1. Respiratory Syncytial Virus Prophylaxis The 2010-2011 criteria
Chuck Hui MD FRCPC
Paediatric Infectious Diseases
Assistant Professor of Paediatrics 1

2. Objectives Review the basics of RSV
Understand the ways to prevent RSV transmission
Discuss the MOHLTC Ontario criteria for palivizumab approval

3. What is RSV? RNA paramyxovirus Humans are only source
2 strains – A and B
Often circulate concurrently
Humans are only source
Almost all children infected at least once by 2yrs of age
Re-infection is common
Presents as a common URI in older children and adults

4. Epidemiology Annual season in Canada Viral shedding 3-8 days
November to April
Viral shedding 3-8 days
May be longer in young and immunosuppressed
Incubation period 2-8 days
Supportive care, no good treatment

5. Burden of RSV in Young Children
Population based study in children < 5yrs
ER ( ); Pediatric offices ( )
5067 enrolled; 919(18%) RSV infections; RSVH overall (11%)
RSV associated with: 18% ER visits
15% office visits (3X ER)
Average RSVH: 17/1000 <6 months of age
3/1000 < 5 years of age
Hall CB et al. NEJM 2009;360:

6. Burden of RSV in Young Children
Majority of children had no underlying medical illness
Only risk factors identified: < 2 years of age, history of prematurity
Under 5 yrs of age RSV results in:
1 of 38 visits to the ER
1 of 13 visits to a primary care (FD) office
Hall CB et al. NEJM 2009;360:

7. How can we prevent RSV transmission?

8. RSV nosocomial outbreaks recognized 1970s
transmission established 1981!!
Hall and Douglas, J Pediatr 1981;99:
3 plausible routes: aerosol, droplet, contact
31 volunteers: cuddlers, touchers, sitters
71% of cuddlers, 40% touchers, 0% sitters developed culture confirmed infection
RSV – illness first described in 1941 (Adams, JAMA); virus identified 1961
Hall – 7 cuddlers (gowns only), 10 touchers, 14 sitters (gowns, gloves, no masks)

9. RSV 107 virus particles per mL of nasal discharge in children
infectious dose - ??
survives on inanimate
objects
for prolonged
periods of time
Goldman PIDJ 2000;19:S97-102

11. Risk factors for RSV hospitalization worldwide
Exposure
Age at start of RSV season
Siblings
Crowding at home
Day care attendance
Day care attendance of siblings
Discharge between October and December
Social Factors
Breast feeding
Physiologic Factors
Low birth weight
Male sex
Family history of wheezing
CLD
Neurologic problems
Birth order >2nd
Eur J Clin Microbiol Infect Dis (2008) 27:891–899

12. Background Palivizumab Efficacy
IMPACT Pediatrics 1998

13. Efficiencies of Sharing Vials
Palivizumab is expensive!
50mg - $752.26
100mg - $1,504.51
The Cost and Safety of Multidose Use of Palivizumab Vials
446 vials - $ savings
One vial had bacterial contamination
16% cost savings
Gooding J et al. Clin Pediatr (Phila) 2008 Mar;47(2):160-3.
Wills S Arch. Dis. Child. 2006;91;717

14. Requests that Satisfy the Recommendations of NACI 2003 and CPS 2009
Infants born prematurely at ≤ 32 completed weeks gestation and aged ≤ 6 months at the start of, or during, the local RSV season
Children < 24 months of age with bronchopulmonary dysplasia (BPD)/chronic lung disease (CLD) AND who required oxygen and/or medical therapy within the 6 months preceding the RSV season
Children < 24 months of age with hemodynamically significant cyanotic or acyanotic congenital heart disease (requiring corrective surgery or on cardiac medication for hemodynamic considerations).

15. Infants who live in isolated communities
Requests that Satisfy the Advice from the Ontario RSV Prophylaxis for High-Risk Infants Advisory Group
Infants in the Completed Weeks (33 weeks and 0 days to 35 weeks and 6 days) Gestational Age Cohort and Aged ≤ 6 Months at the start/during the local RSV season
Infants who live in isolated communities
Infants who do not live in isolated communities
Requests for these infants (33-35 completed weeks) must include a completed Risk Assessment Tool signed by the requesting physician.
Siblings in the Same Multiple Birth Set of a High-Risk Infant
Infants with Down Syndrome/Trisomy 21

16. Variables in the final Logistic Regression Model (Risk Scoring Tool- PICNIC Study)
Variable Score
SGA (GA <10%) [ Yes/No ] 12
Gender (Male/Female)
Birth Month (Nov,Dec,Jan)
Subject or Siblings in Day Care [ Yes/No ] 17
Family History without eczema [ Yes/No ] 12
>5 individuals in the home counting
the subject [ Yes/No ]
Two or more smokers in the house [Yes/No ] 10
Total

17. CONSIDERATION OF SPECIAL CLINICAL CIRCUMSTANCE Individual Patient Case Reviews
Requests for high-risk infants that do not satisfy the above approval criteria will be considered by the ministry’s expert clinicians in RSV prophylaxis
These requests must state the patient’s specific medical illness, include a letter from the requesting physician detailing the clinical rationale, AND a supporting letter from either an infectious disease specialist or a neonatologist or a respirologist
Potential special requests:
Upper airway diseases
Immunodeficiency
Cystic fibrosis

19. Hema Quebec Guidelines
Same
<33 wks
BPD/CLD
CHD
33-35 wk
RAT moderate or high
Different
Yes Transplant patients
Down syndrome – special request

20. Wash your hands!