RSV care in Europe versus low- and middle-income countries

Respiratory syncytial virus (RSV) is the most important virus identified in children with acute lower respiratory tract infection during the initial year of life.[1] Notwithstanding the major amount of hospitalisations caused by RSV in Europe, the burden of disease from RSV is disproportionately high in developing countries: more than 90% of RSV-associated respiratory tract infections and 99% of RSV-related childhood mortality occur in these settings.[2] Ms Mwanajuma Ngama, clinical officer in Kilifi, Kenya, and Dr Simon Drysdale, paediatric infectious diseases consultant in London, England, shared their knowledge and experiences on the differences in RSV care between high and low-middle income countries.

Availability of ICU beds                                                  In contrast to England and the rest of Europe, intensive care units are scarce in low- and middle- income countries. Across Kenya, a country comprising an area of 580,367 square kilometres, there are only 10 public hospitals with an intensive care unit. Ms Ngama told us: ‘Our hospital in Kilifi, Kenya, doesn’t have an ICU. Children who are in urgent need for oxygen support are admitted to our high dependency unit, where we can offer high flow oxygen by use of a ventilator. The nearest hospital with an ICU is a one hour drive away. To be able to transfer a child to the ICU, we have to make sure that there is an ICU bed available, and that the child is stable enough to be transported. Often, we prefer to keep the child at our hospital.’ Dr Drysdale said: ‘In hospitals in the UK that don’t have an ICU, babies with RSV often have to be transferred to another hospital with an ICU. Fortunately, in the UK there is a well-established network for this. Occasionally, in severe RSV seasons, ICUs have to create additional beds to cope with the increased demand or babies have to be transferred from hospitals with ICUs that are full to those with free beds. I have, thankfully, never experienced a complete lack of ICU beds as may happen in some developing countries.’

Treatment and prevention
Although currently there is no cure or vaccine, children who are at high risk for RSV infection can receive Palivizumab to prevent severe infection. While this preventive drug is widely used in high income countries, its use is much less or even completely non-existent in low- and middle income countries. Ms Ngama said: ‘Unfortunately, Palivizumab is very expensive. Because many parents can’t afford it this is not being offered at our hospital.’ But the differences are not only confined to prophylaxis: ‘A lot of children who were admitted to the hospital because of RSV will have complaints of wheezing for many years afterwards’, Dr Drysdale told us. ‘While children in the UK have wide access to follow-up, this is significantly reduced in low income countries. Furthermore, the ability to test for RSV in these areas is also limited. While in the hospitals in the UK we often test for RSV when we suspect this diagnosis, doctors in developing countries will have to act on clinical symptoms only instead of obtaining a microbiology confirmed diagnosis.’

Vaccine development
Currently, there are several candidate vaccines against RSV in development, which are relatively close to becoming available for widespread use. In January 2021, the WHO chief Tedros Adhanom Ghebreyesus expressed his worries about the inequitable access of low- and middle-income countries to vaccines against COVID-19.[3] Dr Drysdale: ‘This COVID era reflects the unbalanced global access to new vaccines. This will probably also be the case regarding vaccines against RSV. When an effective RSV vaccine does make it to the drug market, it will be the Western high-income countries that stake their claim first, despite needing it less. I’m sure any vaccine will eventually also become available in low- and middle-income countries but slower than it probably should. Another important question will be, if a vaccine that is mainly tested in high-income countries will have similar efficacy in low- and middle-income countries.’ GAVI was created to improve access to new and under-used vaccines for millions of vulnerable children in low- and middle-income countries and undoubtedly will help provide them with any licensed and available RSV vaccine.[4] Although it is uncertain when we can expect a vaccine against RSV to become available, we hope that when it does it will become globally available, because all children’s lives have equal value.

Corline Parmentier, Sanne Truijen
On behalf of the RSV Patient Network

1: Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012; 380: 2095-2128
2: Shi T, McAllister DA, O’Brien KL, Simoes EAF, Madhi SA, Gessner BD, et al. Global, regional, and national disease burden estimates of acute lower respiratory infections due to respiratory syncytial virus in young children in 2015: a systematic review and modelling study. Lancet. 2017 Sep 2;390(10098):946-958.
3: BBC News: Covid vaccine: WHO warns of ‘catastrophic moral failure’. [internet] Available from: https://www.bbc.com/news/world-55709428 [Accessed 2nd February 2021].
4: Gavi: the Vaccine Alliance. https://www.gavi.org/