RSV vaccination approved for pregnant women

October 4, 2023

Respiratory syncytial virus (RSV) causes 58,000 to 80,000 hospitalizations of children under 5 each fall. European researchers found that 1.8% of all healthy full-term infants were hospitalized with RSV before their first birthday. Last fall’s RSV epidemic was especially terrible; many cities had no available pediatric inpatient beds. RSV also causes about 60,000 to 160,000 hospitalizations and 6000-10,000 deaths in adults annually - mostly in the elderly.

The Advisory Committee on Immunization Practices (ACIP) just voted to recommend Abrysvo (Pfizer), an RSV vaccine earlier recommended for those over 65, for use in women who are due from October to March each year. The vaccine is recommended for women who are between 32 and 36 weeks pregnant between September and January each year, except in a few geographies (Alaska, the Caribbean including Puerto Rico, Guam and parts of Florida) where RSV is not seasonal so the vaccine is recommended throughout the year. For women who are due between April and August, ACIP recommends that infants receive Beyfortus, a monoclonal antibody that provides protection against RSV.

The good news is that there are now two ways to protect infants from RSV. The bad news is that both of these injections are expensive ($295 for the RSV vaccination, and $495 for the monoclonal antibody). There is no incremental benefit to an infant receiving monoclonal antibody if the mother received the RSV vaccination in late pregnancy.

Implications for employers:

-        Both the RSV vaccine and the monoclonal antibody should be offered to members without cost sharing as they are recommended by ACIP. HOWEVER, the Affordable Care Act allows health plans to delay eliminating cost sharing until the plan starting a full year after such a recommendation is made. (This provision was waived for COVID-19 vaccinations, which must be covered without cost sharing due to the CARES Act).

-        Clinically, I hope most employers will provide members access to these injections without cost-sharing immediately. These injections can prevent many hospitalizations.

-        Even employer plans that wait to eliminate cost-sharing should provide coverage for these injections subject to deductible and cost sharing now.

-        The RSV vaccination should ideally be covered under both the pharmacy and the medical benefit so that moms do not have trouble navigating where to get them. The RSV monoclonal antibody should be covered under the medical benefit, since pharmacies do not administer injections to infants.

-        The ACIP recommendation as noted above, would recommend different standards depending on county, so I believe few plans will implement a “hard stop” for injections given between February and August. If they do, they will need a process to approve RSV vaccinations in the spring and summer for pregnant women in the geographies which have RSV circulating all year.

-        Many plans cannot reliably connect mothers and their infants in their claims systems, so will rely on pediatricians to not treat an infant with the monoclonal antibody if their mom got the RSV vaccine at the end of pregnancy, as it’s unnecessary.

Tomorrow: Pandemic associated with spike of diabetes among children

Illustration by Dall-E

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