How Pediatricians Can Prepare for the RSV Vaccine Rollout

August 24, 2023 - Jonathan Miller, MD, the chief of primary care at Nemours Children’s Health in Delaware, doesn’t think the RSV vaccine rollout is going to go the same as the COVID vaccines for infants and young kids. It’s probably going to go better, he said, although that does remain to be seen as organizations nationwide await their own stores of the shots.

The new monoclonal antibody to protect against respiratory syncytial virus (RSV), nirsevimab, got the nod from the FDA and CDC earlier this summer. Per the American Academy of Pediatrics (AAP), the shot is recommended for all infants under eight months old as they enter their first RSV season, which usually rolls around during the fall.

Nirsevimab is also advised for kids between 8 and 19 months who are at high risk for severe disease from RSV as they enter their second RSV season.

According to Miller, who was recently named Delaware’s pediatric primary care Vaccine Champion by the Association of Immunization Managers and CDC, the monoclonal antibodies are going to be revolutionary after the past two RSV seasons.

“RSV is a virus that wreaks the most havoc on infants and toddlers,” Miller said during a phone interview with PatientEngagementHIT. “Before COVID, that used to happen in the fall and winter every year, and it was the number one reason that children would get hospitalized for any reason.”

RSV causes children to get fevers, runny nose, and cough, all symptoms of the common cold.

But in some cases, RSV can be worse than that, Miller explained.

“Children can sometimes experience labored breathing,” he noted. “Kids can need oxygen sometimes, and they can get dehydrated and need IV fluid sometimes. It's a significant burden on families, on kids, and on the healthcare system. And because it’s just such a common virus, the last two RSV seasons were weird.”

With COVID-19’s protective public health measures, RSV’s seasonality changed. Whereas RSV typically comes in the fall and lasts into the winter, it was thrown off schedule in 2021 and had a peak in the summer. RSV peaked again in the winter and then in 2022 into late summer and early fall.

The news reports about RSV across the nation reflected Miller’s own experience. RSV led to some of the fullest children’s hospitals he’d ever seen in his career, due in large part to the unseasonably high spread of RSV starting around July of 2022.

“The good thing is that this year, we're not seeing that,” Miller said, although careful not to jinx himself. “We'll probably start to see the spread once kids are back in school leading into the fall and then the winter. And this is going to be the first year ever that we have some things that can be done to prevent it.”

Nirsevimab is a monoclonal antibody, meaning it offers passive immunization that gives the body the tools that it needs to recognize and fight off RSV, Miller explained. These types of vaccines tend to be shorter-lived, which is why CDC, FDA, and AAP have recommended that high-risk kids get another round of vaccination entering their second RSV season.

If infants get the vaccines in addition to the pregnant people and over-65 populations who have also had RSV vaccines developed for them, Miller said there could be a compounding effect that may seriously reduce the burden of RSV this year.

“But any new vaccine is met with some skepticism,” he added as a caveat. “We certainly saw that with the COVID vaccine over the last couple of years. For the infants and toddler age group, there's a lot of refusal.”

May 2023 numbers from AAP showed that only around 13 percent of kids ages six months to 4 years have gotten at least their first dose of the COVID-19 vaccine. A July 2022 poll from KFF showed that parents are wary about the vaccine’s newness and that they’d rather wait and see before getting their young child vaccinated.

“That's because, at least in part, people don't perceive COVID as being super high risk for children and infants,” Miller added as a reason for vaccine hesitancy.

But he doesn’t anticipate that will be the situation with the RSV vaccine.

“The difference for RSV is that most parents have heard of RSV, and they know that it's really a problem for infants and children,” he pointed out. “So, I suspect that we're going to see more interest in nirsevimab in that age group than we have seen for COVID.”

Still, Miller and his colleagues at Nemours are working on some messaging around the RSV vaccines. For one thing, Nemours—or any pediatric healthcare provider, for that matter—doesn’t actually have any doses of the vaccine yet. The doses are likely to come closer to the advised rollout date of October 1, and Nemours is clarifying that point with parents and caregivers right now.

There’s also the matter of nirsevimab being a monoclonal antibody, which may not be familiar to many parents and caregivers.

“It's important for families to know that we have been using an RSV monoclonal antibody in high-risk populations for many years now, over a decade,” Miller said, referencing SYNAGIS, the vaccine previously used for high-risk infants ahead of RSV season.

“The problem with that monoclonal antibody isn't its safety. It's very safe,” he noted. “The problem with that one is that it has to be given once a month throughout RSV season.”

The monthly shots make care harder to coordinate for patients. Nirsevimab is a very effective vaccine that only requires kids to get one jab for the whole RSV season. Outlining those features to parents wary of a monoclonal antibody vaccine may help generate buy-in.

There’s also the expectation-setting that may need to happen, Miller acknowledged. Right now, Nemours and its peers that also deliver pediatric healthcare don’t know when they will get their shares of nirsevimab. But when organizations do get them, Miller anticipates a COVID-like rush to the shots, which could require some families to have to wait until it’s their turn.

While there may not be supply chain issues per se, Miller wouldn’t expect that everyone will be able to get their shot on October 1. Some will, he acknowledged, but others will have to be patient and await future shipments.

In the meantime, Miller said it’s important that healthcare providers outline what RSV can mean for kids despite a vaccine being on the way. Most kids and adults with RSV will just have common cold symptoms, which Miller acknowledged can still be bothersome for families.

“What we often will do is help empower parents to know when to be worried,” he advised. “We talk about different signs and symptoms of the illness that are beginning to be warning signs for them that something is up.”

For example, the common cold won’t cause a child to have labored and rapid breathing. During an exam, pediatricians at Nemours will show parents which of their baby’s extra muscles might be used for deeper, heavier, and more labored breathing.

What’s more, Miller and his colleagues can now empower people on how to prevent those severe RSV symptoms, plus the litany of other viral syndromes that are similar to RSV.

“It's really important that families do what they can to prevent all of that from spreading. And so that's not just looking into the RSV antibody, but that also means, when your child is old enough, which is six months old, getting the flu vaccine and getting the COVID vaccine,” Miller implored.

“These are still really important prevention measures to help us get through the fall and the winter without as much viral spread as what happened last year, which was really challenging on healthcare systems,” he concluded.