The world is entering a new era of vaccines. Following the success of COVID-19 mRNA shots, scientists have a far greater capacity to tailor shots to a virus’s structure, putting a host of new vaccines on the horizon.
The most recent arrivals are several new immunizations against respiratory syncytial virus, or RSV.
These shots are welcome since RSV can be dangerous, even deadly, in the very old and very young. But the shots, produced by Pfizer and GlaxoSmithKline, are also expensive, costing about $300 for those directed at adults, and up to $1,000 for one of the shots, a monoclonal antibody rather than a traditional vaccine, intended for babies. Many older vaccines cost pennies.
And in part because of the high cost, there is a shortage of RSV shots for infants, leading the U.S. Centers for Disease Control and Prevention to issue a warning for doctors to prioritize the most vulnerable babies.
The advent of these new drugs is forcing the U.S. to face anew questions it has long sidestepped: How much should an immunization cost that will possibly be given—maybe yearly—to millions of Americans? Also, given the U.S. is one of two countries that permit direct advertising to consumers: How can we ensure the shots get into the arms of people who will truly benefit and not those of people who seek it out as a result of scary marketing, at great expense?
Already, ads on television and the internet show active retirees playing pickleball or going to art galleries whose lives are “cut short by RSV.” This helps explain the lines for the shot at my local pharmacy.
The indiscriminate use of expensive shots could strain both public and private insurers’ already tight budgets.
The risk of RSV for infants
Other developed countries have deliberate strategies for deciding which vulnerable groups need a particular vaccine and how much to pay for it. The U.S. does not, and as specialized vaccines proliferate, public programs and private insurers will need to grapple with how to use and finance shots that can be hugely beneficial for some but will waste precious health dollars if taken by all.
A seasonal viral illness, RSV can cause hospitalization or, in rare cases, death in babies and in people ages 75 or older, as well as those with serious underlying medical conditions such as heart disease or cancer. For most people who get RSV, it plays out as a cold; you’ve likely had RSV many times without knowing it.
But RSV puts about 2% of babies under age 1 in the hospital and annually kills between 100 and 300 of those under 6 months, because their immune systems are immature and their airways too narrow to tolerate the inflammation. Merely having a bad case of RSV in young childhood increases the risk of long-term asthma.
That led to what some have called a “narrow” endorsement from the CDC’s Advisory Committee on Immunization Practices (ACIP) for people 60 to 75: Patients in that age range could get the shot after “shared clinical decision-making” with a health provider.
In part because of this fuzzy, conditional endorsement, it is likely some Americans 60 and over with commercial insurance are finding that their insurers won’t cover it. Under Obamacare, insurers are generally required to cover at no cost vaccines that are recommended by the ACIP.
(In late September, the ACIP recommended immunization of all babies with either the antibody or the maternal vaccine. Insurers have a year to commence coverage and many have been dragging their feet because of the high price.)
A patchwork strategy
There are better and more equitable ways to steer the shots into the arms of those who need it, rather than simply administering it to those who have the “right” insurance or, swayed by advertising, can pay. For example, insurers, including Medicare, could be required to cover only those ages 60 to 75 who have a prescription from a doctor, indicating shared decision-making has occurred.
During the pandemic emergency, the federal government purchased all COVID-19 vaccines in bulk at a negotiated price, initially below $20 a shot, and distributed them nationally. If, to protect public health, we want vaccines to get into the arms of all who benefit, that’s a more cohesive strategy than the patchwork one used now.
Vaccines are miraculous, and it’s great news that they now exist to prevent serious illness and death from RSV. But using such novel vaccines wisely—directing them to the people who need them at a price they can afford—will be key. Otherwise, the cost to the health system, and to patients, could undermine this big medical win.
