Use of Respiratory Syncytial Virus Vaccines in Older Adults

Recommendations of the Advisory Committee on Immunization Practices -- United States, 2023

Michael Melgar, MD; Amadea Britton, MD; Lauren E. Roper, MPH; H. Keipp Talbot, MD; Sarah S. Long, MD; Camille N. Kotton, MD; Fiona P. Havers, MD


Morbidity and Mortality Weekly Report. 2023;72(29):793-801. 

In This Article

Abstract and Introduction


Respiratory syncytial virus (RSV) is a cause of severe respiratory illness in older adults. In May 2023, the Food and Drug Administration approved the first vaccines for prevention of RSV-associated lower respiratory tract disease in adults aged ≥60 years. Since May 2022, the Advisory Committee on Immunization Practices (ACIP) Respiratory Syncytial Virus Vaccines Adult Work Group met at least monthly to review available evidence regarding the safety, immunogenicity, and efficacy of these vaccines among adults aged ≥60 years. On June 21, 2023, ACIP voted to recommend that adults aged ≥60 years may receive a single dose of an RSV vaccine, using shared clinical decision-making. This report summarizes the body of evidence considered for this recommendation and provides clinical guidance for the use of RSV vaccines in adults aged ≥60 years. RSV vaccines have demonstrated moderate to high efficacy in preventing RSV-associated lower respiratory tract disease and have the potential to prevent substantial morbidity and mortality among older adults; postmarketing surveillance will direct future guidance.


In the United States, respiratory syncytial virus (RSV) causes seasonal epidemics of respiratory illness. Although the COVID-19 pandemic interrupted seasonal RSV circulation, the timing and number of incident cases of the 2022–23 fall and winter epidemic suggested a likely gradual return to prepandemic seasonality.[1]

Each season, RSV causes substantial morbidity and mortality in older adults, including lower respiratory tract disease (LRTD), hospitalization, and death. Incidence estimates vary widely and are affected by undertesting and potentially low sensitivity of standard diagnostic testing among adults.[2–5] Most adult RSV disease cases occur among older adults with an estimated 60,000–160,000 hospitalizations and 6,000–10,000 deaths annually among adults aged ≥65 years.[5–10]

Adults with certain medical conditions, including chronic obstructive pulmonary disease, asthma, congestive heart failure, coronary artery disease, cerebrovascular disease, diabetes mellitus, and chronic kidney disease, are at increased risk for RSV-associated hospitalization,[11–13] as are residents of long-term care facilities,[14] and persons who are frail* or of advanced age (incidence of RSV-associated hospitalization among adults increases with age, with the highest rates among those aged ≥75 years).[6,15] RSV can also cause severe disease in persons with compromised immunity, including recipients of hematopoietic stem cell transplantation and patients taking immunosuppressive medications (e.g., for solid organ transplantation, cancer treatment, or other conditions).[16,17]

In May 2023, the Food and Drug Administration (FDA) approved the first vaccines for prevention of RSV-associated LRTD in adults aged ≥60 years. RSVPreF3 (Arexvy, GSK) is a 1-dose (0.5 mL) adjuvanted (AS01E) recombinant stabilized prefusion F protein (preF) vaccine.[18] RSVpreF (Abrysvo, Pfizer) is a 1-dose (0.5 mL) recombinant stabilized preF vaccine.[19]

*Frailty is a multidimensional geriatric syndrome and reflects a state of increased vulnerability to adverse health outcomes. Although there is no consensus definition, one frequently used tool is the Fried frailty phenotype in which frailty is defined as a clinical syndrome with three or more of the following signs or symptoms: unintentional weight loss (10 lbs [4.5 kg] in the past year), self-reported exhaustion, weakness (grip strength), slow walking speed, and low physical activity.