Palivizumab: a debate about funding

Bronchopulmonary dysplasia: A review of the pulmonary sequelae in the post-surfactant era

We describe the respiratory complications of bronchopulmonary dysplasia (BPD) in childhood and adolescence. The pathophysiology of bronchopulmonary dysplasia has evolved in the era of modern neonatal intensive care. In this review, we aim to summarise the contemporary evidence base and describe the common respiratory morbidities related to BPD including; home oxygen therapy, rehospitalisation, asthma and exercise limitation.

Effectiveness of Palivizumab against Respiratory Syncytial Virus: Cohort and Case Series Analysis

OBJECTIVE

To measure the real-world effectiveness of palivizumab immunoprophylaxis against respiratory syncytial virus (RSV)-confirmed infection before age 2 years in a population-cohort of high-risk infants.

STUDY DESIGN

Palivizumab is funded for high-risk infants in Western Australia. We used probabilistically linked administrative data encompassing RSV laboratory-confirmed infections, hospital admissions, and palivizumab dispensing records for a cohort of 24 329 high-risk infants admitted to neonatal intensive care units, born 2002-2013 with follow-up to 2015. We used a traditional cohort method with Cox proportional hazards regression and a self-controlled case series analysis to assess effectiveness of palivizumab in reducing RSV-confirmed infection by number of doses.

RESULTS

From the cohort of 24 329 infants, 271 (1.1%) received at least 1 dose of palivizumab and 1506 (6.2%) had at least 1 RSV-confirmed infection before age 2 years. Using the traditional cohort approach, we found no protective association of palivizumab receipt with RSV detection (adjusted hazard ratio = 0.99 [95% CI 0.5, 1.9] for 1 dose). However, using a self-controlled case series to eliminate confounding by indication, a protective association was seen with a 74% lower RSV incidence (relative incidence = 0.26; 95% CI 0.11, 0.67) following any dose of palivizumab compared with control (nonexposed) periods.

CONCLUSIONS

After accounting for confounding by indication through a self-controlled analysis, palivizumab appeared effective for reducing virologically confirmed RSV in this high-risk cohort.

A population study of respiratory rehospitalisation in very preterm infants in the first 3 years of life

AIM

Very premature infants consume healthcare resources following discharge from neonatal intensive care units (NICU). This study aimed to evaluate the burden of respiratory related rehospitalisation within the first 3 years post discharge in very premature infants in an Australian population.

METHODS

Rehospitalisation of a 4-year cohort of NICU survivors, born less than 32 weeks gestation, was derived from data linkage of three state-wide databases including NSW Neonatal Intensive Care Units' Data Collection, Admitted Patient Data Collection and the Death Registry. Rehospitalisation diagnoses were determined by ICD-10 AM codes.

RESULTS

Of the 2939 survivors, 525 (18%) had bronchopulmonary dysplasia (BPD) and 261 BPD infants (50%) were discharged on home oxygen. Almost two-third (1860, 63%) of the survivors are required rehospitalisation, respiratory causes, including 394 respiratory syncytial virus (RSV)-related, accounted for 2668 (48%) of the 5599 rehospitalisations. Significantly more home oxygen BPD survivors had respiratory (70%) and RSV-related (22%) rehospitalisations than the BPD infants not needing home oxygen (58% and 18%, respectively), and the survivors without BPD had the lowest rates (32% and 10%, P < 0.001). Most respiratory (61%) and RSV-related (74%) rehospitalisations occurred during the first 12 months post discharge. No RSV-related fatality occurred. Amongst the total 17 562 hospital days, respiratory and RSV-related admissions accounted for 10 905 (62%) and 3031 (17.2%) days. In multivariable logistic analyses, home oxygen and maternal indigenous status were independently associated with high (3 or more) respiratory and RSV rehospitalisation rates.

CONCLUSIONS

Respiratory rehospitalisations are common in very premature survivors. Home oxygen and indigenous status are significant risk factors for respiratory and RSV-related rehospitalisations.

Should respiratory care in preterm infants include prophylaxis against respiratory syncytial virus? The case against

Preterm infants are at increased risk of severe respiratory syncytial virus (RSV) infection. The monoclonal antibody palivizumab reduces the frequency of preterm infants being admitted to hospital with RSV infection. However, palivizumab is expensive, has to be given by intramuscular injection monthly for 5 months and has to be given prophylactically to 17 preterm children to prevent one hospital admission with RSV and to 59 children to prevent one intensive care admission. Cost-effectiveness analyses have not shown that palivizumab is cost-effective for any sub-group with sufficient certainty to recommend its public funding. Palivizumab will only be cost-effective if the price drops. Paying for palivizumab is an opportunity cost; the money could be spent better on other more cost-effective health care interventions. Palivizumab should not be prescribed for any preterm child unless it can be shown to be cost-effective in that situation.