OBJECTIVE

To describe the implementation of nirsevimab for the prevention of respiratory syncytial virus-associated lower respiratory tract disease in a pediatric hospital, focusing on strategies to ensure equitable access and address logistic challenges. Additionally, we aimed to identify predictors of nirsevimab deferral among eligible infants.

METHODS

Our hospital implemented a universal immunization campaign to all eligible infants, including those discharged from the newborn nursery, intermediate care nursery, and neonatal intensive care unit. We identified key drivers and barriers, formed a multidisciplinary team, and applied a systematic approach for integration of nirsevimab orders into existing workflows. We developed and disseminated educational resources for staff and caregivers. After the implementation, we conducted univariable and multivariable analyses to identify predictors of nirsevimab deferral to evaluate implementation success and possible gaps.

RESULTS

Despite challenges, we offered nirsevimab to 99% of eligible infants prior to discharge from the newborn nursery, intermediate care nursery, and neonatal intensive care unit with 71% receiving the immunization. On the multivariable analysis, independent predictors of nirsevimab deferral included preferred language of English, deferral of hepatitis B vaccine, discharge from the newborn nursery, and public insurance.

CONCLUSIONS

Our implementation strategy ensured equitable access to nirsevimab for newborns with both our high uptake and acceptance rate underscoring the effectiveness of our approach. Key strategies for success included early stakeholder engagement, multidisciplinary collaboration, and proactive logistic planning. Our approach serves as a model for other institutions to offer nirsevimab prior to hospital discharge and highlights the importance of addressing both clinical and socioeconomic barriers.

In July 2023, the Food and Drug Administration (FDA) approved nirsevimab, a novel monoclonal antibody for the prevention of respiratory syncytial virus (RSV)-associated lower respiratory tract disease.1 Based on several clinical trials showing benefit, its approval applied to all infants born during or entering their first RSV season and children aged up to 24 months who remain vulnerable to severe RSV disease in their second RSV season.2,3 In August 2023, the Advisory Committee on Immunization Practices (ACIP) and American Academy of Pediatrics (AAP) formally published guidance recommending nirsevimab for all infants aged less than 8 months born during or entering their first RSV season and children aged 8 to 19 months who are at increased risk of severe RSV disease and entering their second RSV season.4,5 

Following FDA approval and ACIP/AAP recommendations, hospitals and clinics faced a short turnaround time to develop strategies incorporating nirsevimab into clinical practice before the 2023 to 2024 RSV season. Additional challenges included the high cost of the medication, high demand, immunization hesitancy, and the need to educate providers, frontline staff, and caregivers.6 Further complicating the roll out, a shortage of nirsevimab was announced in late October 2023, prompting the Centers for Disease Control and Prevention (CDC) to publish interim recommendations for the reprioritization of nirsevimab administration for certain high-risk populations.7,8 

Despite these obstacles, we successfully deployed an implementation approach at our hospital that enabled nirsevimab administration to all eligible infants and young children per the original ACIP/AAP recommendations.4 Prioritizing equity and access, we offered nirsevimab to all eligible infants discharged from our newborn nursery, intermediate care nursery (ICN), or neonatal intensive care unit (NICU). Herein, we detail our implementation strategy, including the navigation of early logistic hurdles. We also summarize the uptake of nirsevimab in our infant population during the 2023 to 2024 RSV season and provide a subanalysis of deferral reasons to inform implementation efforts for the 2024 to 2025 RSV season.

We used concepts from the Reach, Effectiveness, Adoption, Implementation, Maintenance framework to guide this implementation effort.9 As detailed below, we selected this model to ensure that the strategies chosen to enhance access to nirsevimab for eligible infants would reach the most patients, minimize potential health disparities, result in positive health benefits, be adoptable and adaptable across patient care areas, and be sustainable postimplementation.10 The strategies chosen aligned with the RAND Health Care/Patient-Centered Outcomes Research Institute implementation strategies recommended to promote evidence-based practices and included coalition building, educational outreach, promoting adaptability, and developing patient-centered materials, among others.11 Where appropriate, we also used quality improvement tools (eg, key driver diagrams) to help identify factors that may facilitate the success of this implementation project.12 

Stakeholder meetings

Our 461-bed quaternary care hospital in the western United States has a labor and delivery department that delivers about 5000 infants per year, a 40-bed level 4 NICU, and a 34-bed ICN providing NICU step-down services or advanced care for mild to moderately ill newborns. We identified and summarized key drivers for our implementation approach in Figure 1. Anticipating the FDA approval of nirsevimab in the summer of 2023, we formed a multidisciplinary committee to develop, endorse, and support an implementation plan. Members included hospital leaders (eg, Chief Quality Officer, Chief Pharmacy Officer) and content experts (eg, pediatric infectious diseases, neonatology, newborn medicine, and pharmacy). A core implementation team of infectious diseases physicians and pharmacists served as the primary leaders and facilitators of this project. This team hosted meetings with partner primary care clinics and local health care systems to discuss their implementation plans. Insights from these meetings helped us understand nirsevimab availability in our community and the potential impact of deferring nirsevimab to an infant’s first outpatient follow-up appointment. This collaborative approach facilitated the development of a comprehensive and community-informed implementation plan.

FIGURE 1.

Key drivers for nirsevimab implementation plan.

FIGURE 1.

Key drivers for nirsevimab implementation plan.

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Ensuring equitable access to all eligible patients guided our implementation approach for nirsevimab. Recognizing potential disparities in community availability and the risk of loss to follow-up, we decided to offer nirsevimab prior to discharge to all eligible patients. Children aged less than 8 months and up to 19 months for the first and second season, respectively, were deemed eligible for nirsevimab per ACIP/AAP recommendations. This ensured all patients, regardless of socioeconomic status, geographic location, or primary care access, received this preventive care without delay or barrier.

Forecasting

While finalizing our implementation plan, we forecasted the volume of nirsevimab needed for the 2023 to 2024 RSV season based on discharge census data for infants aged less than 8 months during the 2 prior RSV seasons. Additionally, we incorporated projections from our obstetric patient census for anticipated births. Our pharmacy buyers closely monitored wholesaler inventory to ensure an adequate supply. We proactively engaged with drug manufacturers and maintained open communication throughout the season to stay informed about FDA drug approval status, product availability, and emerging efficacy and safety data.

Informatics

We collaborated with clinical informatics and stakeholders from our newborn nursery, ICN, and NICU to create a nirsevimab order within our electronic health record (EHR). The order defaulted to the appropriate route and dose based on patient age and weight.1 Frequency was defaulted to be given prior to discharge with administration instructions to offer nirsevimab within 48 to 72 hours before discharge. An embedded order question required the prescriber to select the patient-specific indication (eg, aged <8 months in patient’s first RSV season) at the time of order entry (Supplemental Figure 1).

Nirsevimab was available both as a stand-alone order and as an integrated part of newborn admission order sets routinely used for all admissions to the newborn nursery, ICN, or NICU. We built logic within these order sets to check the linked parent’s medical record for RSV vaccine administration and to autoselect nirsevimab for all newborns unless the pregnant parent had received the RSV vaccination 14 days or more prior to delivery. This logic, developed with nursing staff, aimed to prevent unnecessary medication orders and reduce the need for manual medical record review. This logic streamlined the workflow and decreased administrative burden. During testing, we identified that the order-set logic would not work if the pregnant parent’s RSV vaccine was not reported in the California Immunization Registry. We, therefore, created a tip sheet for nursing staff on how to document historical immunizations in the pregnant parent’s EHR.

During discharge preparations, the nurse performed final nirsevimab screening, including a final check for the pregnant parent’s RSV immunization status, and recorded nirsevimab administration or declination as part of mandatory medication administration record (MAR) documentation. We provide pertinent sections from these admission order sets, including the clinical decision support for recommended weight-based dose and timing of administration around discharge, in Supplemental Figure 2.

A clinical decision support alert (Supplemental Figure 3) appeared for infants whose caregivers identified the patient as American Indian or Alaska Native with a discharge date of less than 72 hours. This alert aligned with the ACIP/AAP guidelines, which emphasizes an increased focus on this group due to their disproportionately higher RSV-associated hospitalizations. This approach was novel for nirsevimab compared with previous RSV antibody prophylaxis criteria.4,13 

Education

Early in the planning process, the core implementation team hosted a town hall meeting to educate on nirsevimab, relevant clinical trials, and the anticipated roll out. Additionally, the core implementation team hosted tailored educational sessions for care services that were more likely to recommend nirsevimab for their patient populations (eg, neonatology, pulmonology). We also developed several educational resources. For nursing staff, multiple tip sheets were prepared in collaboration with nursing education leadership and informatics to provide updates on changes within the admission order sets, stand-alone nirsevimab orders, appropriate MAR documentation, and documentation of the pregnant parent’s RSV vaccination when not available in the California Immunization Registry. For nursing staff, physicians, and pharmacists, we developed clinical and operational education, which included answers to common clinical questions based on an available AAP document of frequently asked questions (FAQ).14 We disseminated these resources 2 weeks prior to the go-live date and included them in the physician newsletter, emails to relevant department listservs and leadership, daily huddle discussions, and the hospital intranet.

We also developed several educational resources for patients and caregivers including 2 caregiver FAQs—1 explaining the difference between nirsevimab and the RSV vaccine and 1 focused on nirsevimab—as well as nirsevimab-specific after visit summary information in collaboration with our Office of Patient/Family Education and Health Literacy. These resources were also translated into Spanish. We embedded both the CDC RSV preventive antibody immunization information and our FAQ documents as hyperlinks within the nirsevimab order and MAR for ease of the nursing staff and provider access. Documentation of nirsevimab administration within the MAR triggered the inclusion of educational materials in the after visit summary provided to the caregivers on discharge (Supplemental Figure 4).

Go-live

We began offering nirsevimab to all eligible inpatients on October 24, 2023 based on the positivity rates of local and state RSV test results, following successful coordination of EHR builds and nursing staff, physician, and pharmacist education. On the go-live date, a pharmacist from our core implementation team as well as pharmacy and nursing leadership visited the units to address any questions and ensure all staff members were prepared. For patients born before the go-live date, we distributed a tip sheet with instructions on ordering nirsevimab for eligible infants because the order-set updates would not apply to patients already admitted.

Despite months of planning, our implementation strategy required additional interventions after the go-live date. Based on supply concerns from providers, we developed a second memo and new FAQ document. While our institution had adequate supply, we acknowledged the challenges faced by other institutions experiencing shortages and aimed to provide transparent and empathetic communication. Additionally, in collaboration with neonatology and nursing leadership, we revised verbiage in the administration instructions, which required nursing staff to check with medical providers before nirsevimab administration to remove the responsibility of reconciling the pregnant parent’s RSV vaccination status from the bedside nurse.

End of season

Based on local epidemiology that suggested low circulating rates of RSV (ie, 2 consecutive weeks with <3% of polymerase chain reaction tests with positive results for RSV), we made the decision to end the nirsevimab immunization campaign on April 1, 2024.15 Halting the campaign demanded numerous interventions: deactivation of the nirsevimab order in our EHR, removal of nirsevimab from the neonatal admission order sets, communication by email and staff newsletter to inform relevant stakeholders and units, and discontinuation of any active nirsevimab orders on April 1, 2024.

We retrospectively collected nirsevimab order information including dose, ordering department, administration date and time, or declination reason as documented in the MAR. We also captured sociodemographic information including sex at birth, hospital length of stay, race, ethnicity, preferred language, and medical payor type. We included race and ethnicity as variables in our analysis due to their established associations with disparities in pediatric vaccination that were reported in prior studies.16–18 This study was deemed exempt by our institutional review board.

We reviewed patients discharged from the newborn nursery, ICN, or NICU who qualified for nirsevimab based on the age of less than 8 months in their first RSV season or up to 19 months in their second RSV season with other qualifying conditions per ACIP/AAP recommendations for receipt or deferral of nirsevimab.4 We excluded patients who received nirsevimab before admission to our hospital, were born to a pregnant parent vaccinated for RSV at least 14 days before delivery, or who did not meet eligibility criteria for another reason (eg, aged ≥8 months at discharge without other qualifying conditions). For patients with multiple encounters, we included only the first encounter between September 24 and April 1 of 2024. We outline our institution’s eligibility definition for nirsevimab in Figure 2.

FIGURE 2.

Flowchart of patient eligibility.

FIGURE 2.

Flowchart of patient eligibility.

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We extracted the binary outcome of nirsevimab receipt (administered vs deferred) from the MAR documentation. We classified reasons for caregivers deferring nirsevimab based on review of hepatitis B vaccine administration, MAR documentation, progress notes, and immunization records at the end of RSV season (Supplemental Figure 5). We classified caregivers who deferred both the hepatitis B vaccine and nirsevimab as “vaccine hesitant.” If caregivers agreed to hepatitis B vaccine but deferred nirsevimab, the medical record was then reviewed for explicit documentation of deferral reason or immunization records to categorize as “defer until PCP,” “other,” or “reason not given or not clearly documented.”

Patient demographics were summarized using descriptive statistics. Differences between patients who received and did not receive nirsevimab were compared using the Mann-Whitney U and χ2 tests for continuous and categorical variables, respectively. A logistic regression model estimated the probability of nirsevimab deferral based on the additive effects of categorical variables deemed clinically or operationally relevant. We used a backward-stepwise selection, dropping variables with a P value of greater than 0.05, where the P value was calculated from an F-distribution based on the likelihood-ratio test. The initial model was an additive model incorporating the following variables: preferred language, ethnicity, public insurance, sex at birth, receipt of hepatitis B vaccine, age of less than 4 days, length of stay less than 3 days, and discharge department. Ethnicity/race, sex at birth, age of less than 4 days, and length of stay less than 3 days were dropped from the model due to lack of statistical significance. Modeling was performed in the R, version 4.0.2 (R Foundation for Statistical Computing).19 Results were presented as odds ratios (ORs) with 95% CIs.

Of the 2181 patients discharged from the newborn nursery, ICN, or NICU during the study period, 1121 (51.4%) qualified for nirsevimab (Figure 2). Nirsevimab was offered to 99% of eligible patients. Eleven patients were discharged without a nirsevimab order placed or documentation of nirsevimab eligibility assessment within the EHR and were excluded from statistical analysis. Of the eligible patients, 794 (71%) received nirsevimab before hospital discharge. All but 1 patient included in the study were aged less than 8 months, so we did not perform further stratification by age. Of the 316 eligible patients whose caregivers declined nirsevimab, 15% deferred until a subsequent outpatient newborn visit, 24% declined both hepatitis B vaccine and nirsevimab prior to discharge, and 57% lacked documented deferral reasons. Few patients (4%) had “other” documented reasons for nirsevimab deferral, which included hesitancy on the recent introduction of this novel agent, family history of vaccine-related adverse reactions, and March deferrals due to the proximity to the end of the RSV season. A month-over-month analysis revealed declining nirsevimab administration rates from October to January, while deferrals remained relatively stable (Figure 3). The percentage of infants not eligible for nirsevimab due to the pregnant parent receiving the RSV vaccine (offered September to January per CDC recommendations) increased significantly, rising from 5.4% in October to 65.8% in January, before declining in subsequent months.20 

FIGURE 3.

RSV prophylaxis received by discharge month. October 24 to October 31 of 2023 administrations only include the period from September 24 to September 31 of 2023 to correlate with first day of availability at our institution.

FIGURE 3.

RSV prophylaxis received by discharge month. October 24 to October 31 of 2023 administrations only include the period from September 24 to September 31 of 2023 to correlate with first day of availability at our institution.

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On univariable analysis, patient characteristics of race/ethnicity, preferred language, discharge unit, hepatitis B vaccine receipt, and length of hospital stay were found to be statistically significant when compared against those who received vs declined nirsevimab (Table 1). Several factors emerged as significant predictors of nirsevimab deferral on multivariable analysis. Preferred language of Spanish (OR 0.46; 95% CI, 0.3–0.67), discharge from the ICN (OR 0.28; 95% CI, 0.2–0.4), and receiving hepatitis B vaccine (OR 0.14; 95% CI, 0.12–0.16) were associated with lower odds of nirsevimab deferral, while public insurance payor was associated with significantly higher odds of nirsevimab deferral (OR 1.61; 95% CI, 1.16–2.23) (Table 2).

TABLE 1.

Patient Characteristics at Time of Hospital Discharge

CharacteristicsTotal Population (N = 1110), nNirsevimab Administered (N = 794) n (%)Nirsevimab Deferred (N = 316) n (%)P Value
Male sex at birth 537 374 (69.6) 163 (30.4) 0.18 
Age at time of discharge, d    0.01 
 ≤3 762 528 (69.3) 234 (30.7)  
 >3 348 266 (76.4) 82 (23.6)  
Race and ethnicity    0.003 
 Hispanic/Latino 478 360 (75.3) 118 (24.7)  
 Non-Hispanic/Non-Latino: Asian 255 190 (74.5) 65 (25.5)  
 Non-Hispanic/Non-Latino: white 199 132 (66.3) 67 (33.7)  
 Non-Hispanic/Non-Latino: other 92 52 (56.5) 40 (43.5)  
 Multiracial 42 31 (73.8) 11 (26.2)  
 Unknown/other 44 29 (65.9) 15 (34.1)  
Preferred language    <0.001 
 English 769 525 (68.3) 244 (31.7)  
 Spanish 291 234 (80.4) 57 (19.6)  
 Other 50 35 (70) 15 (30)  
Insurance    0.34 
 Private/managed care 550 395 (71.8) 155 (28.2)  
 Public 557 398 (71.5) 159 (28.5)  
 Other 1 (33.3) 2 (66.7)  
Underlying health conditions    0.14 
 Hemodynamically significant CHD 63 56 (88.9) 7 (11.1)  
 BPD or CLD and medical supporta 36 28 (77.8) 8 (22.2)  
Discharge unit    <0.001 
 Newborn nursery 821 567 (69.1) 254 (30.9)  
 ICN 180 152 (84.4) 28 (15.5)  
 NICU 109 75 (68.8) 34 (31.2)  
Received hepatitis B vaccine 998 757 (75.9) 241 (24.1) <0.001 
Length of stay, h    <0.001 
 <72 618 412 (66.7) 206 (33.3)  
 ≥72 438 382 (87.2) 110 (25.1)  
CharacteristicsTotal Population (N = 1110), nNirsevimab Administered (N = 794) n (%)Nirsevimab Deferred (N = 316) n (%)P Value
Male sex at birth 537 374 (69.6) 163 (30.4) 0.18 
Age at time of discharge, d    0.01 
 ≤3 762 528 (69.3) 234 (30.7)  
 >3 348 266 (76.4) 82 (23.6)  
Race and ethnicity    0.003 
 Hispanic/Latino 478 360 (75.3) 118 (24.7)  
 Non-Hispanic/Non-Latino: Asian 255 190 (74.5) 65 (25.5)  
 Non-Hispanic/Non-Latino: white 199 132 (66.3) 67 (33.7)  
 Non-Hispanic/Non-Latino: other 92 52 (56.5) 40 (43.5)  
 Multiracial 42 31 (73.8) 11 (26.2)  
 Unknown/other 44 29 (65.9) 15 (34.1)  
Preferred language    <0.001 
 English 769 525 (68.3) 244 (31.7)  
 Spanish 291 234 (80.4) 57 (19.6)  
 Other 50 35 (70) 15 (30)  
Insurance    0.34 
 Private/managed care 550 395 (71.8) 155 (28.2)  
 Public 557 398 (71.5) 159 (28.5)  
 Other 1 (33.3) 2 (66.7)  
Underlying health conditions    0.14 
 Hemodynamically significant CHD 63 56 (88.9) 7 (11.1)  
 BPD or CLD and medical supporta 36 28 (77.8) 8 (22.2)  
Discharge unit    <0.001 
 Newborn nursery 821 567 (69.1) 254 (30.9)  
 ICN 180 152 (84.4) 28 (15.5)  
 NICU 109 75 (68.8) 34 (31.2)  
Received hepatitis B vaccine 998 757 (75.9) 241 (24.1) <0.001 
Length of stay, h    <0.001 
 <72 618 412 (66.7) 206 (33.3)  
 ≥72 438 382 (87.2) 110 (25.1)  

Abbreviations: BPD, bronchopulmonary dysplasia; CHD, congenital heart disease; CLD, chronic lung disease; ICN, intermediate care nursery; NICU, neonatal intensive care unit.

a

Defined as patients requiring medical support (ie, supplemental oxygen for at least 28 d, ongoing corticosteroid therapy, or diuretic therapy) within the first 6 mo of life.

TABLE 2.

Multivariable Logistic Regression Model of Predictors for Nirsevimab Deferral

ValueOR (95% CI)P Value
Caregiver preferred language 
 English Reference  
 Spanish 0.45 (0.3–0.68) <0.001 
 Other 0.87 (0.44–1.72) 0.7 
Insurance 
 Private/managed care Reference  
 Public 1.67 (1.19–2.33) 0.002 
Discharge unit 
 Newborn nursery Reference  
 ICN 0.28 (0.17–0.46) <0.001 
 NICU 0.76 (0.47–1.22) 0.25 
Received hepatitis B vaccine 0.13 (0.08–0.21) <0.001 
ValueOR (95% CI)P Value
Caregiver preferred language 
 English Reference  
 Spanish 0.45 (0.3–0.68) <0.001 
 Other 0.87 (0.44–1.72) 0.7 
Insurance 
 Private/managed care Reference  
 Public 1.67 (1.19–2.33) 0.002 
Discharge unit 
 Newborn nursery Reference  
 ICN 0.28 (0.17–0.46) <0.001 
 NICU 0.76 (0.47–1.22) 0.25 
Received hepatitis B vaccine 0.13 (0.08–0.21) <0.001 

Abbreviations: ICN, intermediate care nursery; NICU, neonatal intensive care unit; OR, odds ratio.

This study describes our experience with the universal offering of nirsevimab in neonatal and infant units, resulting in effective reach and high uptake of nirsevimab among qualifying infants. We successfully offered nirsevimab to 99% of eligible infants, with 71% receiving this immunization. This rate is higher than the 47.3% reported in a previous outpatient study and approaches the California immunization survey’s 78% uptake of the newborn hepatitis B vaccination.21,22 Forty-seven percent of our cohort had a pregnant parent who received the RSV vaccine, which was much higher than the nationally reported rate of 17.8% and may reflect local RSV vaccination campaigns by our obstetrics colleagues and acceptance in our population.23 

Although it is unknown which was the most impactful, several key strategies likely contributed to the success of this implementation effort. Centralized facilitation and communication from our core implementation team provided crucial support. Integration of tools such as order sets, clinical decision support alerts, and resource links into existing workflows offered minimally disruptive clinical decision support. Input from patient and family advisory groups ensured that patient-facing materials met the needs of our diverse community. We developed comprehensive educational materials for clinicians to explain the safety and efficacy of this novel medication to caregivers. Key stakeholders conducted at-the-elbow educational outreach during the roll out period. Finally, setting a clear end date for de-implementation of seasonal immunization campaigns (eg, nirsevimab, influenza vaccine) ensured judicious use of resources and prevented unnecessary immunizations during periods of low viral circulation.

While our implementation strategy was ultimately effective, it required overcoming several challenges before and during the season. These challenges included educating the health care organization regarding a novel agent, managing drug shortages and shifting ACIP/AAP recommendations, handling implementation costs amidst billing and reimbursement uncertainties, optimizing EHR builds and workflows, and determining parent vaccination status with inadequate documentation or self-reporting. Further interventions, including an additional memo, FAQ document, and updates to the neonatal admission order sets, were also required based on provider feedback. Adaptability and flexibility were crucial for successful implementation, and other institutions should be prepared to modify their approach based on real-time feedback and evolving circumstances.

To better plan for future RSV seasons and assess gaps in equity, we evaluated predictors of nirsevimab deferral. Characteristics identified include preferred language (English), deferral of hepatitis B vaccine (suggesting vaccine hesitancy), discharge from the newborn nursery, and public insurance payor. These findings highlight potential gaps in our implementation strategy that will require additional interventions including targeted education campaigns in our newborn nursery and expanded parental education on immunization safety and efficacy during future RSV seasons. We recommend other hospitals supplying nirsevimab perform similar evaluations to interrogate possible gaps in equity of care. A significant limitation was the lack of recorded reasons for 57% of caregiver deferrals, which represents a lost opportunity to understand barriers to acceptance. Addressing this limitation will be a key target next season. We also observed an increase in deferrals due to caregivers’ perception of reduced RSV risk toward the season’s end, which complicated efforts. This observation will inform our campaign next year by emphasizing the importance of consistent messaging about RSV risk throughout the season. Finally, health systems should regularly review updates to national nirsevimab and pregnant parent RSV vaccination guidelines to ensure appropriate and timely adjustments to EHR builds or screening logic. For the 2024 to 2025 season, we have modified the logic for order sets that include nirsevimab to order if the pregnant parent was vaccinated less than 14 days or more than 9 months prior to birth to reflect the updated recommendation surrounding RSV vaccination of a pregnant parent in a prior pregnancy.24 

Our study has several limitations. While we offered nirsevimab universally, it was not integrated into order sets for older infants outside of the newborn nursery, ICN, or NICU, limiting uptake evaluation in this group. From a sociodemographic perspective, we did not have access to parental factors such as age and education, which have been shown to affect vaccine uptake.25 Additionally, the low percentage of certain racial/ethnic populations, including African American patients, limited our ability to adequately assess vaccine uptake in these groups.25,26 We were not able to fully assess uptake in our high-risk infant populations because patients born with cardiac or immunocompromizing conditions requiring prolonged hospitalization are often transferred to other services (eg, cardiology, oncology) before discharge and would not be captured in this study. Finally, our data did not permit us to evaluate the efficacy of nirsevimab in preventing medically attended lower respiratory tract disease or RSV-related hospitalizations.

In conclusion, we highlight the success of a universal nirsevimab immunization campaign driven by effective stakeholder engagement, education, and EHR integration. The high uptake of nirsevimab and pregnant parent RSV vaccination underscores the importance of comprehensive, systems-based preventive strategies. Through our analysis, we hope to provide valuable insight to other health systems and inform our future RSV season implementation plans. Future efforts should focus on promoting pregnant parent RSV vaccination, addressing immunization hesitancy, and optimizing implementation processes to ensure equitable access to infant RSV prophylaxis across diverse populations.

Drs Puckett and Kushner conceptualized and designed the study; led data collection, analysis, and interpretation; drafted the initial manuscript; reviewed and revised the manuscript; and approved the final manuscript as submitted. Drs Bio and Schwenk conceptualized and designed the study, supervised data analysis and interpretation, critically reviewed and revised the manuscript, and approved the final manuscript as submitted. Mr Cornell and Dr Wood conducted analysis and interpretation of data, critically reviewed and revised the manuscript, and approved the final manuscript as submitted.

CONFLICTS OF INTEREST DISCLOSURES: The authors have no conflicts of interest relevant to this article to disclose.

FUNDING: No financial support was provided relevant to this article.

AAP

American Academy of Pediatrics

ACIP

Advisory Committee on Immunization Practices

APP

Advanced Practice Providers

BPD

bronchopulmonary dysplasia

CDC

Centers for Disease Control and Prevention

CHD

congenital heart disease

CLD

chronic lung disease

EHR

electronic health record

FAQ

frequently asked questions

FDA

Food and Drug Administration

ICN

intermediate care nursery

MAR

medication administration record

NICU

neonatal intensive care unit

OR

odds ratio

PCP

primary care physician

RSV

respiratory syncytial virus

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Supplementary data