Pregnant people have hit hurdles for RSV shot

Megan Costello holds her infant son Fintan Cummins in Los Angeles.

Dec. 13, 2023 3 AM PT

When Megan Costello heard on the radio this fall that a newly approved vaccine for pregnant people could protect their babies from RSV, the Los Angeles resident immediately started asking how she could get the shot.

As a person with asthma, Costello said, she takes any kind of respiratory infection very seriously. So does her husband, whose family lost a child to pneumonia.

The one-time shot would protect her son against respiratory syncytial virus, which has long been the leading cause of hospitalization for infants in the United States.

But despite her eagerness to get vaccinated, the 38-year-old architect kept running into stumbling blocks — and ultimately missed her chance to get the shot while pregnant. Meanwhile, health officials were warning that another set of new immunizations for RSV — those given directly to infants — were in short supply.

Pediatricians “have been waiting for many decades to have an immunization to prevent RSV, and now we have two, but both have these huge barriers to delivery right now,” said Dr. Sean O’Leary, a pediatric infectious-disease specialist at the University of Colorado Anschutz Medical Campus who researches barriers to vaccination.

The shots have been hailed as a game changer for RSV, an illness that crowds pediatric wards in fall and winter and causes tens of thousands of young children in the U.S. to be hospitalized annually. The virus can sicken otherwise healthy infants and cause pneumonia and inflammation of the small airways in the lungs. According to estimates from the national Centers for Disease Control and Prevention, RSV leads to the deaths of 100 to 300 children under age 5 in the U.S. each year.

But babies can now be protected from RSV in two ways: They can be immunized with an antibody called nirsevimab, or their mothers can get a vaccine called Abrysvo during a specific window in the third trimester of pregnancy and pass protection on in utero. (The shot was initially recommended for seniors and became available to pregnant people this fall.)

Most babies need only one or the other, and amid a shortage of nirsevimab, the CDC has urged medical providers to encourage pregnant people to get vaccinated. The American College of Obstetricians and Gynecologists recommends Abrysvo for patients who are between weeks 32 and 36 of pregnancy from September to January, the time of year when RSV spreads.

Yet some pregnant patients eager to get vaccinated have met with obstacles. Computer systems at some pharmacies initially balked at booking shots for the newly eligible patients, pregnant women reported. Insurers are not required to cover newly approved vaccines right away. And medical offices and pharmacies did not necessarily have the shot on hand.

“It has taken many months for people to be able to find it reliably at local pharmacies,” and it’s still rare to get it at a doctor’s office, said Dr. Mya Zapata, an OB-GYN at UCLA Health. The vaccine’s availability “wasn’t clear and transparent,” and many patients had to call around or rely on word of mouth to find it.

Such hiccups are not unusual for a new vaccine, but three factors have made them especially frustrating in the case of the RSV shot, experts said: Pregnant people have only a limited window in which to get the vaccine. There has been a shortage of another shot that could otherwise protect newborns. And federal officials didn’t officially recommend the vaccine for pregnant patients until late September, when RSV was already on the rise.

Vaccine rollout issues usually are worked out within a few months, but “this is a seasonal vaccine,” said Dr. Kevin Ault, an OB-GYN at the Western Michigan University Homer Stryker M.D. School of Medicine. “If it’s all settled by the end of January, that doesn’t really help us that much.”

O’Leary, of CU Anschutz, pointed to a host of early challenges in getting the vaccine to pregnant patients. Priced at roughly $300, the new shot is expensive for clinics, which typically have to buy a vaccine, administer it to a patient, then bill the patient’s insurance for payment. Under federal law, private insurers have at least a year after CDC officials recommend a new vaccine to cover it, and “with such an expensive product, that puts [clinics] at serious financial risk,” he said.

As pregnant patients are directed to pharmacies, other obstacles can arise. Among them: There are two RSV vaccines for adults, but only one can be given to pregnant patients — and some pharmacies may not be stocking it.

Pharmacies may choose not to administer particular vaccines for a range of reasons, said Dr. Dima Qato, an associate professor at the USC Mann School of Pharmacy. Some might not have been immediately aware of the new recommendations to give the shot to pregnant patients, while others may not have been equipped to screen them for eligibility.

For a pharmacy, there’s the question of “how would you confirm a woman is 32 to 36 weeks pregnant,” Qato said. “It’s much easier for a vaccine that has no restrictions, like COVID or the flu, for a pharmacy to administer it.”

Costello, the pregnant architect with asthma, said a retail pharmacy initially told her it was only offering the shot to people 60 and older, the group that had first been eligible for the RSV vaccine. After she got a prescription from her obstetrician, the pharmacy was willing to give her the shot, but warned that her insurance would not cover it and she’d have to pay more than $350, Costello said.

She and her friends traded stories via text about their struggles to get vaccinated. “My doctor literally said some insurance is refusing to pay and her patients are getting charged $300+,” one of her friends wrote.

Costello said she phoned her insurer and was told her plan would only cover the vaccine if it was administered by a doctor in their office. So she booked an appointment with her primary care doctor, only for it to be canceled because it was against the practice’s policy to give vaccines in the office, she was told.

“Why are they even recommending this if it’s so inaccessible??” another friend texted when Costello told her the appointment had been canceled.

In Van Nuys, Rachel Palmer had little time left to get the vaccine when the CDC endorsed it for mothers-to-be. Her doctor sent her with a note to a local pharmacy, but “their system wouldn’t even make it a possibility for me to have it” because she was under 60, she said.

“It is frustrating that my doctor was recommending it. The pharmacist had it. The pharmacist saw that the CDC recommended it. And it was just a computer program that stopped me from getting it,” said Palmer, 36, whose second child was born in October.

After the birth, her newborn had the option of getting the infant RSV immunization, but the shot was not yet covered by the family’s insurance, Palmer said. As a writer who’s been on strike this year, she has wrestled with whether her family can afford to pay hundreds of dollars out of pocket.

Zapata, at UCLA Health, said some insurers have insisted on prior authorizations for the shots, “which then delays the patient and puts them out of the window to get the vaccine.”

It is unclear how many pregnant people have been vaccinated. The CDC said it does not yet have enough data to include the maternal vaccine on its public dashboard for RSV vaccination coverage. The California Department of Public Health also said it didn’t have confirmed data.

Vaccination rates for other seasonal shots recommended for pregnant patients have lagged in recent years, but many people jumped at the opportunity to get the RSV vaccine. One woman in Maryland said she was excited when the shots were announced in September.

“I was having a baby in November — the peak of cold and flu and RSV and all of those things — and I was going to have an opportunity to protect him,” said the woman, who asked not to be named to prevent harassment over her vaccination decisions. But “it seemed like nobody in the pharmacy industry had gotten the memo.”

One pharmacy told her its system wouldn’t process the RSV shot due to her birth date, she said. Another told her to make an online appointment, but its system balked for the same reason.

She phoned the Maryland Department of Health, but said she couldn’t reach anyone there who could help her. She called more pharmacies and was told they didn’t have the vaccine. The woman then turned to a Reddit forum about pregnancy for advice, and eventually got vaccinated at a grocery store pharmacy.

“I was hellbent on getting this shot and managed to get it,” the woman said. “But for a lot of people who don’t have the time or resources that I had to dedicate to finding the shot, they’re missing out.”

Several doctors say that early headaches like hers seem to have eased. Representatives for Rite Aid, Walgreens and CVS said their pharmacies now offer the vaccine to pregnant patients who are in the eligible window.

“I haven’t heard any issues from patients about coverage, nor about getting it from their local pharmacy” in recent weeks, said Dr. Roxanna A. Irani, a maternal-fetal medicine specialist at UC San Francisco. “Certainly we have it in our clinic.”

If the vaccine had been approved earlier, problems might have been resolved before RSV season, “but I’m happy to have it now,” Irani said. “The uptake has been unbelievable. Patients the very first day were sending us messages, bombarding our nursing lines with questions about it.”

“It’s not even about them — they’re getting it to protect their newborn,” she added.

In Van Nuys, Palmer was alarmed when her older child tested positive for RSV. She’s trying to keep the toddler away from her newborn.

“We’re obviously very nervous” for the baby, she said. “And I really wish I had gotten that vaccine!”