Q&A: Refresher on RSV vaccines for older adults

Key takeaways:

• The CDC has said older adults may receive an RSV vaccine — a softer recommendation than it has made for other vaccines.
• “RSV is not just a virus of infants and young children,” an expert said.

Many health care workers, including primary care providers, may have lingering questions surrounding the new respiratory syncytial virus vaccines for older adults.

Last summer, the FDA approved two vaccines for older adults to prevent respiratory syncytial virus (RSV). Shortly thereafter, the CDC’s Advisory Committee on Immunization Practices (ACIP) recommended that people aged 60 years or older talk to their doctors about getting vaccinated against RSV.

Because the recommendation says older patients “may receive” an RSV vaccine, it is not necessarily as strong as what the ACIP has done for other vaccines, recommending that patients “should” receive one.

According to the CDC, 21.1% (95% CI, 19.8%-22.3%) of older adults in the United States reported receiving an RSV vaccine.

Healio spoke with William Schaffner, MD, a professor of preventive medicine and infectious diseases at Vanderbilt University Medical Center, to learn more about the RSV vaccine recommendations, the past year’s uptake and patient hesitancy.

Healio: What are the current RSV vaccines available in the U.S. and recommendations regarding them?

Schaffner: The CDC Advisory Committee has said an RSV vaccine should be considered for people aged 60 and older in the context of what they call “shared clinical decision-making,” which is having a discussion with your patients.

There are two fairly newly licensed RSV vaccines available: one from Pfizer and one from GSK. They're slightly different, but the CDC considers them equivalent ... and certainly, that's the way I think about them.

When I speak to physicians, I say, ‘Don't make this thing too complicated.’ First, let's recognize — and this is new information to a lot of PCPs — that RSV is not just a virus of infants and young children, but it's also a virus that causes substantial illness, hospitalizations and deaths in older adults. This is new. This is the sort of information about the upper end of the age spectrum that has been slowly accumulating over the last 20 years, and if you went to medical school before then, you learned that RSV was a pediatric virus. It was a virus that affected infants. So, in order to appreciate and implement the RSV vaccine, you have to first understand that RSV, the virus itself, can cause, in some seasons, as much illness as influenza. So, that's the first thing. We have to let them know about that.

Then, when they consider giving this vaccine to older adults, I think there are just two things they have to consider and talk to their patients about. One is age. Increasing age is a very powerful risk factor for serious disease with RSV. So, the 70-year-olds have more risk than the 60s, the 80s more than the 70s and with each year that you're older, your risk increases. So, on the basis of age alone, the older your patient is, the firmer your recommendation to give an RSV vaccine should be. To me, that doesn't appear to be very complicated. That's very simple. The second thing is that, if you have any chronic underlying condition — of course, many people older than age 60 years do — your risk increases further. If your patient does have underlying heart disease, lung disease, diabetes, liver disease, kidney disease, if they're obese, etc., and if you have multiple of these, your risk increases further also. So, take that into consideration in the enthusiasm of your recommendation for an individual patient whom you see who's older than 60 years of age.

Healio: Should the ACIP’s recommendation be stronger? Do we have the data to support a stronger recommendation?

Schaffner: I think the enthusiasm, the assertiveness of the CDC’s recommendations will likely increase. There were a number of things that gave them just a little pause.

First of all, these are brand new vaccines, and sometimes with brand new vaccines, they're a little bit more cautious just out of the box. Number two: although the studies (both of the Pfizer vaccine and the GSK vaccine) were really very convincing — after all, we got these recommendations — they were not large enough to show specifically an impact on hospitalizations, ICU admissions and deaths. They certainly showed an impact on less severe disease. And yes, if you have an impact on less severe disease, you anticipate that you will also have an impact on more severe disease, but they didn't have the data in hand. Number three was that there were some events that occurred during the trial that caused the advisory committee to just raise their eyebrows. There were some cases of neuroinflammatory disease, a Guillain-Barré-like syndrome. And so, they said, “Look, before we make a routine recommendation, let's gather some data during the first year when this vaccine is administered to hundreds of thousands of people.” ... And so there was that little bit of caution. ... Lastly, in the studies that were done, although old people and frail people were part of the study, they were not the dominant participants in the study; they were healthier people aged 60 and older. And there were several members of the advisory committee who said, “Listen, if you want us to recommend this vaccine for people who are old and who have chronic underlying conditions, why don't you have the majority of people in your study with those circumstances? Where are the people in nursing homes, for example, who are really frail? We'd like to see more of those people in the studies.”

So, all of that put together gave the ACIP just enough pause to say, “Yes, we recommend this vaccine, but we're staying a step shy of giving it a universal routine recommendation. Think about it with your individual patient.”

Healio: Are PCPs giving the vaccine as much as they should be? What can they do to improve RSV vaccine uptake?

Schaffner: Recognize that this is the first year the vaccines are available and that we don't expect optimal performance the first year. And remember, a lot of these practitioners really have to get the updated information that RSV is important in this older age group. So, you have kind of a double lesson to learn: you have to learn about the virus and the disease, as well as about the new vaccines. So, I think we'll do better next year than we did this year. This year, we're just getting started. It's like a train: those first two rotations of the wheel are slower until the momentum gets going.

Then, of course, there's one other point for these older patients: This year, on a seasonal basis, we weren't recommending just one vaccine (influenza), not just two (influenza and the updated COVID-19) but three with the RSV vaccine, and this in the context of a general atmosphere of vaccine hesitancy and vaccine fatigue.

I think we've done reasonably well given all those considerations, and I hope we get better organized and become more persuasive with the public next year.

Healio: What should PCPs say to patients who are hesitant about taking the vaccine?

Schaffner: Well, the first thing is that you have to always respect the patient's concern. The way I teach our students, our residents and fellows is when you hear hesitancy, pause. It's going to take a little more time. And then acknowledge that you've heard it to the patient. “Well, Mr. Jones, I hear you're a little hesitant. You know, I get that fairly frequently.” That calms the patient; it normalizes the patient's concern. The patient is not an outlier or freak. “I get a lot of questions. What's your concern specifically?” So, then you open up the door for the patient to come to you with whatever concerns them, and then you can address those, and then I think you will want to bridge in your messaging to the patient [and try] to make this the norm. “I'm older than age 60, and I've taken the vaccine myself and so has my wife. I know a lot, and I've taken the vaccine — that validates [the recommendation].” Some physicians are not as comfortable at being that personal, but I think it helps a lot.

Healio: What is the take-home message for PCPs here? If nothing else, what should they take away from this article?

Schaffner: I think as we particularly look beyond this winter to next winter, [know that] RSV is another vaccine that's recommended for your older patients. Get some information about RSV. The vaccines are available. And let's make an effort to optimally vaccinate every patient who comes into your office who's eligible and is interested in receiving the vaccine, but pay particular attention to your older patients, as well as those — and this is very important — who already have a chronic underlying condition.

Reference:

• CDC. Vaccination trends—adults. https://www.cdc.gov/respiratory-viruses/data-research/dashboard/vaccination-trends-adults.html. Reported on Jan. 19, 2024. Accessed Jan. 23, 2024.