Since the initial isolation in 1956 of what is now identified as respiratory syncytial virus (RSV), seasonal outbreaks of illness attributable to this enigmatic respiratory virus have troubled generations of pediatricians and parents because of the absence of therapeutic options other than supportive care.1 Recognition that RSV infection is the most common cause of hospitalization among children in the first 12 months of life resulted in numerous attempts to prevent or treat this disease. Three distinct avenues have been explored: antiviral therapy, passive immunity with hyperimmune globulins and monoclonal antibodies, and active immunity with vaccines. After >65 years of investigation, 2 types of effective and practical disease prevention finally are available (Table 1).
The report in this issue of Pediatrics reveals important recommendations from the Advisory Committee on Immunization Practices regarding an improved option for RSV prophylaxis for infants and young children.2
Ribavirin, a synthetic nucleoside...
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RSV Prevention Equity in Practice
I am now the medical director of an academic newborn nursery. The past three months have been consumed with discussions of RSV prevention for infants, specifically with postnatal injection of nirsevimab (Beyfortus) or prenatal vaccination of pregnant people with RSVpreF vaccine (Abrysvo).2 I keep thinking about that starfish poster.
Oblique references to “equity” surface in my meetings, webinars, listserv threads, emails and conversations with colleagues. Physicians and administrators debate “eligibility criteria.” Discussions about equitable distribution end with reference to the inclusion of nirsevimab in the Vaccines for Children program – a laudable program which reduces financial barriers to immunization for children who are Medicaid eligible, uninsured, American Indian, Alaskan Native or underinsured.3 And yet I worry about the opportunity cost of these conversations. Are we no better than the two figures on the beach, debating which starfish to pick?
Here is the truth about pediatrics you can put on a poster: Pediatrics is the field where you learn all the ways a child can die (a quote from my father when I chose this field), and RSV is the etiology that causes the most hospitalizations in the first 12 months of life. When you announce a drug that can “prevent RSV”, every pediatrician sees a child in their mind – it’s the last child they intubated, or the first; it’s the way a chest wall stops rhythmically breathing and only shudders; it’s a nightmare we dread when we become parents ourselves. As a field, we are emotionally primed to desperately throw starfish back into the sea. And yet, no matter the number needed to treat or cost effectiveness per quality adjusted life year, 99% of RSV-associated deaths in the world will happen outside the reach of our institutional eligibility criteria, outside VFC, and outside the (challenged) distribution channels of a single manufacturer of postnatal immunoglobulin. 4, 5
I am not trying to personify the utilitarian pessimist of the starfish story; I am imploring us to widen our view. As one newborn hospitalist, what can I do? I can ensure attention to these novel interventions does not inadvertently detract from investment in equitable breastfeeding initiatives (human milk being the “original” postnatal passive immunoglobulin). I can advocate for accessible maternal vaccination at my institution. I will tell my learners to be unimpressed when I throw a starfish back into the sea; I will tell them, challenge me (us) to turn the tide.