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However, post-hoc stratified analyses identified an excess of preterm births in the intervention arm in two upper-middle-income countries, most prominently in South Africa. This study weighs the potential benefits and risks in mortality associated with maternal RSV vaccination in South Africa, assuming the increased risk of preterm births observed in the trial was caused by vaccination.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec002\">\n                    <jats:title>Methods and findings<\/jats:title>\n                    <jats:p>We compared the estimated RSV-associated infant deaths averted by vaccination (benefits) and neonatal mortality potentially associated with vaccine-associated risk in preterm birth (risks) in South Africa. The benefit model estimated the South African RSV disease burden in 2011\u22122016 and waning vaccine protection during infancy. The risk model estimated excess neonatal mortality using gestational age (GA)-specific mortality data from the Drakenstein Child Health Study and the GA-specific birth distribution in South Africa in the MATISSE trial, but did not incorporate the mortality risk found in the MATISSE vaccine trial in which no excess deaths occurred.<\/jats:p>\n                    <jats:p>The benefit model estimated that vaccination would reduce RSV-associated infant deaths by 31 (95% credible interval (Crl): 27, 35) per 100,000 live births born to vaccinated mothers in South Africa. Using the number of infants born to mothers vaccinated at 24\u201336 GA weeks in the MATISSE trial, if the association in South Africa between vaccination and preterm birth is actually causal, the risk model suggested that neonatal deaths would increase by 44 (95%CrI: \u221243, 210), totaling 1.4 (95%CrI: \u22121.4, 6.9) excess neonatal deaths for every infant RSV death prevented. When this was changed to the number of infants born to mothers vaccinated at 27\u201336 GA weeks in the MATISSE trial, the predicted risks dropped and in 97% of the simulations the benefits outweighed the risks. The outcome was sensitive to the GA window that we used to determine which infants to include in the analysis. The study was limited by only considering mortality associated with RSV disease and preterm birth.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec003\">\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>If RSVpreF increases preterm birth risk, and if this increases neonatal mortality, then the benefit-risk analysis failed to show that the direct benefits of vaccination in reducing RSV-associated infant mortality would substantially outweigh the risks of preterm birth-associated neonatal mortality in South Africa with vaccination from 24 GA to 36 GA weeks. There was large uncertainty in the analyses due to small numbers of preterm births. With vaccination from 27 GA weeks, the benefit-risk analysis favored vaccination. RSVpreF vaccination has the potential to be safe and effective when used from the third trimester.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1371\/journal.pmed.1004625","type":"journal-article","created":{"date-parts":[[2026,1,20]],"date-time":"2026-01-20T18:28:14Z","timestamp":1768933694000},"page":"e1004625","update-policy":"https:\/\/doi.org\/10.1371\/journal.pmed.corrections_policy","source":"Crossref","is-referenced-by-count":5,"title":["The benefits and risks of maternal RSV vaccination on mortality in South Africa: A modeling study"],"prefix":"10.1371","volume":"23","author":[{"ORCID":"https:\/\/orcid.org\/0009-0000-8499-2526","authenticated-orcid":true,"given":"Ayaka","family":"Monoi","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6377-7296","authenticated-orcid":true,"given":"Akira","family":"Endo","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0380-1503","authenticated-orcid":true,"given":"Simon R.","family":"Procter","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6585-2824","authenticated-orcid":true,"given":"Sequoia I.","family":"Leuba","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5808-2606","authenticated-orcid":true,"given":"Stefan","family":"Flasche","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6658-8255","authenticated-orcid":true,"given":"Mark","family":"Jit","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"name":"Maternal RSV Vaccine Benefit-Risk Advisory Group","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2026,1,20]]},"reference":[{"issue":"10340","key":"pmed.1004625.ref001","doi-asserted-by":"crossref","first-page":"2047","DOI":"10.1016\/S0140-6736(22)00478-0","article-title":"Global, regional, and national disease burden estimates of acute lower respiratory infections due 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RSVVW\u201924"},{"issue":"2","key":"pmed.1004625.ref012","doi-asserted-by":"crossref","first-page":"147","DOI":"10.1097\/AOG.0000000000005817","article-title":"Preterm birth frequency and associated outcomes from the MATISSE (Maternal Immunization Study for Safety and Efficacy) maternal trial of the bivalent respiratory syncytial virus prefusion F protein vaccine","volume":"145","author":"SA Madhi","year":"2025","journal-title":"Obstet Gynecol"},{"key":"pmed.1004625.ref013","unstructured":"Monoi A, Endo A, Procter S, Leuba S, Flasche S, Jit M, et al. Benefit-risk analysis of maternal vaccination in South Africa [Internet]. Hybrid presented at: SAGE meeting. Strategic Advisory Group of Experts on Immunization 23-26 September 2024; 2024 9 [cited 2024 Oct 9]; Geneva, Switzerland. Available from: https:\/\/terrance.who.int\/mediacentre\/data\/sage\/SAGE_Slidedeck_September-2024.pdf"},{"issue":"11","key":"pmed.1004625.ref014","doi-asserted-by":"crossref","first-page":"1009","DOI":"10.1056\/NEJMoa2305478","article-title":"RSV prefusion F protein-based maternal vaccine\u2014preterm birth and other outcomes","volume":"390","author":"I Dieussaert","year":"2024","journal-title":"N Engl J Med"},{"key":"pmed.1004625.ref015","doi-asserted-by":"crossref","DOI":"10.4324\/9781315166414","volume-title":"Vaccination programmes: epidemiology, monitoring, evaluation [Internet]","author":"S Hahn\u00e9","year":"2021","edition":"1"},{"issue":"11","key":"pmed.1004625.ref016","article-title":"Maternal health and birth outcomes in a South African birth cohort study","volume":"14","author":"HJ Zar","year":"2019","journal-title":"PLoS One"},{"key":"pmed.1004625.ref017","volume-title":"R: a language and environment for statistical computing. [Internet]","author":"R Core Team","year":"2023"},{"key":"pmed.1004625.ref018","unstructured":"Feikin D. Overview of the RSVPreF Maternal vaccine [Internet]. SAGE meeting. Strategic Advisory Group of Experts on Immunization 23-26 September 2024; 2024 09 [cited 2024 Oct 9]; Geneva, Switzerland. Available from: https:\/\/terrance.who.int\/mediacentre\/data\/sage\/SAGE_Slidedeck_September-2024.pdf"},{"issue":"2","key":"pmed.1004625.ref019","doi-asserted-by":"crossref","first-page":"157","DOI":"10.1097\/AOG.0000000000005816","article-title":"Efficacy, safety, and immunogenicity of the MATISSE (Maternal Immunization Study for Safety and Efficacy) maternal respiratory syncytial virus prefusion F protein vaccine trial","volume":"145","author":"EAF Sim\u00f5es","year":"2025","journal-title":"Obstet Gynecol"},{"key":"pmed.1004625.ref020","unstructured":"World Health Organization. WHO position paper on immunization to protect infants against respiratory syncytial virus disease, May 2025 [Internet]. 2025 May [cited 2025 Oct 28] p. 193\u2013218. Report No.: 22. Available from: https:\/\/www.who.int\/publications\/i\/item\/who-wer-10022-193-218"},{"issue":"1","key":"pmed.1004625.ref021","doi-asserted-by":"crossref","first-page":"95","DOI":"10.1093\/cid\/cix740","article-title":"In- and out-of-hospital mortality associated with seasonal and pandemic influenza and respiratory syncytial virus in South Africa, 2009\u20132013","volume":"66","author":"C Cohen","year":"2018","journal-title":"Clin Infect Dis"},{"key":"pmed.1004625.ref022","article-title":"Neonatal mortality risk of vulnerable newborns by fine stratum of gestational age and birthweight for 230 679 live births in nine low\u2010 and middle\u2010income countries, 2000\u20132017","author":"EA Hazel","year":"2024","journal-title":"BJOG"},{"key":"pmed.1004625.ref023","unstructured":"The American College of Obstetricians and Gynecologists\u2019 Committee on Obstetric Practice. Methods for estimating the due date; 2017 May. Report No.: Number 700."},{"key":"pmed.1004625.ref024","unstructured":"World Health Organization. Meeting of the Strategic Advisory Group of Experts on Immunization, September 2024: conclusions and recommendations [Internet]. 2024 Dec [cited 2025 Oct 28] p. 719\u201340. Report No.: 99 (49). Available from: https:\/\/iris.who.int\/handle\/10665\/379718"},{"issue":"10","key":"pmed.1004625.ref025","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pmed.1001330","article-title":"Removing the age restrictions for rotavirus vaccination: a benefit-risk modeling analysis","volume":"9","author":"MM Patel","year":"2012","journal-title":"PLoS Med"},{"issue":"10","key":"pmed.1004625.ref026","doi-asserted-by":"crossref","DOI":"10.1016\/S2214-109X(20)30308-9","article-title":"Routine childhood immunisation during the COVID-19 pandemic in Africa: a benefit-risk analysis of health benefits versus excess risk of SARS-CoV-2 infection","volume":"8","author":"K Abbas","year":"2020","journal-title":"Lancet Glob Health"},{"key":"pmed.1004625.ref027","doi-asserted-by":"crossref","first-page":"100325","DOI":"10.1016\/j.jvacx.2023.100325","article-title":"Benefit-risk assessment of Covid-19 vaccine, MRNA (MRNA-1273) for males age 18-64 years","volume":"14","author":"ON Yogurtcu","year":"2023","journal-title":"Vaccine X"},{"issue":"1","key":"pmed.1004625.ref028","doi-asserted-by":"crossref","DOI":"10.1007\/BF00208786","article-title":"Status-quo and omission biases","volume":"5","author":"I Ritov","year":"1992","journal-title":"J Risk Uncertainty"},{"issue":"4","key":"pmed.1004625.ref029","doi-asserted-by":"crossref","first-page":"263","DOI":"10.1002\/bdm.3960030404","article-title":"Reluctance to vaccinate: omission bias and ambiguity","volume":"3","author":"R Ilanam","year":"1990","journal-title":"Jounal Behav Decis Mak"},{"key":"pmed.1004625.ref030","unstructured":"U.S. Centers for Disease Control and Prevention. RSV vaccine guidance for pregnant people [Internet]. Respiratory Syncytial Virus Infection (RSV); 2024 [cited 2024 Oct 26]. Available from: https:\/\/www.cdc.gov\/rsv\/hcp\/vaccine-clinical-guidance\/pregnant-people.html"},{"issue":"49","key":"pmed.1004625.ref031","doi-asserted-by":"crossref","first-page":"6047","DOI":"10.1016\/j.vaccine.2016.03.045","article-title":"Preterm birth: Case definition & guidelines for data collection, analysis, and presentation of immunisation safety data","volume":"34","author":"J-A Quinn","year":"2016","journal-title":"Vaccine"},{"key":"pmed.1004625.ref032","doi-asserted-by":"crossref","first-page":"154","DOI":"10.12688\/wellcomeopenres.19161.1","article-title":"Assessment of gestational age at antenatal care visits among Kenyan women to inform delivery of a maternal respiratory syncytial virus (RSV) vaccine in low- and middle-income countries","volume":"8","author":"JU Nyiro","year":"2023","journal-title":"Wellcome Open Res"},{"key":"pmed.1004625.ref033","unstructured":"EMA. A post-marketing safety study using a pregnancy registry to evaluate the safety of respiratory syncytial virus vaccine (ABRYSVOTM) exposure during pregnancy (C3671041) [Internet]. 2024 Jun [cited 2025 Feb 11]. Available from: https:\/\/catalogues.ema.europa.eu\/node\/4080\/administrative-details?utm_source=chatgpt.com"},{"key":"pmed.1004625.ref034","unstructured":"EMA. A rapid surveillance and cohort post-marketing safety study to evaluate the safety of respiratory syncytial virus vaccine (ABRYSVOTM) exposure during pregnancy in the United States (C3671027) [Internet]. 2024 May [cited 2025 Feb 11]. Available from: https:\/\/catalogues.ema.europa.eu\/node\/4016\/administrative-details"},{"key":"pmed.1004625.ref035","unstructured":"DeSilva M. Prenatal RSVpreF vaccine safety 2023\u20132024 respiratory season the vaccine safety datalink (VSD) [Internet]. 2025 Jun 25. Available from: https:\/\/www.cdc.gov\/acip\/downloads\/slides-2025-06-25-26\/04a-DeSilva-Mat-Peds-RSV-508.pdf"},{"key":"pmed.1004625.ref036","unstructured":"A phase-IV individually randomized, placebo-controlled trial on safety of RSVA\/B-preF vaccine in pregnant women and efficacy against severe RSV-associated lower respiratory tract infection in infants [Internet]; 2025 [cited 2025 Aug 8]. Available from: https:\/\/clinicaltrials.gov\/study\/NCT06955728"},{"key":"pmed.1004625.ref037","volume-title":"Impact of RSV infections on the health system [Internet]","author":"S Saha","year":"2023"},{"key":"pmed.1004625.ref038","volume-title":"Health Commemorates World Prematurity Awareness Month, 22 Nov [Internet]. The Lakes Hotel and Conference Center\u2014Benoni, Ekurhuleni: South African Government","year":"2023"},{"issue":"10409","key":"pmed.1004625.ref039","doi-asserted-by":"crossref","first-page":"1261","DOI":"10.1016\/S0140-6736(23)00878-4","article-title":"National, regional, and global estimates of preterm birth in 2020, with trends from 2010: a systematic analysis","volume":"402","author":"EO Ohuma","year":"2023","journal-title":"Lancet"},{"issue":"11","key":"pmed.1004625.ref040","doi-asserted-by":"crossref","first-page":"1050","DOI":"10.1056\/NEJMe2401072","article-title":"Maternal RSV vaccine\u2014weighing benefits and risks","volume":"390","author":"SA Rasmussen","year":"2024","journal-title":"N Engl J Med"},{"issue":"5","key":"pmed.1004625.ref041","doi-asserted-by":"crossref","first-page":"426","DOI":"10.1056\/NEJMoa1908380","article-title":"Respiratory syncytial virus vaccination during pregnancy and effects in infants","volume":"383","author":"SA Madhi","year":"2020","journal-title":"N Engl J Med"},{"issue":"7","key":"pmed.1004625.ref042","article-title":"Nonadjuvanted bivalent respiratory syncytial virus vaccination and perinatal outcomes","volume":"7","author":"M Son","year":"2024","journal-title":"JAMA Netw Open"},{"issue":"6","key":"pmed.1004625.ref043","doi-asserted-by":"crossref","first-page":"588","DOI":"10.1056\/NEJMoa0804877","article-title":"The burden of respiratory syncytial virus infection in young children","volume":"360","author":"CB Hall","year":"2009","journal-title":"N Engl J Med"}],"container-title":["PLOS Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pmed.1004625","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,1,20]],"date-time":"2026-01-20T18:28:27Z","timestamp":1768933707000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pmed.1004625"}},"subtitle":[],"editor":[{"given":"Annettee","family":"Nakimuli","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2026,1,20]]},"references-count":43,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2026,1,20]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pmed.1004625","relation":{},"ISSN":["1549-1676"],"issn-type":[{"value":"1549-1676","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,1,20]]}}}