

Patient attestation alone is sufficient evidence of risk factors, and vaccination should not be denied due to lack of medical documentation. 2, 3 Extensive medical documentation should not be required. 1, 3

Adults aged ≥75 years should not be delayed vaccination while waiting for documentation of risk factors, as age alone is sufficient indication. 3

If vaccine supply is limited, prioritize: 1, 3

1. Adults aged ≥75 years
2. Adults aged ≥50 years with multiple comorbidities
3. Residents of long-term care facilities

Pediatric Immunoprophylaxis

For high-risk infants and young children, palivizumab (Synagis) is indicated for prevention of serious lower respiratory tract disease caused by RSV in the following populations: 5

• Premature infants: History of premature birth (≤35 weeks gestational age) who are ≤6 months of age at the beginning of RSV season 5
• Bronchopulmonary dysplasia (BPD): Children with BPD that required medical treatment within the previous 6 months and who are ≤24 months of age at the beginning of RSV season 5
• Congenital heart disease (CHD): Children with hemodynamically significant CHD who are ≤24 months of age at the beginning of RSV season 5

Palivizumab Dosing

The recommended dose is 15 mg/kg body weight given monthly by intramuscular injection. 5 The first dose should be administered prior to commencement of the RSV season, with remaining doses administered monthly throughout the RSV season. 5

Children undergoing cardiopulmonary bypass should receive an additional dose as soon as possible after the procedure (even if sooner than a month from the previous dose), then continue monthly dosing as scheduled. 5

Important Caveats

Palivizumab is for prevention only—it has not been established as effective for treatment of active RSV disease. 5 Children who develop RSV infection should continue to receive monthly prophylactic doses throughout the RSV season. 5

The RSV season in the northern hemisphere typically runs from November through April, though it may begin earlier or persist later in certain communities. 5

Common Pitfalls to Avoid

• Do not administer multiple doses of RSV vaccine to adults—only a single lifetime dose is recommended. 2, 3
• Do not delay vaccination for adults ≥75 years while waiting for medical documentation—age alone is sufficient indication. 3
• Do not withhold vaccination from adults aged 60-74 years who attest to having risk factors, even without formal medical records. 2
• Do not use palivizumab for treatment of active RSV infection—it is indicated for prevention only. 5