Use of the Pfizer Respiratory Syncytial Virus Vaccine During Pregnancy for the Prevention of Respiratory Syncytial Virus–Associated Lower Respiratory Tract Disease in Infants: Recommendations of the Advisory Committee on Immunization Practices — United States, 2023
Weekly / October 13, 2023 / 72(41);1115–1122
On October 6, 2023, this report was posted online as an MMWR Early Release.
Katherine E. Fleming-Dutra, MD1,*; Jefferson M. Jones, MD1,*; Lauren E. Roper, MPH1; Mila M. Prill, MSPH1; Ismael R. Ortega-Sanchez, PhD1; Danielle L. Moulia, MPH1; Megan Wallace, DRPH1; Monica Godfrey, MPH1; Karen R. Broder, MD2; Naomi K. Tepper, MD3; Oliver Brooks, MD4; Pablo J. Sánchez, MD5; Camille N. Kotton, MD6; Barbara E. Mahon, MD1; Sarah S. Long, MD7; Meredith L. McMorrow, MD1 (View author affiliations)
View suggested citationSummary
What is already known about this topic?
Nirsevimab is recommended in infants to prevent respiratory syncytial virus (RSV)-associated lower respiratory tract infection (LRTI). In August 2023, the Food and Drug Administration approved Pfizer RSV vaccine for pregnant persons at 32–36 weeks’ gestation to prevent RSV-associated LRTI in infants aged <6 months.
What is added by this report?
On September 22, 2023, CDC’s Advisory Committee on Immunization Practices recommended RSV vaccine for pregnant persons at 32–36 weeks’ gestation using seasonal administration (meaning September–January in most of the United States) to prevent RSV-associated LRTI in infants aged <6 months.
What are the implications for public health practice?
CDC recommends protecting all infants against RSV-associated LRTI through use of either the maternal RSV vaccine or infant receipt of nirsevimab.
Abstract
Respiratory syncytial virus (RSV) is the leading cause of hospitalization among U.S. infants. Nirsevimab (Bevfortus, Sanofi and AstraZeneca) is recommended to prevent RSV-associated lower respiratory tract infection (LRTI) in infants. In August 2023, the Food and Drug Administration (FDA) approved RSVpreF vaccine (Abrysvo, Pfizer Inc.) for pregnant persons as a single dose during 32–36 completed gestational weeks (i.e., 32 weeks and zero days’ through 36 weeks and 6 days’ gestation) to prevent RSV-associated lower respiratory tract disease in infants aged <6 months. Since October 2021, CDC’s Advisory Committee on Immunization Practices (ACIP) RSV Vaccines Pediatric/Maternal Work Group has reviewed RSV epidemiology and evidence regarding safety, efficacy, and potential economic impact of pediatric and maternal RSV prevention products, including RSVpreF vaccine. On September 22, 2023, ACIP and CDC recommended RSVpreF vaccine using seasonal administration (i.e., during September through end of January in most of the continental United States) for pregnant persons as a one-time dose at 32–36 weeks’ gestation for prevention of RSV-associated LRTI in infants aged <6 months. Either maternal RSVpreF vaccination during pregnancy or nirsevimab administration to the infant is recommended to prevent RSV-associated LRTI among infants, but both are not needed for most infants. All infants should be protected against RSV-associated LRTI through use of one of these products.
Introduction
In August 2023, the Food and Drug Administration (FDA) approved RSVpreF vaccine (Abrysvo, Pfizer Inc.) for pregnant persons to prevent RSV-associated lower respiratory tract disease and severe lower respiratory tract disease in infants aged <6 months (1,2). The Pfizer bivalent RSVpreF vaccine, which is the same formulation and dose approved for use in adults aged ≥60 years, contains stabilized prefusion F glycoproteins from RSV A and RSV B and is approved as a single 0.5 mL intramuscular dose administered during 32 through 36 weeks’ gestation.
In clinical trials among pregnant persons at 24–36 weeks’ gestation, more preterm births (<37 weeks’ gestation) were observed among RSVpreF vaccine recipients than placebo recipients, although the differences were not statistically significant (1,2). Available data were insufficient to establish or exclude a causal relationship between preterm birth and RSVpreF vaccine. FDA labeled the potential risk for preterm birth as a warning and approved RSVpreF vaccine for use in pregnant persons at 32–36 weeks’ gestation to avoid the potential risk for preterm birth at <32 weeks’ gestation, which is associated with increased risk for morbidity and mortality (2). More hypertensive disorders of pregnancy were observed among RSVpreF vaccine recipients compared with placebo recipients, although the differences were not statistically significant. FDA determined that, when RSVpreF is administered during 32–36 weeks’ gestation, the benefit of vaccination in preventing RSV-associated LRTI in infants outweighed risks, including the potential risk for preterm birth and hypertensive disorders of pregnancy (1,2).
On August 3, 2023, CDC’s Advisory Committee on Immunization Practices (ACIP) and CDC recommended nirsevimab (Beyfortus, Sanofi and AstraZeneca), a long-acting monoclonal antibody for prevention of severe RSV disease, for infants aged <8 months who are born during or entering their first RSV season and for children aged 8–19 months at increased risk for severe RSV disease entering their second RSV season (3). On September 22, 2023, ACIP and CDC recommended RSVpreF vaccine for pregnant persons as a one-time dose during 32–36 completed weeks’ gestation using seasonal administration (September–January in most of the continental United States) to prevent RSV-associated lower respiratory tract infection (LRTI) in infants. Either maternal RSVpreF vaccination during pregnancy or nirsevimab administration to the infant is recommended to prevent RSV-associated LRTI in infants, but both are not needed for most infants. This report describes new recommendations for the use of maternal RSVpreF during pregnancy and updated clinical guidance regarding the use of nirsevimab and maternal RSVpreF vaccine. These recommendations will be updated as new evidence becomes available.
Epidemiology of RSV in U.S. Infants
RSV is a common cause of LRTI in U.S. infants, most of whom are infected with RSV during the first year of life (4,5). All infants are at risk for experiencing severe RSV disease. RSV is the leading cause of hospitalization among U.S. infants (6); 2% to 3% of young infants will be hospitalized for RSV disease (7–9). Approximately 58,000–80,000 RSV-associated hospitalizations and 100–300 RSV-associated deaths occur annually among U.S. children aged <5 years (10–13). An estimated 79% of children aged <2 years hospitalized with RSV had no underlying medical conditions (7). RSV-associated hospitalization rates are highest in infants aged <6 months, with hospitalization peaking at age 1 month, and then decreasing with increasing age (7).
Before the COVID-19 pandemic, RSV circulation consistently peaked during winter months in the continental United States, although the timing varied by geographic region (14); however, the COVID-19 pandemic disrupted RSV seasonality, with historically low RSV circulation during 2020–21 and early and prolonged circulation during 2021–22 (14). RSV circulation in 2022–23 began later than during the 2021–22 season but earlier than prepandemic seasons (14). RSV activity in August and September 2023 suggests that transmission patterns are returning to prepandemic seasonal RSV trends.†
Methods
Since October 2021, the ACIP RSV Vaccines Pediatric/Maternal Work Group (the Work Group) has met at least monthly to review evidence regarding RSV epidemiology and safety, efficacy, and potential economic impact of pediatric and maternal RSV prevention products, including RSVpreF vaccine. A systematic literature search was completed to review evidence regarding the efficacy and safety of maternal RSVpreF vaccination during pregnancy. The Work Group determined a priori outcomes that were critical or important to vaccine policy decisions.§ Evidence of efficacy and safety were derived from multicountry trials that randomized pregnant persons to receive maternal RSVpreF vaccination or placebo during 24–36 weeks’ gestation: a phase 2b trial¶ with 581 pregnant persons (115 of whom received the phase 3 vaccine dose and formulation and 117 of whom received placebo) and a phase 3 trial** including 7,392 pregnant persons, randomized 1:1 to vaccine and placebo arms (15,16). The Work Group used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach†† to assess the certainty of evidence for outcomes related to maternal RSVpreF vaccination during pregnancy, rated on a scale of very low to high certainty. The Work Group employed the Evidence to Recommendation (EtR) Framework§§ to guide its deliberations on recommendations for maternal RSVpreF vaccination during pregnancy and review of data on the public health problem, benefits and harms, value to the target population, acceptability to key stakeholders, feasibility, direct and indirect resource utilization, and equity.
Vaccine Efficacy and Safety
In the Pfizer phase 2b and 3 trials, maternal RSVpreF vaccination was administered during 24–36 weeks’ gestation (15,16). For the GRADE assessment, data were included from phase 2b and 3 trials using the trial dosing interval of 24–36 weeks’ gestation. Using all available data from the trial dosing interval provided increased power to detect potential benefits and harms. Additional analyses of efficacy and safety outcomes from participants who received vaccine or placebo during the approved dosing interval of 32–36 weeks’ gestation were reviewed and are included as a supplement to the evidence included in GRADE (2,9). The details of the GRADE evidence profile and supporting evidence for the EtR Framework are available at https://www.cdc.gov/vaccines/acip/recs/grade/pfizer-RSVpreF-pregnant-people.html and https://www.cdc.gov/vaccines/acip/recs/grade/pfizer-RSVpreF-pregnant-people-etr.html.
Vaccine Efficacy
For the GRADE assessment of benefits, data on vaccine efficacy among infants from birth through 180 days of life were evaluated (9,16). Efficacy against medically attended RSV-associated LRTI was 51.3% among the full trial population (trial dosing interval of 24–36 weeks’ gestation) and 57.3% when maternal RSVpreF vaccination was given during the approved dosing interval (32–36 weeks’ gestation). Efficacy against hospitalization for RSV-associated LRTI was 56.8% during the full trial dosing interval and 48.2% during the approved dosing interval (Table 1).
Vaccine Safety
For the GRADE assessment of harms, results from the phase 2b and phase 3 trials were pooled¶¶ (9,16). The overall evidence certainty using GRADE criteria was rated as very low, driven by the uncertainty in the critical harm outcome of preterm birth (<37 weeks’ gestation).*** ACIP judged the benefits of maternal RSVpreF vaccination at 32–36 weeks’ gestation to outweigh the potential risks for preterm birth and hypertensive disorders of pregnancy.
The most common local and systemic adverse reactions were pain at the injection site, headache, muscle pain, and nausea.††† Although not statistically significant, in the full trial population more preterm births and hypertensive disorders of pregnancy (including preeclampsia) were observed in persons administered the vaccine rather than the placebo, and more infants whose mothers received the vaccine had low birthweight ≤5.5 lbs (≤2,500 g) and neonatal jaundice compared with infants whose mothers received the placebo.§§§ Pregnant persons at increased risk for preterm delivery were excluded from the phase 2b and phase 3 trials. In the full trial population, preeclampsia occurred among 1.8% (95% CI = 1.4%–2.3%) of vaccine recipients and in 1.4% (95% CI = 1.1%–1.9%) of placebo recipients (2). Pregnancy-related serious adverse events overall (which include preeclampsia) occurred in 16.2% (95% CI = 15.1%–17.5%) of participants in the vaccine group and 15.2% (95% CI = 14.0%–16.4%) in the placebo group¶¶¶ (2).
The data reviewed by ACIP support that limiting vaccine administration to the approved dosing interval (32–36 weeks’ gestation) reduces the potential risk for preterm birth and thereby, the potential for related complications compared with the trial dosing interval of 24–36 weeks’ gestation. In the Pfizer phase 3 trial, using the full trial dosing interval, 5.7% of infants born to RSVpreF vaccine recipients were preterm compared with 4.7% of those born to placebo recipients (Table 2). In the full trial population, more than one half of preterm births occurred >30 days after vaccination (121 [60%] of 201 preterm births in the vaccine group and 98 [58%] of 169 preterm births in the placebo group), and most preterm births occurred at or after 33 weeks’ gestation (194 [97%] of 201 preterm births in the vaccine group versus 161 [95%] of 169 preterm births in the placebo group). When the prevalence of preterm birth was assessed among phase 3 trial participants who received vaccine during the approved dosing interval (32–36 weeks’ gestation), 4.2% of infants were born preterm in the vaccine group versus 3.7% in the placebo group. The majority of preterm births among participants who received vaccination during the approved dosing interval occurred at 36 weeks’ gestation (49 [72%] of 68 preterm births in the vaccine group and 35 [59%] of 59 preterm births in the placebo group).
The Pfizer maternal RSVpreF vaccine is the same formulation and dose approved for use in adults aged ≥60 years. In clinical trials in adults aged ≥60 years for RSVpreF vaccine, three inflammatory neurologic events (two cases of Guillain-Barré syndrome, including one case of the Miller-Fisher variant, and one case of undifferentiated motor-sensory polyneuropathy) were reported within 42 days after vaccination among 20,255 investigational vaccine recipients aged ≥60 years, whereas no cases were observed among placebo recipients (17). No cases of Guillain-Barré syndrome or other inflammatory neurologic events were reported in the phase 2b or phase 3 trials among pregnant persons (15).
Economic Analysis
ACIP considered whether use of RSVpreF vaccine in pregnant persons is a reasonable and efficient allocation of resources. The societal incremental cost effectiveness ratio for RSVpreF vaccine, assuming year-round dosing and cost of $295 per dose, was $400,304 per quality-adjusted life year (QALY) saved. Assuming a pre–COVID-19 typical RSV seasonality in most of the continental United States, the societal incremental cost effectiveness ratio for administering RSVpreF to pregnant persons during September–January would be $167,280/QALY saved (9).
Recommendations for Use of RSVpreF Vaccine in Pregnant Persons
On September 22, 2023, ACIP and CDC recommended maternal Pfizer RSVpreF vaccination in pregnant persons as a one-time dose at 32 weeks and zero days’–36 weeks and 6 days’ gestation using seasonal administration (meaning September–January in most of the continental United States) for prevention of RSV-associated LRTI in infants aged <6 months.**** These recommendations will be updated as new evidence becomes available.
Clinical Guidance
Seasonal Administration of RSVpreF Vaccine. Maternal RSVpreF vaccine should be administered to pregnant persons during September–January in most of the continental United States to target vaccine to pregnant persons whose infants will be in their first months of life, when protection from maternal vaccination would be at its highest, during the RSV season. Administering maternal RSVpreF vaccine starting in September (1–2 months before the anticipated start of the RSV season) and continuing through January (2–3 months before the anticipated end of the RSV season) will maximize cost-effectiveness and benefits. In jurisdictions with RSV seasonality that differs from most of the continental United States, including Alaska, southern Florida, Guam, Hawaii, Puerto Rico, U.S.-affiliated Pacific Islands, and U.S. Virgin Islands, providers should follow state, local, or territorial guidance on timing of maternal RSVpreF vaccination.††††
Simultaneous Administration with Other Vaccines. In accordance with CDC’s General Best Practices Guidelines for Immunization, maternal RSVpreF vaccine can be administered to pregnant persons with other recommended vaccines, such as tetanus, diphtheria, and pertussis (Tdap), influenza, and COVID-19 vaccines, without regard to timing, including simultaneous vaccination at different anatomic sites on the same day (18).
Additional Vaccine Doses in Subsequent Pregnancies. Currently, no data are available on either the efficacy of the first lifetime dose to protect infants born after subsequent pregnancies or the safety of additional doses given during subsequent pregnancies. Additional data are needed to determine whether additional seasonal doses during subsequent pregnancies are indicated, and ACIP might update recommendations in the future, as data become available.
Updated Clinical Guidance for Use of Nirsevimab and Maternal RSVpreF Vaccine
Recommendations for nirsevimab, a long-acting monoclonal antibody product, have been previously published (3). Either maternal RSVpreF vaccination during pregnancy at 32–36 weeks’ gestation or nirsevimab immunization for infants aged <8 months who are born during or are entering their first RSV season is recommended to prevent RSV-associated LRTI in infants, but administration of both products is not needed for most infants. Providers who care for pregnant persons should discuss the relative advantages and disadvantages of both maternal RSVpreF vaccination and nirsevimab and consider patient preferences when determining whether to vaccinate the pregnant person or to rely on administration of nirsevimab to the infant (Box) (19).
No data are available directly comparing the efficacy of nirsevimab and maternal RSVpreF vaccine in preventing RSV-associated LRTI in infants. Protection conferred through maternal vaccination will likely wane after 3 months, as has been observed in infants born to pregnant persons who have received influenza and COVID-19 vaccines (16,20,21). However, because maternal RSV vaccination at 32–36 weeks’ gestation is recommended during only September–January in most of the continental United States, most infants of vaccinated mothers will be born during an RSV season. Mothers of most infants born outside of RSV season (i.e., during April–September) will not have been vaccinated; therefore, nirsevimab is recommended for these infants at the onset of the RSV season if they are aged <8 months.
At least 14 days are likely needed after maternal vaccination for development and transplacental transfer of maternal antibodies to protect the infant (16,22); therefore, nirsevimab is recommended for infants born <14 days after maternal RSVpreF vaccination. The earliest an infant could be born and be considered protected by maternal receipt of RSVpreF vaccine at 32 weeks’ gestation (the earliest recommended time for vaccination) would be at 34 gestational weeks. Therefore, nirsevimab is recommended for all infants born at <34 weeks’ gestation.
Nirsevimab is recommended for infants aged <8 months born during or entering their first RSV season whose mother did not receive RSVpreF vaccine, whose mother’s receipt of RSVpreF vaccine is unknown, or who were born <14 days after maternal vaccination. Nirsevimab is not needed for most infants aged <8 months whose mother received RSVpreF vaccine ≥14 days before birth. Nirsevimab may be considered for infants born to vaccinated mothers in rare circumstances when, based on the clinical judgment of the health care provider, the potential incremental benefit of administration is warranted. These situations include, but are not limited to, infants born to mothers who might not have mounted an adequate immune response to vaccination (e.g., persons with immunocompromising conditions) or who have conditions associated with reduced transplacental antibody transfer (e.g., persons living with HIV infection) (23); infants who might have experienced loss of maternal antibodies, such as those who have undergone cardiopulmonary bypass (24) or extracorporeal membrane oxygenation; and infants with substantially increased risk for severe RSV disease (e.g., hemodynamically significant congenital heart disease, or intensive care admission requiring oxygen at hospital discharge).
Infants and children aged 8–19 months who are at increased risk for severe RSV disease and are entering their second RSV season are recommended to receive nirsevimab regardless of maternal RSVpreF vaccination (3). Recommendations for timing of nirsevimab administration, coadministration of nirsevimab with routine childhood vaccines, reporting of adverse events, and recommendations for use for infants and children aged 8–19 months who are at increased risk for severe RSV disease and who are entering their second RSV season have been previously published and remain unchanged (3).
Precautions and Contraindications
As with all vaccines, RSV vaccination should be delayed for persons experiencing moderate or severe acute illness with or without fever (precaution). RSV vaccines are contraindicated for and should not be administered to persons with a history of severe allergic reaction, such as anaphylaxis, to any component of the vaccine.
Reporting of Vaccine Adverse Events
Adverse events after vaccination should be reported to the Vaccine Adverse Event Reporting System (VAERS). Reporting is encouraged for any clinically significant adverse event even if it is uncertain whether the vaccine caused the event. Information on how to submit a report to VAERS is available at https://vaers.hhs.gov/index.html or by telephone at 1-800-822-7967.
Future Research and Monitoring Priorities
CDC will monitor adverse events, including preterm birth, hypertensive disorders of pregnancy, and inflammatory neurologic events after RSVpreF vaccination in pregnant persons through VAERS and the Vaccine Safety Datalink (https://www.cdc.gov/vaccinesafety/ensuringsafety/monitoring/vsd/index.html). Reactions and health impacts after RSVpreF vaccination will also be monitored through v-safe. According to FDA post-marketing requirements, the manufacturer will conduct post-marketing studies to assess preterm birth and hypertensive disorders of pregnancy, including preeclampsia (25).
Acknowledgments
Voting members of the Advisory Committee on Immunization Practices (in addition to listed authors): Lynn Bahta, Minnesota Department of Health; Beth P. Bell, University of Washington; Wilbur H. Chen, University of Maryland School of Medicine; Sybil Cineas, Warren Alpert Medical School of Brown University; Matthew F. Daley, Kaiser Permanente Colorado; Grace M. Lee, Stanford University School of Medicine; Jamie Loehr, Cayuga Family Medicine; Veronica V. McNally, Franny Strong Foundation; Katherine A. Poehling, Wake Forest School of Medicine.
ACIP Pediatric/Maternal RSV Work Group
Chair: Sarah S. Long, Drexel University College of Medicine; ACIP Members: Oliver Brooks, Watts Healthcare Corporation; Camille N. Kotton, Harvard Medical School; Pablo J. Sánchez, The Research Institute at Nationwide Children’s Hospital; Consultants: Kevin Ault, Western Michigan University; Carol Baker, McGovern Medical School, University of Texas Health Science Center; Helen Chu, University of Washington; Daniel Feikin, World Health Organization; Natasha Halasa, Vanderbilt University; Denise Jamieson, Emory University School of Public Health; Cody Meissner, Dartmouth Geisel School of Medicine; Liaison Representatives: Nicole Chaisson, American Academy of Family Physicians; Molly Howell, Association of Immunization Managers; Brenna L. Hughes, American College of Obstetricians and Gynecologists; James McAuley, Infectious Diseases Society of America; Sean T. O’Leary, American Academy of Pediatrics; Jennifer Schuster, Pediatric Infectious Diseases Society; Patsy Stinchfield, National Foundation for Infectious Diseases; Ex-officio Members: Judy Beeler, Food and Drug Administration; Yodit Belew, Food and Drug Administration; Matthew Clark, Indian Health Service; Terry Dalle-Tezze, Department of Health and Human Services, Health Resources and Services Administration; Nicholas Geagan, Food and Drug Administration; April Killikelly, Public Health Agency of Canada; Sonnie Kim, National Institute of Allergy and Infectious Diseases; Jessica Lee, Centers for Medicare & Medicaid Services; Lucia Lee, Food and Drug Administration; Valerie Marshall, Office of the Assistant Secretary for Health; Winnie Siu, Public Health Agency of Canada; Prabha Viswanathan, Food and Drug Administration; Robin Wisch, Food and Drug Administration; Rachel Zhang, Food and Drug Administration; CDC Leads: Katherine Fleming-Dutra, Jefferson Jones; CDC Contributors: Amadea Britton, Latifah Boyce, Karen R. Broder, Angela P. Campbell, Doug Campos-Outcalt, Melissa Coughlin, Nicole Dowling, Jarrett Gartin, Monica Godfrey, Kate Grusich, Aron Hall, Anne Hause, Fiona Havers, Demorah Hayes, Andrew Leidner, Ruth Link-Gelles, Elizabeth Greene, Jessica MacNeil, Meredith McMorrow, Michael Melgar, Sarah Meyer; Claire Midgley, Heidi Moline, Rebecca Morgan, Danielle Moulia, Neil Murthy, Christine Olson, Ismael Ortega-Sanchez, Manisha Patel, Pragna Patel, Monica Patton, Amanda Payne, Georgina Peacock, Jamison (Jamie) Pike, Derrell Powers, Mila Prill, Lauren Roper, Hannah Rosenblum, Heather Scobie, Andrea Sharma, David Shay, Tom Shimabukuro, Jordan Singleton, Tami Skoff, Chris Taylor, Naomi Tepper, Natalie Thornburg, Megan Wallace, Denis Wang, Melinda Wharton, Raigan Wheeler, Amber Winn, Patricia (Akpobome) Wodi.
Corresponding author: Katherine E. Fleming-Dutra, media@cdc.gov.
1Coronavirus and Other Respiratory Viruses Division, National Center for Immunization and Respiratory Diseases, CDC; 2Immunization Safety Office, National Center for Emerging and Zoonotic Infectious Diseases, CDC; 3Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC; 4Watts Healthcare Corporation, Los Angeles, California; 5The Research Institute at Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, Ohio; 6Harvard Medical School, Boston, Massachusetts; 7Drexel University College of Medicine, Philadelphia, Pennsylvania.
All authors and work group members have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.
* These authors contributed equally to this report.
† https://emergency.cdc.gov/han/2023/han00498.asp; https://www.cdc.gov/surveillance/nrevss/rsv/index.html
§ Critical outcomes: medically attended RSV-associated LRTI in infants, hospitalization for RSV-associated LRTI in infants, serious adverse events in pregnant persons, serious adverse events in infants, and preterm birth (<37 weeks’ gestation). Important outcomes: intensive care unit (ICU) admission from RSV hospitalization in infants, mechanical ventilation from RSV hospitalization in infants, RSV-associated death in infants, all-cause medically attended LRTI in infants, all-cause hospitalization for LRTI in infants, and reactogenicity (grade 3 or higher) in pregnant persons.
¶ Trial conducted in Argentina, Chile, New Zealand, South Africa, and United States.
** Trial conducted in Argentina, Australia, Brazil, Canada, Chile, Denmark, Finland, The Gambia, Japan, Mexico, Netherlands, New Zealand, Philippines, South Africa, South Korea, Spain, Taiwan, and United States.
†† https://www.cdc.gov/vaccines/acip/recs/grade/about-grade.html
§§ https://www.cdc.gov/vaccines/acip/recs/grade/downloads/acip-evidence-recs-framework.pdf
¶¶ A serious adverse event is defined as any untoward medical occurrence that results in death, is life-threatening, requires inpatient hospitalization or prolongation of existing hospitalization, results in persistent disability or incapacity, or is a congenital anomaly or birth defect. Serious adverse events in pregnant persons were collected ≤6 months after delivery. Serious adverse events in infants were collected ≤12 months after delivery. Reactogenicity events were collected ≤7 days following injection.
*** The outcome of preterm birth was rated as very low certainty. Very serious concern for imprecision was noted because of the CI range containing estimates for which different policy decisions might be considered as well as not meeting optimum information requirements. In addition, serious concern for indirectness was present as 55% of participants in the phase 3 trial and 62% of participants in the phase 2b trial did not receive vaccine or placebo in the approved dosing interval (32–36 weeks’ gestation). In the approved dosing interval, there is less opportunity for serious adverse events, including preterm birth, compared with the trial dosing interval (24–36 weeks’ gestation).
††† In the phase 3 trial among 3,663 RSVpreF recipients and 3,638 to 3,639 placebo recipients, injection site pain was reported by 40.6% of RSVpreF and 10.1% of placebo recipients; headache by 31.0% of RSVpreF and 27.6% of placebo recipients; muscle pain by 26.5% of RSVpreF and 17.1% placebo recipients; and nausea by 20.0% of RSVpreF and 19.2% of placebo recipients.
§§§ Low birthweight ≤5.5 lbs (≤2,500 g) and neonatal jaundice are more common among infants born preterm than among infants born at term. https://www.marchofdimes.org/find-support/topics/birth/premature-babies
¶¶¶ Among the full trial population, gestational hypertension occurred in 1.1% (95% CI = 0.8%–1.5%) of vaccine recipients and 1.0% (95% CI = 0.7%–1.4%) of placebo recipients. Hypertension occurred in 0.4% (95% CI = 0.2%–0.6%) of vaccine recipients and 0.2% (95% CI = 0.1%–0.4%) of placebo recipients.
**** On September 22, 2023, ACIP voted 11–1 in favor of the recommendation: maternal RSV vaccine is recommended for pregnant persons during 32–36 weeks’ gestation, using seasonal administration, to prevent RSV-associated LRTI in infants.
†††† The timing of maternal RSVpreF vaccination might vary in these jurisdictions because the historic timing of RSV circulation differs from the rest of the United States. As maternal RSVpreF vaccination should start 1–2 months before the anticipated start of the RSV season and continue through 2–3 months before the anticipated end of the RSV season, it is not feasible to change maternal RSVpreF vaccination timing based on year-to-year variations in RSV circulation. Thus, in most of the continental United States, maternal RSVpreF vaccination should be given in September–January, regardless of year-to-year variation in RSV circulation.
References
- Food and Drug Administration. FDA approves first vaccine for pregnant individuals to prevent RSV in infants [Press release]. Silver Spring, MD: US Department of Health and Human Services, Food and Drug Administration; 2023. https://www.fda.gov/news-events/press-announcements/fda-approves-first-vaccine-pregnant-individuals-prevent-rsv-infants
- Food and Drug Administration. ABRYSVO package insert. Silver Spring, MD: US Department of Health and Human Services, Food and Drug Administration; 2023. https://www.fda.gov/media/168889/download?attachment
- Jones JM, Fleming-Dutra KE, Prill MM, et al. Use of nirsevimab for the prevention of respiratory syncytial virus disease among infants and young children: recommendations of the Advisory Committee on Immunization Practices—United States, 2023. MMWR Morb Mortal Wkly Rep 2023;72:920–5. https://doi.org/10.15585/mmwr.mm7234a4 PMID:37616235
- Glezen WP, Taber LH, Frank AL, Kasel JA. Risk of primary infection and reinfection with respiratory syncytial virus. Am J Dis Child 1986;140:543–6. https://doi.org/10.1001/archpedi.1986.02140200053026 PMID:3706232
- Rosas-Salazar C, Chirkova T, Gebretsadik T, et al. Respiratory syncytial virus infection during infancy and asthma during childhood in the USA (INSPIRE): a population-based, prospective birth cohort study. Lancet 2023;401:1669–80. https://doi.org/10.1016/S0140-6736(23)00811-5 PMID:37086744
- Suh M, Movva N, Jiang X, et al. Respiratory syncytial virus is the leading cause of United States infant hospitalizations, 2009–2019: a study of the national (nationwide) inpatient sample. J Infect Dis 2022;226(Suppl 2):S154–63. https://doi.org/10.1093/infdis/jiac120 PMID:35968878
- Hall CB, Weinberg GA, Blumkin AK, et al. Respiratory syncytial virus-associated hospitalizations among children less than 24 months of age. Pediatrics 2013;132:e341–8. https://doi.org/10.1542/peds.2013-0303 PMID:23878043
- Langley GF, Anderson LJ. Epidemiology and prevention of respiratory syncytial virus infections among infants and young children. Pediatr Infect Dis J 2011;30:510–7. https://doi.org/10.1097/INF.0b013e3182184ae7 PMID:21487331
- Fleming-Dutra KE; CDC. Evidence to Recommendations Framework updates: Pfizer maternal RSVpreF vaccine. Presentation to Advisory Committee on Immunization Practices. Atlanta, GA: US Department of Health and Human Services, CDC; 2023. https://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2023-09-22/06-Mat-Peds-Fleming-Dutra-508.pdf
- Hall CB, Weinberg GA, Iwane MK, et al. The burden of respiratory syncytial virus infection in young children. N Engl J Med 2009;360:588–98. https://doi.org/10.1056/NEJMoa0804877 PMID:19196675
- McLaughlin JM, Khan F, Schmitt HJ, et al. Respiratory syncytial virus-associated hospitalization rates among US infants: a systematic review and meta-analysis. J Infect Dis 2022;225:1100–11. https://doi.org/10.1093/infdis/jiaa752 PMID:33346360
- Hansen CL, Chaves SS, Demont C, Viboud C. Mortality associated with influenza and respiratory syncytial virus in the US, 1999–2018. JAMA Netw Open 2022;5:e220527. https://doi.org/10.1001/jamanetworkopen.2022.0527 PMID:35226079
- Thompson WW, Shay DK, Weintraub E, et al. Mortality associated with influenza and respiratory syncytial virus in the United States. JAMA 2003;289:179–86. https://doi.org/10.1001/jama.289.2.179 PMID:12517228
- Hamid S, Winn A, Parikh R, et al. Seasonality of respiratory syncytial virus—United States, 2017–2023. MMWR Morb Mortal Wkly Rep 2023;72:355–61. https://doi.org/10.15585/mmwr.mm7214a1 PMID:37022977
- Food and Drug Administration. Vaccines and Related Biological Products Advisory Committee FDA briefing document. Respiratory syncytial virus vaccine (proposed trade name: Abrysvo). Silver Spring, MD: US Department of Health and Human Services, Food and Drug Administration; May 18, 2023. https://www.fda.gov/media/168185/download
- Kampmann B, Madhi SA, Munjal I, et al.; MATISSE Study Group. Bivalent Prefusion F vaccine in pregnancy to prevent RSV illness in infants. N Engl J Med 2023;388:1451–64. https://doi.org/10.1056/NEJMoa2216480 PMID:37018474
- Melgar M, Britton A, Roper LE, et al. Use of respiratory syncytial virus vaccines in older adults: recommendations of the Advisory Committee on Immunization Practices—United States, 2023. MMWR Morb Mortal Wkly Rep 2023;72:793–801. https://doi.org/10.15585/mmwr.mm7229a4 PMID:37471262
- Kroger A, Bahta L, Long S, Sanchez P. General best practice guidelines for immunization. best practices guidance of the Advisory Committee on Immunization Practices (ACIP). Atlanta, GA: US Department of Health and Human Services, CDC; 2023. https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/index.html
- Jones JM; CDC. Updated clinical considerations for use of both nirsevimab and Pfizer RSVpreF vaccine. Presentation to ACIP. Atlanta, GA: US Department of Health and Human Services, CDC; 2023. https://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2023-09-22/07-Mat-Peds-Jones-508.pdf
- Nunes MC, Madhi SA. Prevention of influenza-related illness in young infants by maternal vaccination during pregnancy. F1000 Res 2018;7:122. https://doi.org/10.12688/f1000research.12473.1 PMID:29445450
- Zerbo O, Ray GT, Fireman B, et al. Maternal SARS-CoV-2 vaccination and infant protection against SARS-CoV-2 during the first six months of life. Nat Commun 2023;14:894. https://doi.org/10.1038/s41467-023-36547-4 PMID:36854660
- CDC. Vaccines during and after pregnancy. Atlanta, GA: US Department of Health and Human Services, CDC; 2023. https://www.cdc.gov/vaccines/pregnancy/vacc-during-after.html
- Palmeira P, Quinello C, Silveira-Lessa AL, Zago CA, Carneiro-Sampaio M. IgG placental transfer in healthy and pathological pregnancies. Clin Dev Immunol 2012;2012:1–13. https://doi.org/10.1155/2012/985646 PMID:22235228
- Feltes TF, Cabalka AK, Meissner HC, et al.; Cardiac Synagis Study Group. Palivizumab prophylaxis reduces hospitalization due to respiratory syncytial virus in young children with hemodynamically significant congenital heart disease. J Pediatr 2003;143:532–40. https://doi.org/10.1067/S0022-3476(03)00454-2 PMID:14571236
- Food and Drug Administration. BLA approval letter. Silver Spring, MD: US Department of Health and Human Services, Food and Drug Administration; August 21, 2023. https://www.fda.gov/media/171492/download?attachment
Abbreviations: GRADE = Grading of Recommendations, Assessments, Development, and Evaluations; LRTI = lower respiratory tract infection; RR = relative risk; RSV = respiratory syncytial virus; VE = vaccine efficacy.
* 95% CI unless otherwise noted. When 95% CI not used, the CI was adjusted using the Bonferroni procedure, accounting for the primary endpoints’ results.
† Vaccine efficacy was calculated as (1 – [P / (1 – P)]) x 100%, where P is the number of cases in the RSVpreF group divided by the total number of cases.
§ Vaccine efficacy was calculated as (1 − [hP / (1 − P)]) x 100%, where P is the number of cases in the RSVpreF group divided by the total number of cases and h is the ratio of number of participants at risk in the placebo group to the number of participants at risk in the RSVpreF group.
¶ 97.58% CI.
** Severe medically attended RSV-associated LRTI was a co-primary endpoint of the phase 3 clinical trial. This outcome was not included by CDC’s Advisory Committee on Immunization Practices RSV Vaccines Pediatric/Maternal Work Group as an a priori GRADE outcome critical or important to vaccine policy decision making.
†† 99.17% CI.
§§ Pooled RR estimates were independently calculated using counts of events and participants in the phase 3 trial interim analysis and phase 2b trial among those who received the phase 3 vaccine formulation.
¶¶ Serious adverse events in pregnant persons were collected through 6 months after delivery.
*** Up to 7 days after injection. When selecting the a priori harm outcomes, CDC’s Advisory Committee on Immunization Practices RSV Vaccines Pediatric/Maternal Work Group defined reactogenicity as both local and systemic reactions. These data only reflect systemic reactions.
††† Serious adverse events in infants were collected through 6 months after delivery.
* All differences between vaccine group and placebo group were not statistically significant, as determined by nonoverlapping CIs.
† https://www.fda.gov/media/168889/download?attachment
§ Data obtained directly from the sponsor during August, 2023.
¶ Less than 37 weeks’ gestation.
** Less than ≤5.5 lbs (2,500 g).
BOX. Relative advantages and disadvantages of maternal RSVpreF vaccination and nirsevimab administration to infants to prevent respiratory syncytial virus lower respiratory tract infection in infants — United States, 2023
Maternal RSVpreF vaccination
Advantages
• Provides protection immediately after birth
• Might be more resistant to potential mutations in F protein*
Disadvantages
• Protection potentially reduced if fewer antibodies are produced or are transferred from pregnant person to baby (e.g., pregnant person is immunocompromised or infant born soon after vaccination)
• Potential risk for preterm birth and hypertensive disorders of pregnancy
Infant nirsevimab administration
Advantages
• Studies of antibody levels suggest that protection might wane more slowly than protection from the maternal RSV vaccine
• Assures direct receipt of antibodies rather than relying on transplacental transfer
• No risk for adverse pregnancy outcomes
Disadvantages
• Potentially limited availability during 2023–24 RSV season
• Requires infant injection
Abbreviation: RSV = respiratory syncytial virus.
* Maternal RSV vaccination results in a polyclonal immune response, which is expected to be more resistant to potential mutations in the RSV F protein than a monoclonal antibody product.
Suggested citation for this article: Fleming-Dutra KE, Jones JM, Roper LE, et al. Use of the Pfizer Respiratory Syncytial Virus Vaccine During Pregnancy for the Prevention of Respiratory Syncytial Virus–Associated Lower Respiratory Tract Disease in Infants: Recommendations of the Advisory Committee on Immunization Practices — United States, 2023. MMWR Morb Mortal Wkly Rep 2023;72:1115–1122. DOI: http://dx.doi.org/10.15585/mmwr.mm7241e1.
MMWR and Morbidity and Mortality Weekly Report are service marks of the U.S. Department of Health and Human Services.
Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of
Health and Human Services.
References to non-CDC sites on the Internet are
provided as a service to MMWR readers and do not constitute or imply
endorsement of these organizations or their programs by CDC or the U.S.
Department of Health and Human Services. CDC is not responsible for the content
of pages found at these sites. URL addresses listed in MMWR were current as of
the date of publication.
All HTML versions of MMWR articles are generated from final proofs through an automated process. This conversion might result in character translation or format errors in the HTML version. Users are referred to the electronic PDF version (https://www.cdc.gov/mmwr) and/or the original MMWR paper copy for printable versions of official text, figures, and tables.
Questions or messages regarding errors in formatting should be addressed to mmwrq@cdc.gov.