RSV immunization in adults and children: A practical guide for clinicians

Trate DeVolld; Kaitlyn R. Rivard

doi:10.3949/ccjm.91.s1.03

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TABLE 1

Immunizations for respiratory syncytial virus (RSV)

Agent	Indications	Dosing	Adverse events	Estimated $ per dose
Monoclonal antibodies
Palivizumab	First year of life: Infants born < 29 weeks’ gestation, or > 29 weeks with chronic lung disease, congenital heart disease, or other immunocompromising conditions Second year of life: Infants born < 32 weeks’ gestation who continue to need supplemental oxygen, chronic corticosteroids, or bronchodilator therapy, or those with immunocompromising conditions	15 mg/kg monthly throughout RSV season	Minimal, low risk Fever, injection-site reactions including erythema, pain, or swelling, nervousness, and rhinitis	$2,100–$4,200
Nirsevimab	Infants < 8 months old entering first season if: Mother did not receive RSV vaccine during pregnancy Mother’s RSV vaccination status is unknown Born within 14 days of the mother being vaccinated Infants 8–19 months old at increased risk of RSV,^a entering second season	First RSV season (1 dose): < 5 kg: 50 mg ≥ 5 kg: 100 mg Second RSV season (1 dose): 200 mg	Minimal, low risk Fever, injection-site reactions including erythema, pain, or swelling, nervousness, and rhinitis	$519.75
Vaccines
RSVpreF	Adults 75 years of age and older Adults 60–74 years at increased risk of severe RSV disease^b Pregnant women at 32 to 36 weeks’ gestation^c	0.5 mL (1 dose)	Fatigue, headache, injection-site pain, myalgia Rare inflammatory neurologic events	$295
RSVPreF3	Adults 75 years of age and older Adults 60–74 years at increased risk of severe RSV disease^b	0.5 mL (1 dose)	Fatigue, headache, injection-site pain, myalgia Rare inflammatory neurologic events	$280
mRNA-1345	Adults 75 years of age and older Adults 60–74 years at increased risk of severe RSV disease^b	0.5 mL (1 dose)	Fatigue, headache, injection-site pain, myalgia	Not yet available

All doses are given intramuscularly. Prices are per Lexicomp, and CDC vaccine price list (https://www.cdc.gov/vaccines/programs/vfc/awardees/vaccine-management/price-list/index.html).
↵^aBorn premature with chronic lung disease, immunocompromising condition, or severe cystic fibrosis; American Indian or Alaskan native.
↵^bThe CDC will publish considerations for chronic medical conditions and other risk factors for severe RSV disease for clinicians to use when implementing this risk-based recommendation.
↵^cInfants whose mothers received maternal RSV vaccine during pregnancy are not recommended to receive nirsevimab, unless infant is born within 14 days of maternal vaccination, or the potential incremental benefit of administration is indicated based on clinical judgment.

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TABLE 2

Strategies to prevent errors related to RSV immunizations

Errors with age-specific formulation
Highlight immunization packaging to denote product differences
Store immunizations in separate containers by type and formulation
Store look-alike products in different areas of the storage unit (eg, pediatric and adult formulations on different shelves)
Use color-coded labels to differentiate pediatric and adult formulations
Use vaccine order sets to guide providers to select the appropriate product by age

Errors with vaccine preparation
Denote vaccines that require preparation (eg, dilution, reconstitution) prior to administration
Establish process to keep 2-component vaccines together
Use vaccine diluent supplied by the manufacturer, do not interchange vaccine diluents
Clearly label diluents to prevent inadvertent administration of diluent only
Prepare immunizations for 1 patient at a time
Label prepared syringes with vaccine name and expiration date
Keep reference materials for each vaccine product in the vaccine preparation area

Errors with vaccine storage and handling
Rotate vaccine stock to use earliest-expiring products first
Routinely check for expired product and remove expired vaccines and diluents from vaccine storage units

Errors with immunization administration
Prepare and administer immunizations 1 patient at a time
Verify patient’s identity using 2 unique identifiers
Involve the patient or family member in verification process

Errors due to vaccine nomenclature
Use ACIP-approved terminology or abbreviations when referring to immunization products
Order products with look-alike names using brand names

Errors due to education and training
Require baseline and ongoing comprehensive training on vaccine storage, handling, and administration for all staff
Provide education when new immunizations are added to clinic inventory or when recommendations have changed
Keep reference materials on vaccine preparation and administration recommendations in medication preparation area
Distinguish between RSV vaccine and RSV antibody when discussing RSV prevention strategies
Require baseline and ongoing education and training for vaccine providers handling immunizations