Hawaii DOH urges year‑round RSV protection; details nirsevimab use and VFC ordering

The Hawaii Department of Health on Sept. 24 briefed clinicians and Vaccines for Children (VFC) providers on updated guidance for preventing severe respiratory syncytial virus (RSV) illness in infants, emphasizing that Hawaii recommends year‑round protection and providing operational details for nirsevimab distribution and use.

Josephine Araki, RN (the transcript also records her name as “Josephine Alakti”), a quality assurance assessor with the Hawaii VFC program, presented clinical indications, dosing, storage, and ordering procedures for nirsevimab and reviewed alternatives, including palivizumab (brand Synagis) and maternal RSV vaccination. Araki stated: “RSV protection is recommended year round in our state.”

Why it matters: RSV is the leading cause of infant hospitalization, and Hawaii’s surveillance data (current to Sept. 19) showed an upward trend in positive RSV tests following seasonal lows. The state’s recommendation of year‑round prophylaxis differs from jurisdictions with discrete RSV seasons and affects timing for newborn immunization and provider ordering practices.

Key clinical guidance from the webinar

- Who should receive nirsevimab: Infants younger than 8 months entering their first RSV season should receive nirsevimab if the pregnant parent did not receive a recommended maternal RSV vaccine, if maternal vaccination status is unknown, or if the infant was born within 14 days of maternal vaccination. Araki said clinicians may consider nirsevimab for infants of vaccinated parents in rare circumstances — for example, if the parent is immunocompromised or the infant had cardiopulmonary bypass or ECMO.

- Dosing and administration: For infants <8 months, the recommended dose is 50 mg for those weighing <5 kg and 100 mg for those ≥5 kg. Children aged 8–19 months at increased risk receive 200 mg administered as two 100 mg injections at separate sites. The preferred intramuscular site for infants is the anterolateral thigh; nirsevimab is not administered intravenously. Araki reiterated: “Nirsevimab is a monoclonal antibody … it doesn’t activate the immune system like a vaccine.”

- Storage and handling: Nirsevimab is supplied as single‑use prefilled syringes. Store refrigerated at 2°C–8°C (36°F–46°F), protect from light in the original carton, do not freeze, and do not use beyond the printed expiration date. Prefilled syringes may be held at room temperature for up to eight hours.

- Prioritization and supply: Nirsevimab orders must be placed through the Nirsevimab order form (not the Hawaii Immunization Registry). The Centers for Disease Control and Prevention (CDC) is using a two‑week top‑off replenishment cadence for VFC allocations; providers were asked to submit orders to the Hawaii VFC program so the state can maximize CDC replenishment distributions. Araki said the 50 mg formulation is prioritized for birthing hospitals, while 100 mg doses may be distributed to hospitals and outpatient VFC providers. "If nirsevimab supply is limited," she said, "prioritize infants and children at the highest risk for severe RSV disease, first by their high risk conditions and then by age, prioritizing the youngest first."

- Alternatives and sequencing with palivizumab (Synagis): If nirsevimab is unavailable or infeasible, high‑risk infants eligible for palivizumab should receive palivizumab in its recommended schedule (15 mg/kg once monthly for up to five doses). Araki described sequencing: if fewer than five palivizumab doses have been given, providers may give a single dose of nirsevimab and discontinue further palivizumab; there is no required minimum interval between the last palivizumab dose and nirsevimab, but when possible nirsevimab should be given within 30 days after the last palivizumab dose.

- Maternal RSV vaccination: The maternal RSV vaccine (referred to variously in the presentation) is an approved vaccine recommended for pregnant people who meet VFC eligibility criteria; it should be administered as a single intramuscular dose between 32 weeks 0 days and 36 weeks 6 days of gestation. Presenter guidance stressed that "most infants don't need both" maternal vaccination and nirsevimab, though clinical exceptions exist (for example, if the pregnant person is unlikely to have mounted an adequate immune response).

- Safety and reporting: Nirsevimab and palivizumab are contraindicated in individuals with a history of anaphylaxis to the product or its components; use caution in patients with thrombocytopenia or coagulation disorders. Adverse events should be reported to the Vaccine Adverse Event Reporting System (VAERS).

Operational notes and next steps

Slides, references, and a recording of the webinar will be posted to the Hawaii VFC website, and the presenter provided contact information for follow‑up questions. The presenter apologized for an incorrect survey link in the slide deck and noted a user named "Kelohy" posted the corrected link in the chat. Providers were encouraged to place routine two‑week or one‑month standing orders consistent with the VFC guidance so the state can allocate and distribute doses efficiently.

What the webinar did not change: The session provided clinical and operational guidance but did not announce a change in statutory authority or new regulation; it reiterated ACIP and AAP guidance where applicable and described how CDC allocation practices affect local ordering and distribution.

The Hawaii VFC program expects to make slides and the webinar recording available online; providers who still have questions were advised to contact the Hawaii VFC program directly.