What are the current recommendations for respiratory syncytial virus (RSV) vaccination in adults, including age eligibility, high‑risk groups, dosing schedule, co‑administration with other vaccines, and contraindications?

RSV Vaccination for Adults: Current Recommendations

All adults aged ≥75 years should receive a single lifetime dose of RSV vaccine, and adults aged 60–74 years should receive it only if they have qualifying risk factors for severe RSV disease. 1

Age-Based Vaccination Framework

Universal Vaccination (Age ≥75 Years)

• Every adult aged 75 years or older qualifies for RSV vaccination regardless of health status, comorbidities, or frailty. 1
• This universal recommendation reflects significantly elevated rates of RSV-associated hospitalization, severe disease, and mortality in this age group. 1
• No medical documentation is required—age alone is sufficient indication. 2

Risk-Based Vaccination (Ages 60–74 Years)

Adults aged 60–74 years qualify for RSV vaccination only if they possess at least one of the following risk factors:

Cardiovascular Conditions

• Chronic heart failure, coronary artery disease, or congenital heart disease qualify for vaccination. 2
• Isolated hypertension alone does NOT qualify—this is a critical pitfall to avoid. 2

Respiratory Conditions

• Chronic obstructive pulmonary disease (COPD), asthma, emphysema, interstitial lung disease, or cystic fibrosis are qualifying conditions. 2

Metabolic & Renal Conditions

• End-stage renal disease or dialysis dependence qualifies. 2
• Diabetes with end-organ complications (chronic kidney disease, neuropathy, retinopathy) qualifies. 2
• Diabetes requiring insulin or SGLT2 inhibitor therapy qualifies. 2

Neurologic Conditions

• Disorders causing impaired airway clearance or respiratory-muscle weakness (post-stroke dysphagia, amyotrophic lateral sclerosis, muscular dystrophy) qualify. 2
• A history of stroke without ongoing airway impairment does NOT qualify. 2

Other Chronic Conditions

• Chronic liver disease (cirrhosis) qualifies. 2
• Chronic hematologic disorders (sickle-cell disease, thalassemia) qualify. 2
• Severe obesity (BMI ≥40 kg/m²) qualifies. 2

Immunocompromise & Living Situation

• Moderate or severe immunocompromise (as defined in COVID-19 vaccination guidance) qualifies. 2
• Residence in a nursing home or long-term care facility qualifies. 1, 2
• Frailty (≥3 criteria of the Fried phenotype) qualifies. 2

Available Vaccines

Three FDA-approved RSV vaccines are acceptable for adults aged ≥60 years:

• Arexvy (GSK, protein subunit) 1
• Abrysvo (Pfizer, protein subunit) 1
• mResvia (Moderna, mRNA) 1

For adults aged 50–59 years with risk factors, only Arexvy is FDA-approved, though ACIP has not yet voted on recommendations for this age group. 1

Dosing Schedule & Timing

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
• A single dose provides protection for at least two consecutive RSV seasons. 1
• The need for additional doses will be evaluated by ACIP as more data become available. 1

Optimal Timing

• Vaccination is preferably administered in late summer or early fall (August–October) in the continental United States, just before RSV season begins. 1
• Eligible adults may be vaccinated at any time of year, but late summer/early fall provides maximum benefit. 1

Co-Administration with Other Vaccines

• RSV vaccine may be co-administered with seasonal influenza vaccine at separate injection sites. 1, 4
• Immunologic non-inferiority has been demonstrated for concomitant administration of Abrysvo with FLUAD QUADRIVALENT. 4
• Caution with Tdap: When Abrysvo was co-administered with Tdap, lower antibody responses to pertussis antigens were observed, though the clinical relevance is unknown. 4

Implementation Guidance

Documentation Requirements

• Patient self-attestation of a qualifying risk factor is sufficient—vaccinators should not deny vaccination due to lack of formal medical documentation. 1, 2
• Qualified vaccinators (pharmacists, nurse practitioners, other providers per state law) may determine eligibility based on clinical assessment. 1

Provider Flexibility

• Clinicians may offer RSV vaccine to patients they deem at increased risk even if the patient does not fall within an explicitly listed category. 1, 2
• This flexibility is particularly important in remote or rural settings where transport is limited. 2

Safety Considerations

Guillain-Barré Syndrome Risk

• Postlicensure surveillance identified a potential increased risk of Guillain-Barré syndrome (GBS) following protein subunit RSV vaccines (Arexvy and Abrysvo). 1
• This safety signal prompted ACIP to shift from universal vaccination to a risk-stratified approach for adults aged 60–74 years. 1
• Modeling demonstrates that in high-risk populations, preventable RSV-related hospitalizations, ICU admissions, and deaths exceed estimated vaccine-attributable GBS cases. 1
• Patients should be informed of both benefits and potential GBS risk when receiving protein subunit vaccines. 1

Contraindications & Precautions

• Standard vaccine contraindications apply (severe allergic reaction to vaccine components). 1
• Additional contraindication and precaution information is available at https://www.cdc.gov/vaccines/vpd/rsv/hcp/older-adults.html. 1

Rationale for Updated Recommendations

The June 2024 ACIP update replaced the previous "shared clinical decision-making" recommendation with clear age- and risk-stratified guidance to:

• Maximize RSV vaccination coverage among persons most likely to benefit. 1
• Reduce implementation barriers associated with shared clinical decision-making. 1
• Balance benefits against potential GBS risk in lower-risk populations. 1

Estimated preventable outcomes per 1 million doses in adults ≥75 years include 4,283 RSV-associated hospitalizations, 630 ICU admissions, and 605 deaths over two seasons, compared to an estimated 3 vaccine-attributable GBS cases. 1

Common Pitfalls to Avoid

• Do not vaccinate adults aged 60–74 years with isolated hypertension alone—cardiovascular qualification requires heart failure, coronary artery disease, or congenital heart disease. 2
• Do not administer multiple doses—only a single lifetime dose is recommended. 1, 3
• Do not delay vaccination for adults ≥75 years while waiting for medical documentation—age alone is sufficient. 2
• Do not deny vaccination based on lack of formal medical records—patient attestation is sufficient. 1, 2
• Do not assume stroke history alone qualifies—only stroke with ongoing impaired airway clearance qualifies. 2