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FAQs on RSV Vaccines in Adults
Expert Answers to Questions on RSV Vaccination in Adults

Released: May 15, 2024

Expiration: May 14, 2025

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Key Takeaways
  • The ACIP recommends a single dose of the RSV vaccine in persons aged 60 years and older using shared clinical decision-making, with administration in late summer or early fall for maximal benefit.

The following is a recap of key questions asked by healthcare professionals (HCPs) during a program featuring Angela Branche, MD, FIDSA and Jewel Mullen, MD, MPH, MPA, discussing the burden of respiratory syncytial virus (RSV) in older adults, latest data and guideline recommendations for vaccination, and strategies to effectively recommend the RSV vaccine using shared clinical decision-making.

Can we develop a natural immunity against RSV?

Angela Branche, MD, FIDSA:
After an RSV infection, you do develop a natural immunity and will have partial immunity for the rest of your life, but it is not enough to protect you from being reinfected or having severe disease. In fact, based on natural history studies completed, people can be reinfected with RSV as soon as 2 months later, though the infection might be less severe. This is why we have always known we needed a vaccine to protect us against RSV.

How often should the RSV vaccine be administered?

Angela Branche, MD, FIDSA:
Currently, the Advisory Committee on Immunization Practices (ACIP) recommends a single dose of the RSV vaccine in persons aged 60 years and older. However, based on available data demonstrating protection over at least 2 respiratory seasons, I do not think people will need another vaccine the following season. In fact, you might not even need another vaccine for the third season because it looks like it will protect against severe disease for more than 2 seasons. But the jury is still out on that, so stay tuned.

Is it too early to administer the RSV vaccine in the spring to benefit the patient for the next RSV season?

Angela Branche, MD, FIDSA:
I would wait until late summer or early fall of that year (eg, August to October). You can vaccinate in the spring or summer, but with all RNA vaccines there will be waning of immunity. Therefore, to get the most benefit or greatest durability over 2 seasons, I would vaccinate in the fall of the next respiratory season.

Are there differences in safety with the protein subunit vaccines and the mRNA vaccine under investigation?

Angela Branche, MD, FIDSA:
Both FDA-approved RSV vaccines (RSVpreF and RSVPreF3) are protein subunit vaccines. There is an mRNA vaccine (mRNA-1345) that is undergoing FDA review and is expected to be licensed soon. All 3 RSV vaccines were developed with the RSV F glycoprotein in its prefusion confirmation and provide coverage against the 2 main virus subtypes (A and B).

Although we have plenty of experience with mRNA vaccines, one thing that we do not yet know about mRNA-1345 is its durability. There will always be pros and cons with these vaccines, and we do not yet know if the mRNA-1345 will be safer or more durable than the protein subunit vaccines. In addition, Guillain-Barré Syndrome is something we worry about with all vaccines, and its causality with the two licensed RSV vaccines has not yet been established.

At this point, given the evidence we have, I would not necessarily recommend one vaccine over another. I would feel comfortable recommending any of the 3 RSV vaccines to my patients. In addition to more data on rare potential side effects, I suspect we are going to learn more about their durability over the next few seasons, and there may be some differences in certain populations that may inform these decisions.

How do you communicate RSV vaccine safety concerns with your patients?

Jewel Mullen, MD, MPH, MPA, FACP:
The ACIP recommends RSV vaccination for adults aged 60 years and older with shared clinical decision-making. The RSV vaccine is just 1 of the many vaccines—such as the meningococcal B, hepatitis B, human papillomavirus, and conjugated pneumococcal vaccines—that fall into this shared clinical decision-making category. Due to the nature of these vaccines requiring shared clinical decision-making, this is considered an informal recommendation.

The CDC’s recommendation was that RSV vaccination might prevent substantial morbidity in older adults at risk for severe disease, and that postmarketing surveillance for safety and effectiveness will direct future guidance. Therefore, HCPs must be clear in their own minds; that, to me, includes having confidence in our own understanding of the vaccine’s risks and benefits.

We must communicate equitably and ensure people understand what we are saying—that we are not using medical jargon and that we are accommodating patients’ health literacy. Doing so improves our relationships with patients, too, as it builds their self-confidence and perhaps their self-efficacy or satisfaction with us. In addition, shared decision-making builds deeper trust, by conveying that we care about our patients and their health outcomes.

In general, do persons with lower education and socioeconomic status have lower vaccine acceptance?

Jewel Mullen, MD, MPH, MPA, FACP:
Overall, I think we are still learning how best to share information with people to increase vaccine uptake and acceptance, including individuals with lower education and socioeconomic status. We learned from the COVID pandemic that once the COVID-19 vaccine became more available and people were given the opportunity to have their questions answered, vaccination rates increased. Communication increased trust, confidence, and acceptance.

Which patients are at risk for severe RSV disease? How do you assess patients at risk in your clinical practice?

Jewel Mullen, MD, MPH, MPA, FACP:
Last summer, in anticipation of the RSV vaccine, we were just starting to have conversations with people that a vaccine was coming. Anecdotally, people thought RSV was a virus that mainly affected children. I think one of the big challenges is helping people understand the risks of developing severe disease in older adults—this continues to be an area for further education, both at the population and individual level.

Angela Branche, MD, FIDSA:
In my practice, I start with age because it is the most well-defined and known risk factor for severe RSV disease. This is considering data on incidence rates doubling with every decade of life when aging from the 60s to the 70s and onto the 80s. If I have a patient in their mid to late 70s or 80s, I strongly recommend the RSV vaccine unless there is a contraindication.

For adults in their 60s to early 70s, I take into consideration the things that I know have the strongest association with severe disease, such as underlying cardiac and pulmonary conditions. This is true for all respiratory viruses, but particularly for RSV because it is a wheezy and prolonged insidious illness. There is something about how RSV interacts with the lungs and heart that predisposes people to serious outcomes. Therefore, for anyone with underlying cardiac or lung disease, I always recommend the vaccine.

Now, for those living in long-term care facilities and considering how frail they are, any virus is really going to knock them out so this tends to be a group that I feel very strongly about recommending the vaccine.

There are many other conditions to consider, such as endocrine disorders, chronic kidney disease, chronic liver disease, and HIV. And this is where shared clinical decision-making really comes into play. If patients are young and only have 1 of these conditions, it may be possible to defer vaccination for now, especially if there are other more pertinent vaccines to be administered immediately.

For example, if a 61-year-old has an endocrine disease like diabetes, but it is well controlled (eg, hemoglobin A1C of 5.8), I would have a conversation about the RSV vaccine but my recommendation may not be as strong as for a person with other risk factors associated with developing more severe RSV disease.

Would you consider administering the RSV vaccine to patients with sleep apnea?

Angela Branche, MD, FIDSA:
Sleep apnea is a very interesting consideration. If patients are diagnosed with sleep apnea via a sleep study and are using a continuous positive airway pressure machine, I might vaccinate them. But this is not something that I have evidence for, regarding RSV or other respiratory virus vaccinations.

Would you hold methotrexate or other immunosuppressive medications prior to RSV vaccination?

Angela Branche, MD, FIDSA:
In general, we do not hold immunosuppressive medications for vaccination, though we do recognize that those medications will, perhaps, blunt one’s immune response. Fortunately, most single medications affect all parts of the immune system (with the exception, perhaps, of high-dose steroids for very prolonged courses or myeloablative conditioning chemotherapy regimens). Even if someone might not get as good a B-cell response, they may get good T-cell responses. So, giving the RSV vaccine with concurrent immunosuppressive agents is not an issue and should be done as is appropriate for the patient.

What should we expect for insurance coverage for the RSV vaccine?

Jewel Mullen, MD, MPH, MPA, FACP:
The complicated issue around insurance is that, since vaccinating for RSV is an informal recommendation, not all payors are covering it. Medicare D, but not A or B, covers it, but not all commercial insurers are covering it yet. Patients may have to pay out of pocket.

Those with Medicare Part D, might need to get the RSV vaccine at a pharmacy because many medical offices are not stocking it. Moreover, in certain states a prescription may be needed to receive the vaccine at a pharmacy. In addition, there may be a potential gap in coverage, particularly among those 60 to 64 years of age who are eligible for vaccination but are not yet covered under Medicare. Finally, coverage with commercial payers may depend on their specific formulary and policies.

For many within the older adult population, cost has been a barrier. These issues should be simplified once we get to a formal recommendation phase where specific population groups are outlined to receive the vaccine.

Your Thoughts?
In which patients do you recommend the RSV vaccine? How do you communicate RSV vaccine recommendations, including any safety concerns with your adult patients? Join the discussion by posting a comment.