What are the recommendations for Respiratory Syncytial Virus (RSV) vaccine administration in individuals with high-risk conditions, such as heart disease, lung disease, or impaired immune function, including young children, older adults, and those with underlying health conditions?

RSV Vaccine Recommendations

Primary Age-Based Recommendations

All adults aged ≥75 years should receive a single lifetime dose of RSV vaccine regardless of comorbidities or risk factors. 1, 2, 3

Adults aged 60-74 years should receive RSV vaccination if they have any of the following high-risk conditions: 1, 2, 3

Respiratory Conditions

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

Cardiovascular Conditions

• Heart failure 1, 2, 3
• Coronary artery disease 1, 2
• Other chronic cardiovascular diseases 3

Metabolic and Organ Dysfunction

• Diabetes mellitus (particularly with complications) 1, 2, 3
• Chronic kidney disease, especially end-stage renal disease 1, 2, 3
• Chronic liver disease 1, 2, 3

Neurological and Other Conditions

• Chronic neurological or neuromuscular diseases 1, 2, 3
• Severe obesity (BMI ≥40 kg/m²) 3
• Frailty or dementia 2, 3

Immunocompromised States

• Solid organ transplant recipients 3
• Hematopoietic stem cell transplant recipients 3
• Solid tumors or hematological malignancies 3
• Patients on immunosuppressive medications 3
• HIV-positive individuals 3
• Moderate or severe immunocompromise of any cause 2, 3

Living Situation

• Nursing home or long-term care facility residents 2, 3

Special Population: Adults Aged 50-59 Years

For adults aged 50-59 years with any of the above risk factors, RSVPreF3 (Arexvy) is the only vaccine currently approved and should be used. 1, 3

Dosing and Administration Algorithm

Single Lifetime Dose

Only one dose of RSV vaccine is recommended for a lifetime—adults who have previously received any RSV vaccine should not receive another dose. 1, 2, 3

• Current evidence demonstrates protection lasting at least two consecutive RSV seasons 1, 3
• No revaccination is currently recommended 1, 2, 3
• Future guidance on additional doses will be evaluated as more data become available 1, 3

Optimal Timing

Administer the vaccine between September and November, before or early in the RSV season, to maximize protection during peak transmission months. 1, 2, 3

• Eligible adults may be vaccinated at any time of year if they have not previously received RSV vaccination 3
• Late summer or early fall (August-October) provides the most benefit 1, 3

Co-Administration with Other Vaccines

RSV vaccine can be co-administered with seasonal influenza vaccine at different injection sites. 1, 2, 3

• Some studies show numerically lower antibody titers for both RSV and influenza when co-administered, though clinical significance remains unknown 1
• Co-administration with COVID-19 vaccines requires further study, with current data lacking 1

Clinical Implementation Considerations

Documentation Requirements

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

• Adults aged ≥75 years should not be delayed vaccination while waiting for documentation, as age alone is sufficient indication 2, 3
• Extensive medical records should not be required 1, 2

Prioritization if Vaccine Supply is Limited

If resources are constrained, prioritize in this order: 1, 2, 3

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

Safety Profile for Immunocompromised Patients

The approved RSV vaccines are recombinant subunit vaccines that are completely inactivated and contain no live viral particles, making them safe for immunocompromised patients. 1

• No special precautions regarding live vaccine administration apply 1
• Safe for cancer patients, those on immunosuppressive therapy, and transplant recipients 1

Important Clinical Caveats

Previous RSV infection does not confer long-lasting immunity and does not contraindicate vaccination. 1, 3

• Reinfections are common due to short-lived immune responses 3
• Prior infection should not be considered protective 1

The burden of RSV in older adults has been historically underrecognized—it accounts for 10.6% of hospitalizations for pneumonia and 11.4% for COPD exacerbations. 1, 3 Severe outcomes occur in 18.5% of hospitalized patients aged ≥60 years, with 17.0% requiring ICU admission, 4.8% requiring mechanical ventilation, and 4.7% mortality. 4