Healthgrades for Professionals

Empowering physicians with a patient perspective

CDC reports some pregnant women, infants received the wrong RSV shot

rsv vaccine ampoules
Confusion around the recent rollout of three different immunizations to protect against RSV may have led to the errors. Elena Popova/Getty Images
  • The CDC recently issued an emergency alert to clinicians reporting some pregnant people and young children received the wrong RSV vaccine.
  • Vaccine errors are rare, and no adverse events were reported in this instance.
  • Experts say confusion around the recent rollout of three different immunizations to protect against RSV may have led to the errors.
  • Currently, two RSV vaccines are approved for use in older adults, with one of these also approved for use in pregnant people.
  • A third monoclonal antibody treatment is recommended for use in infants up to 8 months to protect against severe illness.

Vaccine administration errors are uncommon but may occasionally occur.

When a trio of immunizations to protect high-risk groups against respiratory syncytial virus (RSV) rolled out last fall, confusion surrounding the vaccines ensued among patients and even clinicians alike.

A recent emergency alert released by the Centers for Disease Control and Prevention (CDC) reports that RSV shots were wrongfully administered to a small number of pregnant people and young children. As of January 17, 2024, the alert states that 128 pregnant people received the wrong RSV shot, and 25 children under 2 received an RSV vaccine approved for use in adults only.

While any number of vaccine errors may seem alarming, the CDC notes the errors are “relative to an estimated 1 million infants protected from RSV either through infant receipt of nirsevimab or through vaccination of pregnant people.”

Young children, pregnant people, and older adults are considered most at risk for severe illness from RSV, a respiratory virus resembling the common cold. Most people recover from RSV in 7–14 days Trusted Source Centers for Disease Control and Prevention (CDC) Governmental authority Go to source , but some high-risk cases may become serious, leading to difficulty breathing and requiring hospitalization.

Abrysvo (Pfizer) and Arexvy (GSK) are both approved for use in adults over 60 Trusted Source Centers for Disease Control and Prevention (CDC) Governmental authority Go to source . However, only Abrysvo is approved for use in pregnant people Trusted Source Centers for Disease Control and Prevention (CDC) Governmental authority Go to source .

Currently, there is no RSV vaccine available to younger children. A monoclonal antibody treatment Trusted Source Centers for Disease Control and Prevention (CDC) Governmental authority Go to source , niresevimab, also known as Beyfortus, (Sanofi and AstraZeneca), is administered to newborns up to 8 months when they are most susceptible to complications from the virus. 

In addition, pregnant people who receive the maternal Abrysvo vaccine may pass antibodies to a developing fetus, which may protect a newborn from severe illness after birth.

Clinicians who administered the wrong RSV vaccines reported them to the Vaccine Adverse Event Reporting System (VAERS). The vaccine errors did not lead to adverse events, but the CDC and Food and Drug Administration (FDA) will continue to monitor the situation.

If you or your child received the wrong RSV vaccine or you are concerned about getting the right one, here’s what you need to know to stay safe.

Why did some people receive the wrong RSV shot?

Lack of clarity around the three different RSV immunizations may have caused some clinicians to mistakenly administer the wrong shot.

“New vaccines and treatments can sometimes lead to confusion, especially in busy healthcare settings,” Dr. Daniel Ganjian, board certified pediatrician at Providence Saint John’s Health Center in Santa Monica, CA, told Medical News Today.

To add to any confusion surrounding the rollout of three different RSV immunizations, Dr. Ganjian noted the RSV shots have similar names — Abrysvo and Arexvy — which may have contributed to the mixups. 

Dr. Patricia Faraz, board certified OB-GYN at The Women’s Hospital at MemorialCare Saddleback Medical Center in Laguna Hills, CA, told MNT that such vaccine errors could be reduced by clinicians if proper systems were put into place. For instance, the patient order and vaccine could be verified by more than one staff member.

Medications for OB patients should not be stored in the same refrigerator as non-OB patients to reduce errors as staff members may not be familiar with these new vaccines, and they are named similarly,” Dr. Faraz suggested.

Should you be worried if you got the wrong RSV vaccine?

If you received a vaccine in error, you should notify your healthcare team and report any adverse events to VAERS, which helps public health officials identify and address potential issues with vaccines, Dr. Ganjian explained.

If you’re concerned your child may have received a vaccine intended for adults, try to stay calm. You should contact their pediatrician who “can review your child’s records and confirm if they received the correct vaccine. If not, they will advise you on the next steps,” Dr. Ganjian noted.

If a vaccine reaction were to occur, symptoms should generally subside within 48 hours. If symptoms persist, contact your doctor right away. “Serious adverse events are very rare in these situations,” Dr. Ganjian said.

No serious reactions were reported among pregnant people and children who received the wrong shot.

RSV vaccines are considered safe and effective when used as intended. No adverse events were reported during clinical trials of the RSV vaccines for pregnant people Trusted Source PubMed Central Highly respected database from the National Institutes of Health Go to source and older adults Trusted Source The New England Journal of Medicine Highly respected journal, Expert written journal, Peer reviewed journal Go to source . Beyfortus, the antibody treatment for young children, is also considered safe and effective Trusted Source PubMed Central Highly respected database from the National Institutes of Health Go to source .

However, any risks of adverse events from receiving the wrong RSV shot are not yet known.

Unfortunately, these vaccines are brand new, and adverse events in pregnant women are not known with Arexvy,” Dr. Faraz said.

Over time, adverse events may be reported, and then we will have a better idea regarding potential side effects or efficacy rates of the Arexvy, which is indicated for individuals over 60,” she explained.

Signs of adverse reactions to vaccines

The two RSV vaccines and the monoclonal antibody treatment for young children are not interchangeable. They should be used only in the high-risk groups for which they are approved.

While no serious adverse events were reported from this vaccine error, any unusual symptoms after vaccination should be relayed to your doctor. 

According to Dr. Ganjian, symptoms of adverse reactions may include: 

Tips to ensure you get the right RSV vaccine

To ensure you or your child receive the correct RSV vaccine, experts say it’s important to ask your doctor questions and get information from reliable sources.

Federal agencies like the CDC can also provide you with the most accurate and up-to-date information about RSV vaccines and treatments.

Dr. Ganjian recommended asking your doctor or vaccine technician for the exact name of the vaccine you’re wanting to receive. 

“For example, if you have a baby, tell your doctor you want nirsevimab. If you are pregnant, ask for [Abrysvo],” he said.

“Don’t hesitate to ask your healthcare provider about the vaccine or treatment you’re receiving. Make sure you understand what it is and why you’re getting it. If you have any concerns, double-check the information with your provider or pharmacist before receiving the vaccine.”

— Dr. Ganjian, pediatrician

This article originally appeared on Medical News Today.

Was this helpful?
0
View All Healthgrades Pulmonology Professionals Articles
© 2004-2022 Healthline Media UK Ltd, Brighton, UK, a Red Ventures Company. All rights reserved. MNT is the registered trade mark of Healthline Media. Any medical information published on this website is not intended as a substitute for informed medical advice and you should not take any action before consulting with a healthcare professional. See additional information.
MNT copyright image