Transcript Paediatric Review March 2006

Respiratory Syncytial Virus Prophylaxis
The 2010-2011 criteria
Chuck Hui MD FRCPC
Paediatric Infectious Diseases
Assistant Professor of Paediatrics
Objectives
• Review the basics of RSV
• Understand the ways to prevent RSV
transmission
• Discuss the MOHLTC Ontario criteria for
palivizumab approval
What is RSV?
• RNA paramyxovirus
– 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
Epidemiology
• Annual season in Canada
– 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
Burden of RSV in Young Children
• Population based study in children < 5yrs
• ER (2000-2004); Pediatric offices (2002-2004)
• 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;360:588-598
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;360:588-598
How can we prevent RSV transmission?
RSV
• nosocomial outbreaks recognized 1970s
• transmission established 1981!!
–
–
–
–
Hall and Douglas, J Pediatr 1981;99:100-102
3 plausible routes: aerosol, droplet, contact
31 volunteers: cuddlers, touchers, sitters
71% of cuddlers, 40% touchers, 0% sitters developed
culture confirmed infection
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
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
% reduction in hospitalization
Background
Palivizumab Efficacy
100
80
80
60
55
39
40
47
20
0
Overall
BPD
<32 wks
32-35 wks
IMPACT Pediatrics 1998
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 - $37 410 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
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).
Requests that Satisfy the Advice from the Ontario RSV
Prophylaxis for High-Risk Infants Advisory Group
Infants in the 33-35 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 HighRisk Infant
• Infants with Down Syndrome/Trisomy 21
Variables in the final Logistic Regression Model
(Risk Scoring Tool- PICNIC Study)
Variable
Score
SGA (GA <10%)
[ Yes/No ]
Gender (Male/Female)
Birth Month (Nov,Dec,Jan)
Subject or Siblings in Day Care [ Yes/No ]
Family History without eczema [ Yes/No ]
>5 individuals in the home counting
the subject [ Yes/No ]
Two or more smokers in the house [Yes/No ] 10
12
11
25
17
12
Total
100
13
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
Hema Quebec Guidelines
Same
• <33 wks
• BPD/CLD
• CHD
• 33-35 wk
– RAT moderate or high
Different
• Yes Transplant patients
• Down syndrome –
special request
Wash your hands!