Challenges in the prevention or treatment of RSV with emerging new agents in children from low- and middle-income countries

ABSTRACT

Introduction

Respiratory syncytial virus (RSV) causes approximately 120,000 deaths annually in children <5 years, with 99% of fatalities occurring in low- and middle-income countries (LMICs).

Areas covered

There are numerous RSV interventions in development, including long-acting monoclonal antibodies, vaccines (maternal and child) and treatments which are expected to become available soon. We reviewed the key challenges and issues that need to be addressed to maximize the impact of these interventions in LMICs. The epidemiology of RSV in LMICs was reviewed (PubMed search to 30 June 2020 inclusive) and the need for more and better-quality data, encompassing hospital admissions, community contacts, and longer-term respiratory morbidity, emphasized. The requirement for an agreed clinical definition of RSV lower respiratory tract infection was proposed. The pros and cons of the new RSV interventions are reviewed from the perspective of LMICs.

Expert opinion

We believe that a vaccine (or combination of vaccines, if practicable) is the only viable solution to the burden of RSV in LMICs. A coordinated program, analogous to that with polio, involving governments, non-governmental organizations, the World Health Organization, the manufacturers and the healthcare community is required to realize the full potential of vaccine(s) and end the devastation of RSV in LMICs.

KEYWORDS:

• Bronchiolitis
• developing countries
• immunization
• lower respiratory tract infection
• monoclonal antibodies
• prophylaxis
• respiratory syncytial virus
• treatment
• vaccination
• vaccine

Article Highlights

• In LMICs, approximately 30.5 million cases of acute RSV LRTI occur annually, resulting in 2.6 million hospitalizations and 120,000 deaths

• Only 41% (20/49) of least developed and other low-income countries, 62% (23/37) of lower-middle-income countries, and 61% (34/56) of upper-middle-income countries have published data on the burden of RSV

• A pragmatic approach to diagnose RSV LRTI in LMICs is use of an agreed set of clinical parameters (e.g. age <6 months; oxygen saturation <90%; tachypnea; nasal flaring and/or grunting; apnea; chest retractions; dehydration; poor feeding; cyanosis; lethargy; rales/rhonchi). Development and validation of a clinical score should be a priority. Confirmatory tests on nasopharyngeal swabs and/or nasal wash should be used if available, in particular, for severely ill infants/those in intensive care

• Despite positive efficacy and safety data, logistical issues will likely limit the use of RSV monoclonal antibodies in LMICs unless they are priced cheaply

• Maternal or child vaccines are the only realistic solution for combating RSV in LMICs, although issues around duration of protection and the need for booster doses needs to be resolved

• A coordinated international RSV vaccine program should form part of a wider initiative to tackle poverty and improve healthcare in LMICs

Acknowledgments

Dr John Fullarton provided a final proof read of the article.

Declaration of interest

XCE and BP have received research funding and/or compensation as advisor/lecturer from AbbVie. BRG, working for Strategen, has previously received payment from AbbVie for work on various projects.

Supplemental material

Supplemental data for this article can be accessed here.

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

This paper was not funded.