Important Recommendations for Preventing RSV Disease in Infants During the 2023–2024 Respiratory Virus Season
Bureau of Communicable Diseases
Key points
- Infections with respiratory syncytial virus (RSV), the leading cause of infant hospitalizations in Wisconsin, are currently increasing.
- Nirsevimab, the new monoclonal antibody product approved in 2023 to prevent lower respiratory tract disease in infants, is in very short supply and will not be available for the majority of infants who are eligible to receive it.
- Wisconsin Department of Health Services (DHS) recommends maximizing the use of other prevention interventions. This includes administering the new maternal RSV vaccine (Abrysvo) to people who are between 32 weeks and 36 weeks and 6 days pregnant and using palivizumab for eligible infants, while reserving nirsevimab for the highest risk infants.
Background
Respiratory virus season has begun, and RSV activity is currently increasing in Wisconsin. Both the number of positive tests for RSV and the percent of tests that are positive have been steadily increasing for the past several weeks.
This winter there are new opportunities to prevent hospitalizations of infants and young children due to severe lower respiratory tract disease from infections with RSV.
- Vaccinating pregnant people with Abrysvo who are between 32 weeks and 36 weeks and 6 days of gestation passively immunizes infants for several months via transplacental transfer of antibodies.
- A single intramuscular injection of the new monoclonal antibody, nirsevimab, (administered to infants and young children) prevents severe RSV disease in newborns, infants, and young children for several months (1,2).
- Palivizumab, the first monoclonal antibody for preventing RSV originally approved in 1998, remains available for use in high-risk infants.
Due to unexpected supply chain issues, nirsevimab will be in very short supply during the current RSV season (3,4). As a result, a large majority of infants recommended to receive nirsevimab will not have access to it. In this context, DHS advises clinicians and health systems to prioritize nirsevimab for high-risk patients, and to take advantage of all other available resources for preventing RSV disease, as described below.
Recommendations
Optimize the use of other approved interventions for prevention of RSV in pregnant people and infants who are eligible for palivizumab (5):
- Encourage all pregnant people to consider getting vaccinated to protect their newborns.
- Promote and support breastfeeding after vaccinating the pregnant person.
- Do not vaccinate infants whose birth parent received RSV vaccine at 32–36 weeks gestation and at least 2 weeks before birth of the infant. Confirm the birth parent’s vaccination history in the medical record or the Wisconsin Immunization Registry (WIR).
- Use palivizumab (instead of nirsevimab) in eligible children aged 8 to 19 months.
- Use palivizumab in eligible children younger than 8 months old when the appropriate dose of nirsevimab is not available.
- Document maternal RSV vaccine status in newborn discharge documentation, to assist primary care providers who may not have easy access to parent’s chart or WIR record.
Prioritize nirsevimab 100 mg doses for infants 0–6 months weighing over 5 kg (11 lbs) who meet the following criteria:
- Native American/Alaskan Native.
- Premature birth at <29 weeks' gestation (later gestations could be considered if supplies are available).
- Chronic lung disease of prematurity.
- Hemodynamically significant congenital heart disease.
- Severe immunocompromise.
- Severe cystic fibrosis (either manifestations of severe lung disease or weight-for-length <10th percentile).
- Neuromuscular disease.
- Congenital pulmonary abnormalities that impair the ability to clear secretions (potentially including Trisomy 21).
While CDC has not changed its recommendation to administer nirsevimab 50 mg doses to infants weighing less than 5 kg (11 lbs.), the available supply of 50 mg doses may also be limited during this season. Providers should prioritize the 50 mg doses of nirsevimab to high-risk infants as appropriate if the supply is inadequate.
Use available nirsevimab doses as early in the RSV season as possible:
- Immunization as soon as possible will help provide protection throughout the RSV season.
- Infants weighing less than 5 kg (11 lbs.) can receive the 50 mg dose which has a less limited supply. Immunize early before the infant reaches the weight limit and would need to receive 100 mg.
- Consider contacting parents or guardians of infants meeting the above criteria to come into clinic to receive one of the limited doses of nirsevimab as early in the season as possible.
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Do NOT use two 50 mg doses of nirsevimab when the 100 mg dose is indicated (≥5 kg). The 50 mg doses should be reserved only for infants weighing <5 kg.
Vaccines for Children—Borrowing Policies
Borrowing from VFC stock for non-VFC eligible children (for example, commercially insured)
Borrowing from the VFC stock for non-VFC eligible children is not allowed given that the nirsevimab supply shortage continues to evolve and affect both private and public stocks and is not expected to resolve soon.
The goal of the VFC program is to vaccinate VFC eligible children and a VFC dose cannot be provided to a commercially insured child at the expense of vaccinating a VFC eligible child. Therefore, while there are supply constraints for nirsevimab, VFC supply stock should remain prioritized for VFC eligible children.
Borrowing from private stock for VFC-eligible children
While this practice is allowed, it is up to the organization to determine if this is feasible for them to implement, given the timing of replacement of doses.
Given the situation with nirsevimab, CDC has relaxed some of the provisions around borrowing and the timing of replacement to help alleviate the shortage. If a provider wishes to use private doses of nirsevimab for VFC eligible children and can wait for replacement to occur once VFC stocks are no longer limited, this is allowable. It is important to note that given the VFC program has significantly limited allocations of nirsevimab for this season (and therefore, Wisconsin VFC providers are receiving a very small number of doses), replacement of doses from VFC this season is unlikely and should not be done if it would result in a VFC- eligible child subsequently not having access to the nirsevimab.
Please note that if borrowing occurs, you may need to replace stock next season that is borrowed this season. Therefore, it is of utmost importance to ensure appropriate documentation using the VFC borrowing form; please see page 10 of the Wisconsin VFC Resource Guide for more information.
Sincerely,
Ryan Westergaard, MD, PhD, MPH
Chief Medical Officer and State Epidemiologist
Bureau of Communicable Diseases
Division of Public Health
Wisconsin Department of Health Services
References and Resources
For more information on RSV visit the DHS RSV webpage
(1) CDC: Healthcare Providers: RSV Preventing Information
(2) AAP: ACIP and AAP Recommendations for Nirsevimab
(3) CDC: Limited Availability of Nirsevimab in the United States—Interim CDC Recommendations to Protect Infants from Respiratory Syncytial Virus (RSV) during the 2023–2024 Respiratory Virus Season
(4) AAP: CDC offers guidance on prioritizing infants for limited nirsevimab supplies
(5) AAP: Updated Guidance for Palivizumab Prophylaxis Among Infants and Young Children at Increased Risk of Hospitalization for Respiratory Syncytial Virus Infection
Questions regarding this health alert may be directed to the DHS immunization program via email to DHSImmProgram@dhs.wisconsin.gov
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