RSV Immunization Administration

Start of Season Reminder and Recall

Before RSV season begins, pediatric practices should develop a reminder/recall strategy to identify and schedule infants younger than 8 months who were born before the start of the season and have not previously received RSV immunization; as well as eligible infants and children who are 8-19 months of age and meet high risk criteria for second season administration. These infants should receive RSV immunization as early as possible—ideally shortly before or at the start of the RSV season. This will help ensure protection before exposure risk increases and before the immunization window closes based on age.

Practices can identify eligible infants and children by running EHR reports based on date of birth and age at the start of RSV season, then cross-checking RSV immunization history and maternal RSV vaccination status (for first season) and ICD-10 codes (for second season). Confirm adequate product inventory in advance, and prioritize the youngest infants, those who are medically vulnerable, and those unlikely to have another visit before or early in the season. When appropriate, offer nurse-only, immunization-only, or other flexible scheduling options.

Use multiple outreach methods in reminder/recall workflows, including portal messages, texts, phone calls, postcards, letters, and social media. Consider equity and access needs within the patient/family population, such as language, transportation, or scheduling barriers.

Routine Dosing

A single dose should be administered to all infants <8 months of age born during or entering their first RSV season (typically starting October 1 through March 31 in most of the continental US). For most babies whose mothers received RSVpreF at 32-36 weeks of pregnancy, where at least 14 days have elapsed between vaccine administration and birth, RSV immunization is not indicated. Please see the RSV Immunization Administration Visual Guide to guide your decision making about dosing.

In addition to mother’s vaccination status, eligibility is determined by age at the time of administration. Infants born during the RSV season should receive RSV immunization within 1 week of birth. This can be given either in the hospital before discharge or at the doctor’s office after discharge. Those with a prolonged hospital stay should get it shortly before or promptly after discharge. Safety data for use of RSV immunization in infants with a postmenstrual age (gestational age at birth plus chronologic age) of <32 weeks are limited. To prevent health care-associated RSV disease, providers may consider administering RSV immunization to eligible hospitalized infants during their hospitalization. This decision should be based on clinical judgment, considering the potential risks and benefits as well as local RSV activity. For more information, see https://www.cdc.gov/mmwr/volumes/74/wr/mm7432a3.htm.

Providers, including regional medical centers and health systems, should consult with state or territorial health departments before systematically modifying the recommended months for RSV immunizationantibody administration for their eligible patient populations. For more information, including an outline of potential advantages and disadvantages of modifying timing of administration, see http://dx.doi.org/10.15585/mmwr.mm7432a3. 

Dosing for Infants < 8 Months of Age

A single dose of clesrovimab or nirsevimab should be administered as follows:  

• 105 mg dose of clesrovimab (pink plunger rod) (regardless of weight)
• Infants weighing <5 kg: 50 mg dose of nirsevimab (purple plunger rod)
• Infants weighing ≥5 kg: 100 mg dose of nirsevimab (light blue plunger rod)

Dosing for Children at High Risk During Second RSV Season

Children ages 8-19 months who remain vulnerable to severe RSV disease when entering their second RSV season should receive a single dose of 200 mg of nirsevimab, administered through 2 separate 100 mg IM injections.

This includes:

• Children born preterm, at <32 weeks, 0 days’ gestation, regardless of the need for medication or other support
• Children with chronic lung disease attributable to prematurity or to other significant neonatal conditions (eg, meconium aspiration or congenital diaphragmatic hernia) who required medical support (ie, chronic corticosteroid therapy, diuretic therapy, or supplemental oxygen) at any time during the 6-month period before the start of the second RSV season
• Children with hemodynamically significant congenital heart disease (ie, a defect that can result in symptoms and/ or cardiac chamber dilation)
• Children with anatomic pulmonary abnormalities or neuromuscular disorders that put them at risk for severe RSV disease
• Children with severe immunocompromise
• Children with Down syndrome or other chromosomal differences placing them at higher risk of severe RSV disease
• Children with cystic fibrosis who have either manifestations of severe lung disease (previous hospitalization for pulmonary exacerbation in the first year after birth or abnormalities on chest imaging that persist when stable) or weight-for-length that is less than the 10th percentile
• American Indian or Alaska Native children. American Indian or Alaska Native children are included in the high risk category because they experience significantly higher rates of severe RSV disease and hospitalization associated with social drivers of health, with children living in rural and reservation communities most impacted.

Immunization Information Statement

It is recommended that an Immunization Information Statement be provided to families or caregivers when an infant or toddler receives RSV immunization. Consider offering this resource electronically, to review in-office, and/or to take home.  

The AAP provides Immunization Facts for Families, one-page handouts that can be provided to families during immunization conversations or after immunization administration. Available in English and Spanish.

Reporting Adverse Events

Adverse events when giving nirsevimab alone should be reported to the FDA’s MedWatch Adverse Event Reporting Program.  

If an adverse event occurs while co-administering RSV immunization with a vaccine, it should be reported to the Vaccine Adverse Event Reporting System. 

Additional Information

In the rare event of product wastage (eg, family changed mind at last moment, syringe is dropped or damaged before administration, etc), contact the manufacturer for additional support. For nirsevimab, contact the Sanofi Customer Service at 800-VACCINE or via vaccineshoppe.com to discuss. Sanofi does not have a formal wastage policy in place for nirsevimab.  For clesrovimab, contact the Merck Vaccine Customer Center at 877-VAX-MERCK or via the online contact form (must have a registered Merck account) for questions and concerns.

Resources

• AAP Immunization Facts for Families
• RSV Immunization Administration Visual Guide 
• AAP Immunization Administration in Your Practice  
• AAP RSV Immunization Frequently Asked Questions