OBJECTIVES

Respiratory syncytial virus (RSV) is a common pediatric infection, with young infants being at the highest risk of hospitalization and long-term sequela. New preventive agents have been recommended to prevent severe RSV illness in infants, including a vaccine administered during pregnancy. The current rates of recommended vaccination in pregnancy are suboptimal. Our objective was to characterize interest in RSV vaccination during pregnancy among people across the United States who were pregnant or planning to become pregnant.

METHODS

In March 2023, we conducted a national cross-sectional online survey of individuals 18 to 45 years old who were currently pregnant or trying to become pregnant on their perceptions of RSV-related illness and intentions to get vaccinated against RSV. We performed logistic regression analyses to determine the odds and predicted proportions of the likelihood of RSV vaccination during pregnancy, controlling for sociodemographic factors.

RESULTS

Of 1619 completed surveys, 1528 were analyzed. 54% of respondents indicated that they were “very likely” to get vaccinated against RSV during pregnancy. The perception of RSV as a serious illness was the strongest predictor of vaccination likelihood. In the full regression model, predicted proportions of “very likely” to vaccinate against RSV followed a similar pattern (63% if RSV infection was perceived as serious and likely, 55% if serious and unlikely, 35% if not serious; P < .001).

CONCLUSIONS

Raising awareness of RSV infection as likely and potentially serious for infants may be an influential component of targeted communications that promote RSV vaccine uptake during pregnancy.

What’s Known on This Subject:

With increasing vaccine hesitancy nationwide, RSV vaccination is now recommended during pregnancy. There is modest uptake of vaccination during pregnancy with tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis and influenza vaccines, despite evidence of benefit to the recipient and child.

What This Study Adds:

In this nationwide survey of people who are or plan to become pregnant, 54% expressed interest in RSV vaccination during pregnancy. The demographic factors associated with interest in RSV vaccination can inform further education efforts as vaccines become available.

Respiratory syncytial virus (RSV) is a leading cause of infection among infants,1  frequently resulting in hospital or intensive care admission, especially for children with special health care needs. Almost all children in the United States will contract RSV within the first 2 years of life. RSV infection contributes to significant morbidity and mortality for young infants, with the highest rate of hospitalization at 25 per 1000 among RSV-positive 1-month-old infants.2  Additionally, RSV infections severe enough to require hospitalization have been associated with long-term wheezing and a higher risk of future hospitalization for asthma symptoms compared with children not hospitalized with RSV as infants.3 ,4 

To date, 2 vaccines have been routinely recommended during pregnancy by the American College of Obstetricians and Gynecologists and the Centers for Disease Control and Prevention (CDC): influenza if the patient is pregnant during influenza season and the combined vaccine for tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) for all pregnancies between 27 and 36 weeks’ gestation.5 ,6  For influenza and Tdap vaccines, national data indicate that only approximately one-half of pregnant persons in the United States receive these vaccines as recommended.7 ,8 

Recently, novel agents for the prevention of RSV have received US Food and Drug Administration (FDA) and CDC approval, including nirsevimab, a long-acting monoclonal antibody for administration to young children, and Abrysvo, a vaccine recommended for pregnant individuals and persons aged 60 years and older.9 12  Since the convergence of widespread outbreaks of coronavirus disease 2019, influenza, and RSV in 2022,13  there has been great interest in the pediatric community about the potential of new pharmaceuticals to prevent severe RSV infection among infants.14  To realize the full benefit for children of a novel RSV vaccine for pregnant persons, it is important to examine the attitudes of the potential vaccine recipients to illuminate drivers of individual interest so that health care and public health teams can develop and implement interventions to promote vaccine uptake.

We conducted a nationwide, cross-sectional online survey of people aged 18 to 45 years who were currently pregnant or planning to become pregnant in the coming year.

We recruited participants using QualtricsXM “dynamic surveys,” as in our previously published work on vaccine attitudes in a community-based sample.15  Surveys were distributed to eligible panel members through an online portal. Panel members accessed surveys as they became available. Panels were used to purposefully survey diverse people of childbearing age, with the goal of recruiting a sample with a racial and ethnic composition resembling the US population.

The survey was available in English and Spanish. Survey responses were collected from March 1 to March 20, 2023. To enhance response rates, QualtricsXM used an automated reminder option based on respondents’ preferences. A pilot of 52 respondents was conducted to ensure question comprehension and data validity, after which there were no concerns or changes and response collection continued.

To ensure data quality, several checks were established, including (1) participants’ surveys were terminated if they were “speeding,”16  as indicated by one-half the median of the completion speed during the pilot, (2) only unique internet protocol addresses were included to prevent duplicate responses, and (3) surveys were excluded if respondents chose the same answer for every question, which is known as “straight lining.”16  In addition, a quality attention check question was included midsurvey. Responses were excluded if they failed any of the quality checks.

Pregnancy

Respondents were screened for eligibility by using the first 2 questions of the survey, which determined if they were 18 to 45 years old and if they identified as a person who was pregnant or may become pregnant by asking if respondents were either currently pregnant or planning to become pregnant in 2023.

Sociodemographic Measures

We used our survey to obtain demographic characteristics by self-report. Race and ethnicity information was collected by asking “What is your race and ethnicity? Please select all that apply.” Insurance type was obtained by asking “Which of the following types of health insurance coverage do you have?”; response options included private, public, no health insurance, or prefer not to answer. Those who preferred not to answer were categorized as missing. Respondents were asked for their 5-digit zip code, which was then mapped to 1 of the 4 US census regions.17 

Perceptions of RSV Illness

To understand the perception of RSV illness, respondents were asked about the seriousness and likelihood of RSV. First, respondents were asked, “How likely do you think it is that your future child will get RSV in their first 12 months of life?” Response options included “very likely,” “somewhat unlikely,” “not likely,” “not sure,” and “prefer not to respond.” We dichotomized responses as likely if the respondents selected “very likely” or “somewhat unlikely” and “not likely” if any other response was selected. Next, respondents were asked, “How much do you agree or disagree with this statement? RSV is a serious illness for children.” Response options included “strongly agree,” “agree,” “neutral,” “disagree,” “strongly disagree,” “not sure,” and “prefer not to respond.” We dichotomized responses as “serious” if “strongly agree” or “agree” were selected and “not serious” if any other response was selected. All “prefer not to respond” responses were recorded as missing and excluded from the analyses.

Using these 2 variables, we created a combined “serious and likely” variable regarding respondents’ perceptions of RSV illness for children. Given the small proportion of respondents who perceived RSV as not serious, we created the variable with 3 categories: “serious and likely,” “serious and not likely,” and “not serious, regardless of likelihood.”

RSV Vaccination Intention

At the time of survey administration, FDA approval was pending for a vaccine against RSV during pregnancy. To understand their intentions toward future RSV vaccination during pregnancy, respondents were asked, “To protect your future infant against RSV, how likely is it that you would get vaccinated against RSV during pregnancy?” Response options included “very likely,” “somewhat likely,” “neutral,” “somewhat unlikely,” “very unlikely,” and “prefer not to respond.” We dichotomized responses as very likely to vaccinate if “very likely” was selected and less likely to vaccinate against RSV if the other choices were selected. “Prefer not to respond” was categorized as missing and was excluded from the analyses.

The study was considered exempt human subjects research by the Institutional Review Board at Ann & Robert H Lurie Children’s Hospital of Chicago. Incentives for participation were determined by QualtricsXM and ranged from $3.58 to $3.75 per survey based on the time spent completing the survey and compensation on similar surveys.

Our dichotomous outcome of interest was very likely versus less likely intent to receive the RSV vaccine during pregnancy. Based on previous studies of vaccination intent and hesitancy, predictors of primary interest included race and ethnicity, census region, insurance type, pregnancy status (current, planning), respondent age, and child age if the respondent had a child at home. We conducted bivariate analyses to determine variable inclusion for subsequent multivariable models. Models for 3 analytic samples were evaluated, including all respondents, respondents with child(ren) at home, and respondents without child(ren) at home. The multivariable model included all variables with P ≤ .25 in any of the 3 bivariate analytic samples (total; with child(ren) at home; without child(ren) at home) for consistency in reporting. Child age was removed from the multivariable model because of collinearity. Postestimation testing was conducted to calculate predicted probabilities based on the multivariable analyses. All analyses were conducted by using Stata 17 (Stata Corporation; College Station, Texas).

Of those within our target demographic that were offered the survey, 3413 started the survey and 1619 completed it (survey completion rate = 47%). A total of 90 responses were excluded because of quality concerns, resulting in an overall analytic sample size of 1528. A total of 50 parents completed the survey in Spanish. Approximately one-third of respondents were 18 to 25 years old, and <10% were 40 to 45 years old. Survey respondents generally reflected the racial and ethnic composition of the childbearing population in the United States (Table 1).18  Racial and ethnic demographics were similar for respondents with and without a child at home. Most respondents had health insurance, with 50% of respondents with commercial insurance, 46% with public insurance, and 5% with no insurance. Twice as many respondents lived in the South as in any other major census region.

Responses were split almost evenly between people planning to become pregnant (48%) and those who were currently pregnant (52%). More than one-half already had at least 1 child at home (60%), with most children currently 1 to 5 years old (55%). Among respondents with a previous pregnancy, 39% had received both the Tdap and influenza vaccines and 20% reported receiving the Tdap vaccine alone, for a total of 59% who had received the Tdap vaccine, and 23% reported receiving the influenza vaccine alone, for a total of 62% who had received the influenza vaccine.

In the overall sample, 30% of respondents reported first hearing about RSV illness in 2022, 15% reported first hearing about it in 2021, and 36% reported first hearing about it in 2020 or earlier, whereas 20% said they had never heard of RSV. Among respondents with child(ren) at home, 29% reported first hearing about RSV illness in 2022, 17% reported first hearing about it in 2021, 37% reported first hearing about it in 2020 or earlier, and 16% said they had never heard of RSV. In contrast, a greater proportion of parents without children had not heard of RSV; 30% reported first hearing about RSV illness in 2022, 12% reported first hearing about it in 2021, 33% reported first hearing about it in 2020 or earlier, and 25% said they had never heard of RSV.

In the overall sample, 40% of respondents perceived that RSV illness among children is both serious and likely, whereas 45% perceived RSV illness as serious but not likely, and 16% did not view RSV illness as serious. In the subsample of respondents with child(ren) at home, 44% perceived RSV illness among children as both serious and likely, whereas 40% perceived RSV illness as serious but not likely, and 16% did not perceive RSV illness as serious. In contrast, in the subsample of respondents without a child at home, 33% perceived RSV illness among children as both serious and likely, whereas 52% perceived RSV illness as serious but not likely, and 15% did not perceive RSV illness as serious, regardless of its likelihood.

Among survey respondents, 54% reported that they would be very likely to receive a future RSV vaccine during pregnancy, with the same rates among those who were currently pregnant and trying to become pregnant. A higher proportion of respondents with a child at home reported they would be very likely to receive RSV vaccination during pregnancy (57%) than those without a child at home (50%; P = .01). A total of 63% of respondents who thought that RSV illness was both serious and likely reported they would be very likely to get vaccinated against RSV during pregnancy, whereas 31% of those who thought RSV illness was not serious (regardless of whether they thought it was likely) would do so (P < .001).

In the adjusted overall model, respondents who had received Tdap or influenza vaccines in past pregnancies had significantly higher odds of being very likely to receive a future RSV vaccine during pregnancy (odds ratio 3.56, 95% confidence interval 2.38–5.33; Table 2). Among respondents who thought it was likely, as well as those who thought it was not likely, perceiving RSV illness in children as serious was associated with significantly higher odds of receiving a future RSV vaccine across the 3 models (overall, with child(ren), and without a child at home) when compared with those who believed RSV not to be serious.

Among parents without a child at home, non-Hispanic Black parents and parents with Medicaid had significantly higher odds of reporting that they would be very likely to receive a future RSV vaccine during pregnancy. In the overall sample and the subsample without a child at home, individuals with public insurance had significantly higher odds of saying they were very likely to receive a future RSV vaccine during pregnancy. In contrast, child age and census region were not significantly associated with a parent reporting they would be very likely to receive a future RSV vaccine in the overall model. In the subsample of respondents without a child at home, those who were currently pregnant were significantly less likely than those planning to get pregnant to say they were very likely to get vaccinated against RSV during pregnancy.

Based on the multivariable models described above, the lowest predicted proportions of being very likely to receive a future RSV vaccine during pregnancy were among those who thought RSV illness was not serious (35% overall, 37% with child(ren), 32% without child(ren), P < .001; Fig 1). Similarly low predicted proportions were observed among those who did not receive vaccines during past pregnancies in the subsample of respondents with child(ren) (33%).

Although limited by small subgroup sizes and not reaching statistical significance in regression models (Table 2), low predicted probabilities of future RSV vaccination during pregnancy were observed among respondents without insurance in the model without child(ren) (30%), and the highest predicted proportions were among American Indian/Alaska Native respondents in the overall sample and the subsample with child(ren) at home (70%; 72%), with lower rates seen among those without child(ren) in the home.

The recent FDA approval and subsequent recommendation by the CDC of an RSV vaccine for administration during pregnancy is an advancement in the prevention of RSV in young infants most at risk for serious illness. Our nationwide survey, which revealed a majority interest in an RSV vaccine during pregnancy among people pregnant or trying to become pregnant, provides insights into attitudes among potential recipients of this new preventive strategy. Perceptions of pregnant people are important for public health and health care advocacy designed to reach pregnant people to inform their decision-making.

Our results of likely future RSV vaccination rates are consistent with the authors of other studies, who found suboptimal rates of vaccine uptake among pregnant individuals. In a recent survey fielded to pregnant persons by the CDC, 43% reported receiving the influenza vaccine and 55% reported receiving the Tdap vaccine,7  which generally suggest missed opportunities to realize the full benefits of vaccination during pregnancy in protecting the health of the future child.

Overrepresented among those who said they are not very likely to get an RSV vaccine during pregnancy were respondents who perceive RSV illness for children as not serious and those who do not yet have a child at home. It is possible that individuals without a child at home have little to no experience with RSV because RSV illness is most serious in early childhood. These findings suggest that education efforts regarding RSV infection prevention and the potential harms of RSV among infants <6 months old will likely be important components of an RSV vaccination promotion campaign. The youngest infants are among the most vulnerable to RSV infection,2  and vaccination during pregnancy has been demonstrated to help prevent RSV-related hospitalizations.11  There is also evidence that pregnant individuals appreciate receiving information on the safety and benefit of immunizations for their infant as part of conversations about their decision to receive vaccinations during pregnancy.19 

Other investigators have reported that Black and Hispanic pregnant persons express lower vaccine confidence, including regarding influenza and Tdap vaccines.20  Interestingly, in our findings, non-Hispanic Black individuals without a child at home had significantly higher odds of reporting they would be very likely to get a future RSV vaccine during pregnancy when compared with non-Hispanic white individuals. American Indian and Alaskan Native individuals had somewhat higher odds of reporting they would be very likely to get a future RSV vaccine during pregnancy among the overall sample and had among the highest predicted proportions of any subgroup. This particular finding may reflect the historically high RSV-related hospitalization rates among American Indian and Alaskan Native children21  and that prevention of RSV in Alaskan Natives is already a priority of the Arctic Investigations Program of the CDC.22 

Our study should be considered within the context of some limitations. First, we drew from the previous vaccine literature and our own published work in developing our survey items;15 ,23  however, we could not validate our survey measure on the likelihood of receiving a future RSV vaccine during pregnancy because no gold standard was available at the time of survey fielding. Second, our survey was conducted in spring 2023 before the RSV vaccine had been approved or recommended for pregnant people, and perceptions may have changed once the vaccine was approved and recommended. Third, the fielding of the survey took place before research results on the effectiveness of the RSV vaccine given during pregnancy were publicly available, and the effectiveness was not discussed or presented to survey respondents. Additionally, our fielding period also immediately followed the media coverage of the “triple-demic” in the fall and winter of 2022 to 2023,13  which may have raised awareness of RSV among the general public. Although we used purposeful sampling to be representative of the racial and ethnic demographic characteristics of the US childbearing population, our results may be biased in unobservable ways regarding individuals and their attitudes about RSV illness or vaccination during pregnancy. The proportion of respondents who indicated that they are likely to get vaccinated against RSV during pregnancy in comparison to the proportion of respondents who were vaccinated against influenza and Tdap during pregnancy suggests that such biases are likely small if they exist at all. Moreover, the similarity of the proportion of our respondents who reported they had been vaccinated against Tdap and flu in previous pregnancies suggests that our sample reflected a broad and generally representative cross-section of persons of childbearing age in the US population.

Overall, in March 2023, the majority of respondents who were pregnant or trying to become pregnant said that they were very likely to receive a future RSV vaccine during pregnancy. This interest was greatest among those who perceive RSV illness among children as serious and likely and those who have children at home. Educational efforts about protection against RSV illness in infants through vaccination during pregnancy and the consequent positive health implications for children may be a key component of public health and health care strategies to encourage RSV vaccination among pregnant individuals.

This work was conducted with support from faculty and staff in the Mary Ann & J. Milburn Smith Child Health Outcomes, Research, and Evaluation Center’s Catalyst, Stanley Manne Children’s Research Institute at Ann & Robert H. Children’s Hospital of Chicago. The authors acknowledge and express their gratitude to Zecilly Guzman for her assistance in the creation and dissemination of the online survey instrument.

Dr Saper conceptualized and designed the study, collected data, conducted the initial analyses, and drafted the initial manuscript; Drs Heffernan and Macy designed the data collection elements, reviewed the statistical analysis, and made substantial contributions to the interpretation of the data; Ms Simon designed the data collection elements and reviewed the statistical analysis; Dr Davis conceptualized and designed the study and made substantial contributions to the interpretation of the data; and all authors critically reviewed and revised the manuscript, approved the final manuscript as submitted, and agree to be accountable for all aspects of the work.

FUNDING: Funded by the National Institutes of Health (NIH). Dr Saper receives support from grant 1K23HL165426-01A1 for research related to respiratory syncytial virus prevention access. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no potential conflicts of interest relevant to this article to disclose.

CDC

Centers for Disease Control and Prevention

FDA

Food and Drug Administration

RSV

respiratory syncytial virus

Tdap

tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis

1
Hall
CB
,
Weinberg
GA
,
Iwane
MK
, et al
.
The burden of respiratory syncytial virus infection in young children
.
N Engl J Med
.
2009
;
360
(
6
):
588
598
2
Rha
B
,
Curns
AT
,
Lively
JY
, et al
.
Respiratory syncytial virus-associated hospitalizations among young children: 2015–2016
.
Pediatrics
.
2020
;
146
(
1
):
e20193611
3
Piedimonte
G
.
Respiratory syncytial virus and asthma: speed-dating or long-term relationship?
Curr Opin Pediatr
.
2013
;
25
(
3
):
344
349
4
Coutts
J
,
Fullarton
J
,
Morris
C
, et al
.
Association between respiratory syncytial virus hospitalization in infancy and childhood asthma
.
Pediatr Pulmonol
.
2020
;
55
(
5
):
1104
1110
5
ACOG Committee opinion no. 741: maternal immunization
.
Obstet Gynecol
.
2018
;
131
(
6
):
e214
e217
6
Centers for Disease Control and Prevention
.
Pregnancy and vaccination: vaccines during and after pregnancy
. Available at: https://www.cdc.gov/vaccines/pregnancy/vacc-during-after.html. Accessed October 17, 2023
7
Razzaghi
H
,
Kahn
KE
,
Calhoun
K
, et al
.
Influenza, Tdap, and COVID-19 vaccination coverage and hesitancy among pregnant women - United States, April 2023
.
MMWR Morb Mortal Wkly Rep
.
2023
;
72
(
39
):
1065
1071
8
Razzaghi
H
,
Kahn
KE
,
Black
CL
, et al
.
Influenza and Tdap vaccination coverage among pregnant women - United States, April 2020
.
MMWR Morb Mortal Wkly Rep
.
2020
;
69
(
39
):
1391
1397
9
The IMpact-RSV Study Group
.
Palivizumab, a humanized respiratory syncytial virus monoclonal antibody, reduces hospitalization from respiratory syncytial virus infection in high-risk infants
.
Pediatrics
.
1998
;
102
(
3
):
531
537
10
Medimmune, LLC
,
US Food and Drug Administration
.
Synagis (palivizumab) [package insert]
. Available at: https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/103770s5200lbl.pdf. Accessed October 6, 2021
11
Food and Drug Administration
.
Food and Drug Administration approves first vaccine for pregnant individuals to prevent RSV in infants
. Available at: https://www.fda.gov/news-events/press-announcements/fda-approves-first-vaccine-pregnant-individuals-prevent-rsv-infants. Accessed October 2, 2023
12
Pfizer
.
Pfizer announces positive top-line data of phase 3 global maternal immunization trial for its bivalent respiratory syncytial virus (RSV) vaccine candidate
. Available at: https://www.pfizer.com/news/press-release/press-release-detail/pfizer-announces-positive-top-line-data-phase-3-global. Accessed November 30, 2022
13
Rees
A
;
CNN
.
What to know about the triple threat of influenza, COVID and RSV
. Available at: https://www.cnn.com/2022/12/09/health/covid-influenza-rsv-vaccine-pandemic-wellness/index.html. Accessed October 27, 2023
14
Jenco
M
;
AAP News
.
CDC OKs maternal RSV vaccine, provides updated guidance for nirsevimab
. Available at: https://publications.aap.org/aapnews/news/26165/CDC-OKs-maternal-RSV-vaccine-provides-updated. Accessed October 2, 2023
15
Alfieri
NL
,
Kusma
JD
,
Heard-Garris
N
, et al
.
Parental COVID-19 vaccine hesitancy for children: vulnerability in an urban hotspot
.
BMC Public Health
.
2021
;
21
(
1
):
1662
16
Zhang
C
,
Conrad
FG
.
Speeding in Web Surveys: the tendency to answer very fast and its association with straightlining
.
Surv Res Methods
.
2014
;
8
(
2
):
127
135
17
United States Census Bureau
.
Geographic levels
. Available at: https://www.census.gov/programs-surveys/economic-census/guidance-geographies/levels.html#par_textimage_34. Accessed November 7, 2023
18
March of Dimes
.
Births - data for United States
. Available at: https://www.marchofdimes.org/peristats/data?reg=99&top=2&stop=10&lev=1&slev=1&obj=3. Accessed October 27, 2023
19
Rand
CM
,
Olson-Chen
C
.
Maternal vaccination and vaccine hesitancy
.
Pediatr Clin North Am
.
2023
;
70
(
2
):
259
269
20
Dudley
MZ
,
Limaye
RJ
,
Salmon
DA
, et al
.
Racial/ethnic disparities in maternal vaccine knowledge, attitudes, and intentions
.
Public Health Rep
.
2021
;
136
(
6
):
699
709
21
Atwell
JE
,
Hartman
RM
,
Parker
D
, et al
.
RSV among American Indian and Alaska Native children: 2019 to 2020
.
Pediatrics
.
2023
;
152
(
2
):
e2022060435
22
Centers for Disease Control and Prevention
.
RSV in Alaska Native infants
. Available at: https://www.cdc.gov/rsv/research/aip.html. Accessed October 9, 2023
23
Heffernan
ME
,
Bendelow
A
,
Kociolek
LK
, et al
.
Targeted vaccine messaging to promote COVID-19 vaccines for children and youth
.
Pediatrics
.
2023
;
151
(
6
):
e2022059191
This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (https://creativecommons.org/licenses/by-nc-nd/4.0/), which permits noncommercial distribution and reproduction in any medium, provided the original author and source are credited.