RSV immunization program

Respiratory syncytial virus (RSV) is a common respiratory virus that can be severe for infants and older adults. Vaccinating these populations just before or during RSV season helps to prevent severe disease.

Changes to the RSV prevention program for 2024-25

Products

New this year is the arrival of the monoclonal antibody Beyfortus^TM (nirsevimab), for infants
- Based on real-world data from Europe and the United States for the 2023 RSV season, nirsevimab was 80 to 90 per cent effective in preventing hospitalizations from RSV
The vaccine Abrysvo^TM (RSVpreF) is the publicly funded vaccine for older adults and pregnant individuals who choose not to accept Beyfortus^TM for their infant

Eligibility

All infants born in 2024 and through the 2024-25 RSV season are now eligible for immunization, not just those at high risk
Residents of retirement homes have been added to the list of eligibility for adults 60+
Read the full list of those eligible for publicly-funded RSV immunization

To identify infants and high-risk children in your practice who are eligible for RSV immunization, consider using OMD’s EMR queries.

Administration

Beyfortus^TMand Abrysvo^TM can be co-administered with other vaccines. There is no need to separate them for safety signals

Who is covered for RSV immunization under the publicly funded program?

All infants born in 2024 and through the 2024/2025 RSV season will be eligible for immunization against RSV. The active RSV season is typically November to March.

In addition, children up to 24 months of age who are high risk due to health conditions are eligible. This includes children with:

Chronic lung disease of prematurity (CLD), including bronchopulmonary dysplasia, requiring ongoing assisted ventilation, oxygen therapy or chronic medical therapy in the 6 months prior to the start of RSV season
- Note: Children who were less than 12 months of age and approved for coverage in the previous RSV season for chronic lung disease and bronchopulmonary dysplasia remain eligible
Hemodynamically significant congenital heart disease (CHD) requiring corrective surgery or are on cardiac medication for congestive heart failure or diagnosed with moderate to severe pulmonary hypertension
Severe immunodeficiency
Down Syndrome / Trisomy 21
Cystic fibrosis with respiratory involvement and/or growth delay
Severe congenital airway anomalies impairing the clearing of respiratory secretions

The product to be used for all eligible infants is Beyfortus^TM. It can be given alongside other vaccines during routine childhood vaccine visits.

Beyfortus^TM is only available through the publicly-funded program; it is not available on the private market this year, so individuals cannot choose to purchase it.

Pathways for administration to infants

Infants born in hospital during RSV season, likely starting mid-October: immunized in hospital prior to discharge
Infants born in 2024 before the start of RSV season or those born outside of hospital: immunized by primary care
Children up to 24 months of age who are high risk due to health conditions : immunized by pediatric specialists, primary care, or outpatient hospital clinics

Immunizing the infant directly with Beyfortus^TM is preferred; however, when parents or guardians are unwilling to accept Beyfortus^TM for the infant, the pregnant individual can be vaccinated for passive protection of the infant.  

Pregnant individuals in the third trimester of pregnancy (from 32 to 36 weeks gestation) who will deliver near the start of or during RSV season are eligible for an RSV vaccine. The product to be used is Abrysvo^TM.

If the infant will be receiving Beyfortus^TM, there is no added benefit to the pregnant individual receiving Abrysvo^TM.

Publicly funded RSV vaccines are available for people 60+ years who are:

Residents of long-term care homes, Elder Care Lodges, or retirement homes
Patients in hospital receiving alternate level of care (ALC) including similar settings (e.g. complex continuing care, hospital transitional programs)
Patients receiving hemodialysis or peritoneal dialysis
Recipients of solid organ or hematopoietic stem cell transplants
People experiencing homelessness
People who identify as First Nations, Inuit, or Metis

Abrysvo^TM is the available vaccine this year for individuals 60+. Older adults who are vaccinated early in the season may be offered the Arexvy^TM vaccine, leftover from last year’s supply.

Adults not covered by the publicly funded program

NACI’s statement on the prevention of RSV disease in older adults strongly recommends that all adults 75+ years with health conditions that put them at high risk for severe RSV disease receive an RSV vaccine.

NACI also recommends that adults 60 to 74 years of age may consider an RSV vaccine in consultation with their health-care provider.

Accessing an RSV vaccine privately

Adults who are not eligible for an RSV vaccine through the public program and would like to access the vaccine can purchase it at a pharmacy with a valid prescription. Pharmacists are authorized to administer the RSV vaccine.

Ordering

All publicly-funded RSV products are expected to be available through Public Health Units starting in August 2024. Contact your Public Health Unit for more ordering information.

Billing

The information below is a general summary. For full details, refer to the OHIP Schedule of Benefits for Physician Services. If you are unsure how to bill, please contact the ministry’s Service Support Contact Centre (SSCC) at SSContactCentre.MOH@ontario.ca or 1-800-262-6524. You can also contact the OMA response centre at info@oma.org.

Administration of an RSV immunization

Use OHIP fee code G538 (other immunizing agents)
G538 is an "in-basket" service for physicians in a family health organization (FHO) and family health network (FHN) physicians.
G538 includes the provision of routine information and counselling related to immunizations.
G538 is only eligible for payment if the injection is personally administered by the physician or by a delegate that meets the billing criteria for delegated procedures, in accordance with the conditions described in the Schedule of Benefits for Physician Services.

Fee code: G700 (basic fee) + G538 (other immunizing agents)

Note: If the RSV monoclonal antibody or vaccine is the sole reason for the visit, G700 may be eligible for payment in addition to G538. Eligibility requirements for G700 are on page J3 of the current OHIP Schedule of Benefits for Physician Services.

If you are administering the RSV monoclonal antibody or vaccine at the same time as another vaccine, you can bill G538 for the RSV product in addition to the applicable vaccine fee codes. If these two vaccines are the sole reason for the patient’s visit, G700 can be applied to the visit.

Service: Appropriate assessment fee code (for example, A007 for intermediate assessment or well baby care) + G538 (other immunizing agents)

Service: Appropriate assessment fee code, e.g., H001/H261 (newborn care in hospital and/or home) + G538 (other immunizing agents)

Service: Appropriate individual counselling code (e.g., K013)* + G538 (other immunizing agents)

* One unit of counselling = one-half hour or major part thereof (minimum time requirement for first unit is at least 20 minutes)

NOTE: To be eligible for payment using the K013 individual counselling code, the visit must be pre-booked as a counselling visit, which is a visit dedicated solely to an educational dialogue with a physician.

For example, if a parent comes in for a well-baby visit and a second appointment is required to provide education around vaccine safety and efficacy, a second visit could be booked as a counselling visit and billed using the K013 individual counselling code.

If the visit is not pre-booked as a counselling visit, the amount payable will be adjusted to a lesser assessment fee.

For more information on billing counselling codes, refer to the Schedule of Benefits or page 14 of this OHIP brief on assessments and consultations.

Legal disclaimer: Every effort has been made to ensure that the contents of this page are accurate. Members should, however, be aware that the laws, regulations and other agreements may change over time. The Ontario Medical Association assumes no responsibility for any discrepancies or differences of interpretation of applicable Regulations with the Government of Ontario including but not limited to the Ministry of Health (MOH), and the College of Physicians and Surgeons of Ontario (CPSO). Members are advised that the ultimate authority in matters of interpretation and payment of insured services (as well as determination of what constitutes an uninsured service) are in the purview of the government. Members are advised to request updated billing information and interpretations – in writing – by contacting their regional OHIP office.