In 1967, infants and toddlers immunized with a formalin-inactivated vaccine against respiratory syncytial virus (RSV) experienced an enhanced form of RSV disease characterized by high fever, bronchopneumonia, and wheezing when they became infected with wild-type virus in the community. Hospitalizations were frequent, and two immunized toddlers died upon infection with wild-type RSV. The enhanced disease was initially characterized as a "peribronchiolar monocytic infiltration with some excess in eosinophils." Decades of research defined enhanced RSV disease (ERD) as the result of immunization with antigens not processed in the cytoplasm, resulting in a nonprotective antibody response and CD4؉ T helper priming in the absence of cytotoxic T lymphocytes. This response to vaccination led to a pathogenic Th2 memory response with eosinophil and immune complex deposition in the lungs after RSV infection. In recent years, the field of RSV experienced significant changes. Numerous vaccine candidates with novel designs and formulations are approaching clinical trials, defying our previous understanding of favorable parameters for ERD. This review provides a succinct analysis of these parameters and explores criteria for assessing the risk of ERD in new vaccine candidates. R espiratory syncytial virus (RSV) is the leading respiratory cause of hospitalization in infants and young children in the United States and in the world (1, 2). Most severe infections occur in young infants, with the peak incidence of lower respiratory tract illness (LRTI) occurring between 2 and 4 months of age (3-5). In the United States, hospitalization rates have risen during the last decades (6), and while premature babies and infants with chronic lung disease and/or congenital heart disease are at increased risk for severe presentations, the majority of hospitalizations occur in previously healthy infants. Recent estimates of global mortality suggest that between 66,000 and 234,000 infants and young children die every year due to RSV (1, 2). Ninety-nine percent of deaths occur in the developing world (2). A significant proportion of these fatalities are thought to occur in the community. The need for preventive interventions against the virus is indisputable.The virus. RSV is a member of the pneumovirus genus of the family Paramyxoviridae. The virus is a negative-sense RNA virus with a nonsegmented encapsidated genome and a lipid envelope (7). The envelope is a host plasma membrane-derived lipid bilayer containing three virally encoded transmembrane glycoproteins: the fusion (F) protein, the attachment (G) protein, and the small hydrophobic (SH) protein. RSV F is the main neutralizing antigen, highly conserved and essential for virus viability (7). The secondary protective antigen eliciting neutralizing antibodies is the RSV G protein. Both neutralizing antigens are the main candidates for novel vaccines and targets for monoclonal antibodies.A new scenario. The world of RSV vaccines is experiencing important changes. In recent years, epidemiologic...