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Can We Be RSV Free? Nirsevimab Implementation in Neonatal Care

January 29, 2025

Imagine the pre-rotavirus vaccine era. Veteran pediatricians will tell you of a time hallways were filled with that oh-so-distinct odor of rotavirus diarrhea. Then, almost overnight, the tide shifted. Thanks to the rotavirus vaccine, the stench disappeared, and during my own pediatric residency training at a bustling tertiary care children’s hospital, I only encountered two cases. While not a vaccine, many wonder if the advent of the monoclonal antibody nirsevimab will result in reduced respiratory syncytial virus (RSV) associated lower respiratory tract disease. Will there be a time when I will be one of those veteran pediatricians talking about the history of the annual onslaught of RSV bronchiolitis? In order to see if time will tell, we need strategies on how to implement nirsevimab in pediatric care settings. Puckett et al. describe exactly that in their article “Successful Implementation of Nirsevimab and Factors Influencing Uptake in Neonatal Care” (10.1542/hpeds.2024-008070).

Puckett’s team implemented a universal immunization campaign at a single quaternary care center to all eligible infants, including those discharged from the newborn nursery, the intermediate care nursery, and the neonatal intensive care unit. Per the Advisory Committee on Immunization Practices (ACIP) and the American Academy of Pediatrics (AAP), eligible patients are those that were less than 8 months of age born during or entering their first RSV season and children 8-19 months of age with certain risk factors who are at increased risk of severe RSV and entering their second RSV season. Using key tenants for quality improvement work, her team identified the key drivers and barriers to successful implementation. The campaign was driven by effective stakeholder engagement, education for staff and caregivers, and perhaps most importantly, seamless integration into electronic health records. What is also important to highlight in their work is their prioritization of equity and access as one of their motivations to facilitate nirsevimab administration while infants were inpatient. Their team recognized that there may be disparities in community availability and the risk of loss to follow up for some families.

How effective was Puckett’s group at identifying eligible patients in their 461-bed quaternary care hospital with 5,000 infants delivered per year? Quite effective. Of the 2,181 patients discharged during the nirsevimab eligibility period (October 2023-April 2024), a little over half of these patients were deemed eligible for administration. Puckett’s group offered nirsevimab to an astounding 99% of eligible infants with 71% receiving the monoclonal antibody. The following were found to be predictors of deferral: English as the preferred language, deferral of Hepatitis B vaccine, discharge from the newborn nursery, and having public insurance. Their group plans to use the predictors of deferral to re-invigorate their campaign for the current RSV season. Their approach serves as a model for other institutions to offer nirsevimab prior to hospital discharge. For anyone interested in understanding how system-wide change happens, Puckett et al.’s article is a must read. It’s a clear reminder that with the right strategies and dedication, we can change the trajectory of RSV—just as we did with rotavirus.

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