RSV Season Debrief: What Should Family Physicians Know?

Although respiratory syncytial virus infection has traditionally been thought of as a pediatric disease, it often affects older adults, especially those with multiple chronic medical problems. In fact, RSV causes substantial morbidity and mortality in older adults, with an estimated 60,000 to 160,000 hospitalizations and 6,000 to 10,000 deaths occurring annually among adults age 65 years and older.

Fortunately, we family physicians now have tools that weren’t in our toolbox that long ago. Last May, the FDA approved two vaccines (Abrysvo and Arexvy) to prevent RSV infection in adults age 60 years and older. A few months later, federal agencies approved nirsevimab, a long-acting monoclonal antibody, to prevent lower respiratory tract disease due to RSV infection in infants and young children. And in August, the FDA and CDC approved Abrysvo for pregnant people to protect unborn children from RSV infection via passive immunization.

2023 was quite a year!

Even with these advances, however, we still have challenges. Here’s what we saw during the most recent RSV season, along with some lessons we’ve learned.

Many People Still Don’t Know About RSV Immunizations

Only about 22% of eligible older adults had received the RSV vaccine as of Feb. 24. Why are the numbers so low? The main reason, from what we gather, is awareness. The vaccines are still new to us, which means they’re new to our patients. Add in the one-two punch of misinformation and rising vaccine hesitancy, and that explains a lot.

Anecdotally, we have received many inquiries from older adults who are grandparents. Some who became infected with RSV through contact with their grandchildren have asked to be vaccinated now to be protected next season; others were not aware that vaccines are available until they learned about them from their children or grandchildren.

Some older patients have asked if they’ll need an RSV vaccine every year, like the flu shot. That’s a fair question. Right now, the CDC recommends that people get just one dose of the vaccine, and the available evidence suggests the vaccines offer reasonable protection for at least two RSV seasons. It’s also important to acknowledge what’s still unknown — including the vaccine’s effects on hospitalization and death reduction, potential adverse effects and more — and to watch for updates from evidence-based sources such as the AAFP’s RSV Vaccines and Therapeutics webpage.

For pregnant people, timing is the biggest factor. In most of the continental United States, Abrysvo should only be administered from 32 through 36 weeks gestation from September to the end of January. That’s a short window. The most important point is that at least 14 days are needed from the day of vaccine administration to delivery of the infant for development and transplacental transfer of maternal antibodies.

Some Populations Have Worse Effects

Evidence suggests that racial and ethnic minorities are more severely affected by respiratory illnesses such as RSV. Recent studies found a greater impact among Black and Hispanic youth, Native American/Alaska Native children, and adults who are from lower socioeconomic backgrounds and more crowded environments.

These findings emphasize the importance of ensuring that patients of all ages, races and ethnicities receive the care they need — including timely vaccinations.

Payment and Coverage Issues Need to Be Worked Out

​Confusion over health insurance coverage may be another factor behind the low vaccination rates.

Currently, the RSV vaccines are covered by most private insurers without a patient copay because they are recommended by the Advisory Committee on Immunization Practices. Some Medicare beneficiaries can also obtain Arexvy or Abrysvo at no cost, but only if they are enrolled in Medicare Part D, which deals with drug benefits — and it’s important for patients to confirm their coverage, as not every Medicare recipient has Part D.

Furthermore, it’s important to understand that Part D currently only pays for vaccines dispensed at pharmacies, not physician offices. Because the vaccines can cost between $200 and $300 on the commercial market, Medicare patients with Part D should be directed to their local pharmacy to avoid the out-of-pocket expenses.

Nirsevimab, meanwhile, is covered by the Vaccines for Children program, which provides vaccines at no cost to children who may not otherwise get vaccinated because of an inability to pay. Many private health insurance plans also cover nirsevimab, but there may be associated costs. Patients should ask their insurer about coverage before receiving the vaccine.

Eligibility and cost concerns have presented considerable obstacles to date. We know that many family physicians are concerned about coverage and payment issues, and that because of these barriers, many primary care practices do not offer the RSV vaccines. That said, we expect that most health insurance programs will integrate RSV into their benefits packages at some point in 2024, if they haven’t already done so.

Information Is Key

Generally, recommending older people to get an RSV vaccine has not been difficult. We have received lots of inquiries, often from Medicare patients 65 or older; many of them are at increased risk due to chronic medical conditions such as hypertension and diabetes. Some patients have more severe conditions such as COPD or respiratory failure. In these instances, and especially in older adults at increased risk, we make a strong recommendation for vaccination to reduce the risk of RSV-associated LRTI.

On the other end of the spectrum, we have received inquiries from healthy 60-year-old adults with no complications or chronic medical conditions. In these instances, we engage in patient-centered discussions and encourage vaccination based on patient preferences and values.

Overall, the main patient concern we have encountered is from individuals who have expressed personal hesitancy due to the vaccines being so new. Some of these patients may wish to delay vaccination until another time.

In addition, several fellow physicians have asked us what we think about the RSV vaccines, not only because they are new but also because the shared clinical decision-making element of the recommendation can create confusion.

Bottom line? Talk with your older patients to determine whether the RSV vaccine is best for them. Have an informed discussion with them. Go over the risks and benefits, listen to their concerns and then arrive at a decision together. If they choose to delay vaccination, make sure to remind them during the next RSV season.

It’s also important to remember that not everyone processes information the same way. Generally speaking, many older patients prefer written materials like patient handouts and brochures. Younger patients may prefer websites, links to handouts or other digital resources that they can download to a phone or tablet and read later. Of course, there is some overlap between groups. To ensure access to materials that suit patient preferences, it’s best to have multiple versions of these resources available for everyone.

The AAFP Is Here to Help

As we mentioned, the Academy’s RSV Vaccines and Therapeutics webpage contains a wealth of information, including the latest clinical guidance from the CDC, links to educational activities, an infographic and a clinical guidance sheet for practice planning for RSV in older adults, and recommendations for pregnant patients and those 60 and older. Additional information is available on familydoctor.org, the AAFP’s patient-centered website.

Family physicians will also be interested in a Feb. 4 FPM Getting Paid blog post on how to code RSV antibody injections and vaccines; a free online CME activity, RSV Vaccination for Adults 60 Plus; and an Inside Family Medicine podcast segment featuring LaTasha Seliby Perkins, M.D., on maternal RSV vaccination — and we encourage you to register for a March 27 LinkedIn Live event, hosted by AAFP, where RSV will be the main topic.

Carlos O’Bryan, M.D., FAAFP, and James Bigham, M.D., M.P.H., FAAFP, were selected as part of the 2022-2023 class of AAFP Vaccine Science Fellows. O’Bryan is a core faculty member at the Ventura County Family Medical Center Family Medicine Residency in Ventura, Calif. Bigham is a professor in the Department of Family Medicine and Community Health at the University of Wisconsin School of Medicine and Public Health, Madison.