Deciding Who Gets RSV Prophylaxis: First and Second Season Eligibility

Episode 12 addresses the practical question of which infants qualify for monoclonal antibody prophylaxis and highlights critical gaps in access and equity. Dr. Tan clarifies eligibility: all infants whose mothers were not vaccinated, or who were born fewer than 14 days after maternal vaccination, are appropriate candidates, with infants with congenital heart disease and chronic lung disease representing particularly high-priority cases. For a second RSV season, high-risk children aged 8 to 19 months — including those with chronic cardiopulmonary disease and other significant risk factors — are eligible for a single higher-dose administration.

Dr. Simões draws attention to a troubling real-world disparity: children on Medicaid — who are among the highest-risk for RSV hospitalization — are disproportionately missing their prophylaxis doses. Fewer pediatric practices accept Medicaid patients due to reimbursement challenges, pushing this population toward academic centers or emergency departments where they may not receive timely prophylaxis. He notes that in the 2024–2025 season, hospitalized children who had missed prophylaxis were more likely to be Medicaid-insured — a finding that reflects both a clinical failure and a health equity failure. Embedding the birth dose of monoclonal antibody into hospital delivery reimbursement structures remains an ongoing challenge.

Dr. Simões also raises an important practical point for vaccine-hesitant families: parents who decline traditional vaccines have shown considerably more willingness to accept monoclonal antibodies, which are human proteins rather than vaccines in the traditional sense. This represents an opportunity to protect infants who might otherwise go unprotected.

In the next episode, "RSV and the Challenge of Reinfection: What Long-Term Protection Looks Like," Dr. Creech addresses the reality that RSV will be a lifelong recurrent infection — and explains how current prevention strategies are designed to delay severe first encounters rather than eliminate infection entirely.