Prevention of respiratory syncytial virus infection in infantsBMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7447.1026 (Published 29 April 2004) Cite this as: BMJ 2004;328:1026
All rapid responses
As you wrote palivizumab is effective in preventing RSV
hospitalizations and admission to the intensive care unit (ICU), but not
in preventing mechanical ventilation. None controlled clinical trial has
demonstrated a significant decrease in the rate of mortality attributable
to RSV infection in infants who receive prophylaxis.1
As palivizumab has not impact on mortality and considering reducing
the hospitalization as the main outcome cost-benefit analysis is
particularly important before the intervention could be routinely
For many infants who qualify for the approved indications, risk of
hospitalization for serious respiratory illness will be low, and the cost
and logistic difficulties associated with prophylaxis (five doses over the
season) may outweigh potential benefit.
From recent data from USA infants with chronic lung disease (CLD) seem to
have the highest risk of hospitalization (hospitalized around 56.2/100
child-years), compare to infants with congenital heart disease (12.1/100
child-years), preterm<_28weeks _9.4="_9.4" _100="_100" child-years="child-years" or="or" preterm="preterm" _35weeks="_35weeks" _8.1="_8.1" child-years.="child-years." risk="risk" of="of" icu="icu" admission="admission" and="and" mechanical="mechanical" ventilation="ventilation" is="is" almost="almost" equal="equal" in="in" all="all" the="the" categories="categories" respectively="respectively" _30="_30" around="around" _15.2="_15.2" p="p"/> If all at-risk children were to receive prophylaxis most of the
economic analyses fail to demonstrate overall savings because of the high
cost, even considering all the indirect cost of the illness (e.g. days of
work lost by the family).3
The numbers needed to prevent one hospitalization and one ICU admission by
using immunoglobulin prophylaxis are 17 and 50 respectively.4 Expense to
prevent one hospitalization will then be 2500£ x17=42.500£ that is far
much more than medium cost of one hospitalization of ten days. Cost to
prevent one ICU admission will be 2500£x50=125000£, quite high even
considering all the indirect costs for the family in term of stress and
So, it’s difficult not to agree that except for the richest nation
for very small subgroups of patients, palivizumab is too expensive to have
any impact on overall respiratory syncytial virus admission.
Even if the revised guideline of the AAP suggests a very wide use of
palivizumab5, we think that local guidelines should take into
consideration different benefits in different subgroups of patients and
cost-benefit analysis must be kept in mind in considering local priorities
in public health intervention.
In UK national guideline consider palivizumab only in infants born
prematurely with CLD receiving oxygen at home, having them a twofold risk
In other countries, fail to develop local guideline may lead to
misinterpretation of AAP indications, and possibly to a very inhomogeneous
behavior within one country.
Other simple preventive measures as eliminating cigarette smoke
exposure and the simple practice of hand washing must not be forgotten.
1. Meissner HC, Long SS, and American Academy of Pediatrics, Committee on
Infectious Diseases and Committee on Fetus and Newborn. Technical report:
revised indications for the use of Palivizumab and respiratory syncytial
virus immune globulin intravenous for the prevention of respiratory
syncytial virus infections. Pediatrics.2003; 112 :1447 –1452
2. Robert C. Welliver, Review of epidemiology and clinical risk factors
for severe respiratory syncytial virus (RSV) infection. J Pediatr 2003;
3. David R. Strutton, PhD, Paul E. Stang, Prophylaxis against respiratory
syncytial virus (RSV), varicella, and pneumococcal infections: Economic-
based decision-making. J Pediatr 2003; 143: S157-S162
4. Wang EEL, Tang NK. Immunoglobulin for preventing respiratory syncytial
virus infection (Cochrane Review). In: The Cochrane Library, Issue 2,
2004. Chichester, UK: John Wiley & Sons, Ltd.
5. American Academy of Pediatrics, Committee on Infectious Diseases and
Committee on Fetus and Newborn. Policy statement: revised indications for
the use of palivizumab and respiratory syncytial virus immune globulin
intravenous for the prevention of respiratory syncytial virus infections.
Pediatrics.2003; 112 :1442 –1446
Competing interests: No competing interests
Hilary Butler is, I think, tilting at windmills. It has been many
years since any paediatrician I know has tried to use bronchodilators,
adrenaline, steroids or ribavirin to treat RSV positive bronchiolitis. Nor
do I think it is logical to blame the medical profession for the decline
in breastfeeding. Those most at risk from RSV infection are babies who are
difficult to breastfeed – namely those born extremely preterm (by which I
mean more than 14 weeks early) and those with various forms of serious
congenital cardiac malformation. Preserving the production of breastmilk
through the emotionally fraught early weeks of life in a very preterm baby
is extremely difficult.
I must admit that I was not aware that Sabin had found any protection
from polio virus in breastmilk. However, I doubt that Ms Butler would
contend that this was an effective means of controlling polio. Any
protection that such substances did confer was obviously not sufficient to
prevent endemic polio in most of the world during the 19th century at a
time when all the world’s children were breastfed. It certainly has not
been anything like as effective as polio vaccine which, within 50 years of
its invention, is well on the way to eradicating this disease from the
There is no lack of will within the medical profession to promote
breastfeeding. However, the funds with which to do so are a mere fraction
of those used by milk companies to promote their products. Perhaps Ms
Butler might consider that her anger would be more appropriately addressed
in that direction.
Competing interests: No competing interests
Jenny Handforth et al, talk about prevention and cure of Respiratory
Syncytial virus, as if only they have an answer.
I have a few "difficulties" with this article for the following
Firstly, if Adrenaline, bronchodilators, steroids, and ribavirin all
confer no real benefit what on earth are doctors using them for??? If a
naturopath used such items and admitted they didn't "cure", they would be
sued by the medical profession for touting "snake-oil" type remedies.
Secondly, who says a vaccine is even needed or wanted, or that it is
actually the best way to prevent RSV?
One of the problems with the world today, is that we have economies
run in such a way, that many parents find both parents must work. This is
We know full well, and its in the medical literature, that extend
breastfeeding, is currently the best prevention of respiratory syncytial
virus there is, but how many doctors and paediatricians tell mothers that?
As a long term breastfeeder, I would be insulted if a vaccine for RSV
was put into the schedule, either to be injected into a pregnant mother,
or a newborn baby. Because if it was, it would be considered "abuse" if a
mother refused it.
Such a vaccine should be unnecessary.
And given the historic attempt with the first RSV vaccine, which was
a disaster, making the disease "worse" in recipients, who is to say that
any future vaccine would be safe?
Might there not be is another field of research that it seems has
been totally neglected, with regard to RSV?
Years ago, Sabin identified something in breastmilk, that neutralises
polio-virus, but nothing came of that. A vaccine is so much simpler.
Five years ago, "Discover" magazine published an article in the June
1999 issue, detailing the work of Catharina Svanborg at Lund University.
Catherina Svanborg has also experimented with mother's milk many
times, and found that it does a terrific job or blocking infection by
pneumococcus bacteria, and that breast-fed children suffer significantly
fewer ear and upper respiratory tract infections than babies who don't
They also tracked down studies showing that breast milk protects
against cancer, with the relative risk of childhood lymphoma being nine
times higher in bottle-fed infants. The breastfeeding enhanced cognitive
development, protected the infant against a whole lot of diseases,
including diarrhea, lower respiratory infection, otitis media, bacteremia,
bacterial meningitis, botulism, urinary-tract infection, necrotizing
enterocolitis, suden infant death syndrome, insulin-dependand diabetes
mellitis, Crohn's disease, ulcerative colitis, allergic disases, and
lymphoma and carcinoma.
Furthermore in 1995, she announced the pinpointing of the factor in
breastmilk that kills cancer cells with the acronym "HAMLET" (Humn Alpha-
lactalbumin Made LEthal to Tumor cells)
That's what she said in the article. And I tracked down all her
articles and read the proof myself.
But are parents told any of this by their doctors? Why do we not
hear anything about breast milk and RSV, even in the article above?
Why are researchers not looking to find out what it is in breastmilk
that prevents RSV, and try to develop these factors to use as a basis of
treatment for these diseases in babies and children?
Is it too hard? Or could it be that such a compound wouldn't be
"useful" to the aims and objectives of drug companies?
Parents do want to have the healthiest children possible. They want
to know about good diets and natural protections.
Why is there no political or medical will to REALLY promote
breastfeeding as widely as possible?
Why are there no financial systems in place to encourage all mothers
to stay at home, and produce the best baby possible? After all, we are
talking about future citizens and politicians... and wouldn't we like the
best we could get?
Maybe medical researchers could get along side mothers who are
already committed breastfeeders, and who produce enough milk for several
babies, and collect their "overflow" to really progress study into natural
solutions for many infections in babies.
What are the conditions that make babies "at risk" for RSV? Is that
not in many cases, because of prematurity, much of which is eminently
preventable? And in non-premature babies, isn't RSV prevalent, because
mothers either can't or don't want to breastfeed?
Is the reason a vaccine is touted because it would require less
education, than promoting breastfeeding?
Parents are very amenable to the scientific evident that extend
breastfeeding doesn't just solve the RSV problem, but also solves, or
mitigates a whole raft of them, not just straight away, but that it also
has implications for their children when they are middle aged. But most
parents are never told this. They are told that formula is a "suitable"
substitute. Which is total rubbish.
Sure, the rates of RSV have gone down, as have other respiratory
diseases, though there is no reason given as to why that is...
And its unlikely to be because of anything the medical profession is
Why is it that when the "real" solution is in every potential mother,
that the only research that is being done, is into making yet another
Might not a far better solution be just begging to be found, by
someone with a decent dose of inventive lateral thinking that went outside
the current "square" of medical thinking?
Ah.. but I hear you say. Money is hard to come by. Most of it comes
from drug companies, and you have to prove to them that there is something
in it for them.
Well, if that is so, then it shows just how "wrong" medical research
Please prove to me, that I am wrong.
I believe in extend breastfeeding.
Competing interests: No competing interests