Beyond Blanket Recommendations: A Risk-Based Approach to Vaccination

Tailoring Immunization Strategies to Protect Those Who Need It Most

Many people worry that vaccination follows a blanket, one-size-fits-all approach. But vaccine guidance has evolved—while some vaccines, like the flu shot, remain universally recommended, others are now prioritized for those at highest risk. This shift isn’t about restricting access; it’s about ensuring that those most vulnerable receive the strongest protection.

We recently sat down with Dr. Margot Savoy to explore this shift in our latest episode, "Needles To Say, RSV And Pneumo Vaccines Are Worth A Shot." As Dr. Savoy put it, "It's not about a one-size-fits-all approach; it's about understanding individual risk factors and tailoring our recommendations accordingly."

She highlighted how factors such as age, underlying health conditions, and immunosenescence—the natural aging of the immune system—play critical roles in determining vaccine effectiveness and the need for specific immunizations. Dr. Savoy also discussed how experiences from the pandemic have reshaped our vaccine strategies, leading to more nuanced and risk-based approaches. She stressed the significance of open, personalized discussions between healthcare providers and patients to ensure optimal vaccination outcomes. For a full discussion, listen to our episode with Dr. Savoy here:

Let’s discuss…

The Shifting Landscape of Vaccine Recommendations

The concept of risk-based recommendations represents a significant advancement in how we approach vaccination. Rather than applying a one-size-fits-all approach, we're now able to prioritize vaccination for those at greatest risk, ensuring they receive optimal protection. This shift isn't about restricting access—it's about optimizing protection where it matters most.

RSV vaccine recommendations have rapidly evolved. Initially, they were left to shared clinical decision-making for adults over 60. Now, strong real-world evidence has refined this approach, demonstrating that RSV vaccines reduce hospitalization risk by 75-82% in high-risk adults. As a result, recommendations have been updated to ensure those at greatest risk receive the strongest protection.

For patients 75 and older, the path is now straightforward—universal vaccination is recommended. But it's our patients between 60 and 74 where our clinical expertise becomes crucial. We're looking at a constellation of factors that can significantly impact RSV outcomes: chronic heart conditions like coronary artery disease, lung diseases such as COPD or persistent asthma, complicated diabetes, and immune system challenges. Our nursing home residents, too, fall squarely into this high-risk category.

The arrival of Moderna's mResvia, joining GSK's Arexvy and Pfizer's Abrysvo, gives us three solid options for protection. Each offers robust efficacy, and importantly, we're talking about a one-time vaccination—no complex booster schedules to manage.

The Shift from Shared Clinical Decision-Making

For years, shared clinical decision-making (SCDM) allowed providers and patients to weigh risks and benefits together before choosing vaccination. While this approach offered flexibility, it often led to inconsistent uptake, leaving some high-risk patients unprotected.

Now, real-world data has made the decision clearer. Instead of guessing who benefits most, guidelines now define specific high-risk groups and prioritize them for vaccination. As Dr. Savoy put it, "The data made the decision for us. We now know who’s most likely to get really sick, so we should be making sure they get vaccinated—no guessing game."

RSV vaccine guidance exemplifies this shift. Previously, RSV vaccination for adults over 60 was left to SCDM. Now, evidence has shown that adults over 75 and those with chronic conditions like COPD, heart disease, and diabetes face the greatest risk. With that clarity, the recommendation is now structured rather than discretionary.

By moving toward risk-based recommendations, we’re ensuring that vaccines reach those who need them most—while still allowing room for clinical judgment in cases where risk-benefit discussions are warranted.

Navigating the Pneumococcal Landscape: Another Shift to Risk-Based Recommendations

Just like RSV, pneumococcal vaccine recommendations have shifted from provider discretion to a structured, risk-based approach. For years, decisions about adult pneumococcal vaccination lacked clear-cut guidance, often leaving at-risk individuals unprotected.

For adults, age alone is no longer the sole determinant. Chronic conditions like heart disease, diabetes, lung disease, and smoking-related risks significantly increase vulnerability. A healthy 65-year-old may not need the same vaccination approach as someone with multiple comorbidities.

The main decision for pneumococcal vaccination in adults now follows a structured approach:

• PCV20 alone (a single-dose option for adults who have not previously received a pneumococcal vaccine, eliminating the need for additional doses).

• PCV15 followed by PPSV23 (a two-dose approach when broader serotype coverage is needed).

As Dr. Savoy put it, "These updates take the guesswork out of pneumococcal vaccination. Instead of relying on provider discretion, we now have a clearer framework that ensures high-risk individuals are protected."

This move toward evidence-based, risk-prioritized guidance ensures that those facing the highest burden of pneumococcal disease receive targeted protection, rather than applying blanket recommendations.

Making It Work in Practice

I've heard from many of you about the challenges of implementing these nuanced recommendations in busy clinical settings. The CDC's PneumoRecs VaxAdvisor app has been a game-changer for many practices, offering real-time guidance for complex cases. If you haven't explored it yet, I strongly encourage you to do so.

Timing matters too, especially for RSV. We’re learning to think seasonally, planning ahead to ensure our high-risk patients are protected before RSV season hits.

As these recommendations shift, the biggest challenge isn’t just updating clinical workflows—it’s helping patients understand why they do (or don’t) fall into a recommended group.

As Dr. Savoy pointed out, “It’s not just about knowing who should get the vaccine, it’s about making sure they get it at the right time. If your high-risk patients aren’t vaccinated before RSV starts circulating, it’s too late.”

Communicating Risk-Based Recommendations to Patients

One of the biggest hurdles in adopting risk-based vaccination is explaining it to patients. Many expect universal recommendations, and when they don’t qualify for a vaccine, they may feel left out.

Dr. Savoy highlighted this challenge: “When I tell a 65-year-old they might not ‘need’ an RSV shot, but their 78-year-old neighbor does, I have to be ready for that conversation. People want to understand why they fall into—or outside—certain guidelines.”

Framing the conversation around risk—not just age—helps patients understand why certain conditions make vaccination critical.

Looking Ahead

As we gather more real-world data on these vaccines, we can expect further refinement of recommendations. This isn't a sign of uncertainty—it's evidence of our growing ability to target protection more precisely. The trend toward risk-based recommendations represents a more sophisticated approach to public health, one that acknowledges both the complexity of human health and the power of preventive care.

I encourage you to stay connected with the latest updates through CDC guidelines and ACIP recommendations. The landscape will continue to evolve, and staying informed is crucial to providing optimal care for our patients.

Your experiences and questions matter in this evolution. How are you implementing these recommendations in your practice? What challenges have you encountered, and what solutions have you found? Let's continue this important conversation.

Stay curious,

Unbiased Science

Sources:

1. https://www.cdc.gov/acip-recs/hcp/vaccine-specific/rsv.html

2. https://www.immunize.org/ask-experts/topic/rsv/vaccine-recs-adults-rsv/

3. https://www.cdc.gov/media/releases/2024/s-0626-vaccination-adults.html

4. https://cveep.org/respiratory-disease/rsv/

5. https://www.cdc.gov/pneumococcal/hcp/vaccine-recommendations/index.html

6. https://www.cdc.gov/pneumococcal/hcp/vaccine-recommendations/risk-indications.html

7. https://www.immunize.org/ask-experts/topic/pneumococcal/recommendations-adults/

8. https://cveep.org/respiratory-disease/pneumococcal/