Inuit communities bracing for return of RSV in babies

Health advocates are raising alarm that infants in Nunavut face grave risks as a potent respiratory virus – deadlier than COVID-19 and influenza – re-emerges after a one-year hiatus. 

Respiratory syncytial virus (RSV), which causes disproportionate illness in Inuit babies compared to the rest of the Canadian population, has made a comeback in B.C., Ontario and Quebec after its absence for most of the 2020-2021 winter season; health officials now fear serious outbreaks in Canada’s North.

There is currently no vaccine for RSV. Instead, a drug called palivizumab (PVZ) is the preventive treatment of choice, but health officials in Nunavut authorize it only for preterm babies and those born with heart or lung disease.

Pediatric infectious disease specialist Anna Banerji, backed by a growing petition of 189,000 people, says that expanding PVZ’s use to all Inuit newborns could save lives and prevent costly medical evacuations. Critics, however, say that belief is misplaced. That leaves Nunavut with no new currently marketed options in an RSV season predicted to be worse this year in the Arctic.

“It’s a human rights issue,” Banerji said. “If they were non-Indigenous babies, then they would have gotten it a long time ago.”

Nunavut’s chief medical officer of health Michael Patterson disagrees, citing a 2020 study on a pilot project in Nunavik that showed PVZ did not reduce RSV hospitalizations when given to healthy, full-term infants.

Other studies from Nunavut seem to back Patterson, with one saying expanding the use of PVZ is “not cost-effective” and another claiming it is “highly resource-consuming” with “significant feasibility and acceptability issues.” In the latter, health-care workers administering PVZ said they felt overloaded with the protocol, a series of five injections given monthly in the first year of life

“We have staff shortages all over the country … So, we have to think about what’s lost when we give this,” said Patterson, adding that time spent giving PVZ to every child takes time away from more critical needs. “That’s time that they’re not doing contact tracing on TB; well-child immunization for tetanus; diphtheria and pertussis (or) follow-up for prenatal sessions.”

RSV is a common seasonal virus that causes a flu-like illness in most babies. In its more severe form, babies develop a lung disease called bronchiolitis, the most common reason to end up in hospital before age one. Also circulating in older children and adults in milder forms, RSV is just as infectious as COVID-19, but has fewer evidence-based treatments.

Babies from Canada’s Arctic regions have the highest rates of lung infection in the world, particularly in predominantly Inuit Nunavut and Nunavik. In a 2009 study, nearly a quarter of Nunavut infants and half of Nunavik infants were hospitalized with lung infections that year, 42 per cent of them due to RSV. By comparison, the Northwest Territories only had an admission rate of four per cent, and Canada overall has a rate of three per cent. Inuit children are four times likelier than non-Inuit to get the lung infection.

Before the Nunavik study, there was little research done on PVZ efficacy in the Arctic or in Inuit babies. Banerji references the large 1998 IMpact-RSV Study done in Canada, the U.S. and U.K. that showed PVZ reduced admissions to hospital by 55 per cent for preterm babies or those born with lung disease.

But what about full-term babies? Banerji says despite a lack of studies, there is no biological reason why PVZ would be less effective for them. She says the Nunavik study was plagued with implementation issues, and she calls for the study to be repeated in Nunavut.

Banerji’s own 2016 analysis showed that PVZ would be cost-effective if implemented in Nunavut’s high-risk Kitikmeot and Kivalliq regions. The analysis assumed that all healthy, full-term newborns would receive all five injections of the regimen. However, health-care workers in the Nunavik study reported that only a third actually did, again highlighting the implementation issue.

In March 2020, the public health response to COVID-19 led to a drastic worldwide reduction of RSV, and Nunavut was no exception.

“The numbers of RSV infections and admissions for severe bronchiolitis dropped dramatically and stayed that way for most of 2020-21,” says Patterson. As of Nov. 9, there have been fewer than five cases of RSV in Nunavut this year, compared to 37 in 2020 and 116 in 2019.

However, a re-emergence of RSV in Nunavut is expected. The rest of Canada is already seeing its return, as predicted by experts. Public health data show that in the week ending Nov. 2, 1,107 cases of RSV were detected countrywide, compared to only five cases during the same week in 2020 and 61 in 2019.

“We are bracing for a season of RSV bronchiolitis where the peak number of cases will be expected to be higher than typical years,” says Patterson.

Experts say this RSV season may be more severe than pre-pandemic years. Since immunity to the virus is thought to last only up to a year after infection, there is a year’s worth of newborns who have never encountered the virus and mothers who did not renew their immunity last season cannot pass on antibodies through breast milk.

Recent modeling of the virus’s seasonality predicts every second season to be more severe, even without the COVID pandemic. One 2020 study projected “large future outbreaks” of RSV after COVID restrictions such as physical distancing are removed.

Meanwhile, parents dealing with the virus report coping challenges, not all of them medical.

Parents of babies in hospital with RSV deal with significant stressors that can affect them long after their baby has returned home, according to a March study. Families report financial loss, anxiety, sleep issues, poor health and strained family relationships. The virus also disproportionately affects those with crowded housing and poor education, both prominent issues in Canada’s North.

Babies from Canada’s Arctic have the highest rates of lung infection in the world.

“It was difficult for me as a new parent, not knowing what to do,” says Israel Mablick of Iqaluit. His son, Kyle, was born two weeks premature, diagnosed with RSV shortly thereafter; he was admitted to Iqaluit’s Qikiqtani General Hospital and placed on oxygen for two weeks.

Mablick, a college student at the time, had difficulty coping with the stress, income loss and even failed a class. “Trying to live off (a limited income) as a college student was very difficult, but we were fortunate enough that we had family to help us with groceries.”

So, what is Nunavut’s plan with RSV? Patterson announced earlier this month that all babies who qualify for PVZ will receive it a month early in anticipation of an early RSV season. Apart from that, Patterson says there is no change in strategy planned.

However, other solutions may be on the horizon – a 2020 federal report listed four types of vaccines for mothers and a long-acting monoclonal antibody (LAMA) in development for RSV prevention. One such LAMA, nirsevimab, works similarly to PVZ, but is given as a long-acting single injection. Early studies show that LAMA treatments reduce RSV infections by 70 per cent and appear to be cost-effective. All are in late-phase clinical trials.

The Public Health Agency of Canada says none of these candidates are currently being studied in the Canadian North, although pediatrician and Canadian Immunization Research Network member Joanne Langley says her network will soon publish work that will help us better understand the Arctic context of RSV prevention.

For now, it seems, the North may have to wait a bit longer for a breakthrough on RSV to hit the shelves.