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ACIP Guidance on RSV Vaccination
How I Am Implementing the New ACIP Guidance on RSV Vaccination in My Practice

Released: September 20, 2023

Angela Branche
Angela Branche, MD, FIDSA
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Key Takeaways
  • Two RSV vaccines were approved recently for older adults.
  • The ACIP recommends RSV vaccination for adults aged 60 years and older using shared clinical decision-making.

Respiratory syncytial virus (RSV) is a major cause of severe lower respiratory tract disease (LRTD) in older adults, which can result in significant changes in function, cognition, and quality of life, as well as an increased risk of stroke and myocardial infarction.

In June 2023, the Advisory Committee on Immunization Practices (ACIP) voted to recommend RSV vaccination for adults aged 60 years and older using shared clinical decision-making. The recommendation for shared clinical decision-making is intended to allow flexibility for healthcare professionals (HCPs) and patients to consider individual risk for RSV disease. 

These recommendations came shortly after FDA approval of 2 RSV vaccines for this age group: RSVpreF and RSVPreF3 . In the phase III trials, investigators showed that a single dose of RSVpreF was able to prevent symptomatic LRTD in 88.9% of patients and, similarly, a single dose of RSVpreF3 was able to prevent symptomatic LRTD in 82.6% of patients. However, some unique factors surrounding the RSV vaccine trials complicated ACIP recommendations on how these vaccines should be used in practice.

In this commentary, I discuss reasoning behind these recommendations and how I incorporate them in my practice.

Factors Affecting the RSV Vaccine Trials

COVID-19
The phase III efficacy trials for RSVpreF and RSVPreF3 were affected tremendously by behaviors implemented during the COVID-19 pandemic. For example, the many nonpharmaceutical interventions (eg, masking, social isolation) not only curbed the transmission of COVID-19, but also ultimately led to a massive decrease in viral infections in general, including RSV, for approximately 2 winter seasons. This resulted in very few RSV cases, which complicated vaccine trial results. It is logical to presume that if these vaccines can prevent LRTD (as demonstrated in the clinical trials), they also can prevent hospitalizations and death, but the low case numbers did not allow for those analyses.

Healthy User Bias
In general, vaccine trials are subject to healthy user bias. In other words, the people willing and selected to participate in these longer trials are healthier than the group for whom protection is desired. Accordingly, frail, older people in their 70s and 80s; patients living in nursing homes; and those with medical conditions associated with severe RSV (eg, congestive heart failure and chronic obstructive pulmonary disease) were not well represented in the clinical trials.

Applying ACIP Recommendations
Although the shared clinical decision-making aspect of the ACIP recommendation for RSV vaccination permits some flexibility, I was hoping for more specific recommendations, such as strong recommendations for specific age groups and/or certain medical comorbidities.

In my practice, I recommend RSV vaccination for anyone in their 70s and 80s. I think the shared decision-making really comes into play for adults in their 60s. For those individuals, HCPs need to look at the totality of the patient and analyze their overall health status. It is possible they do not need to be vaccinated, but I would undoubtedly consider it for certain patients, such as those with class III or IV heart failure, advanced chronic obstructive pulmonary disease, and other chronic heart, lung, or endocrine diseases.

Of note, there are populations who have not yet been studied, such as adults with immunocompromising conditions. I am hopeful that educational endeavors will help HCPs navigate this complicated process of understanding some of the known risks, how to weigh those risks, and ultimately how to determine who should be vaccinated against RSV this season.

Learn More
To learn more about the ACIP guidance on vaccination against RSV, join me and a panel of experts at our live symposium at the 2023 Family Medicine Experience (FMX) Conference in Chicago, Illinois. You can participate in person or via live simulcast.

Unable to make it to the FMX 2023 meeting? Check out our encore virtual symposium here.

Your Thoughts?
How are you implementing the new ACIP guidance on RSV vaccinations in your practice? Join the discussion by posting a comment.