Safety and Effectiveness of Palivizumab in Children at High Risk of Serious Disease Due to Respiratory Syncytial Virus Infection: A Systematic Review

Abstract

Introduction: Lower respiratory tract infection (LRTI) is the leading cause of infant mortality globally in post-neonatal infants (i.e., 28-364 days of age). Respiratory syncytial virus (RSV) is the most commonly identified pathogen for infant LRTI and is the second most important cause of death in post-neonatal infants. Despite 50 years of RSV vaccine research, there is still no approved vaccine. Therefore, passive immunity with the monoclonal antibody palivizumab is the sole regulatory-approved option for the prevention of serious LRTI caused by RSV in pediatric patients at high risk of RSV disease.

Methods: We conducted a comprehensive systematic literature review of randomized controlled trials (RCTs), open-label non-comparative clinical trials, and prospective observational studies/registries, and summarized the evidence related to the safety, efficacy, and effectiveness of palivizumab.

Results: The efficacy of palivizumab, as measured by the relative reduction in RSV-related hospitalization rate compared with placebo ranged from 39% to 78% (P < 0.05) in the 2 pivotal RCTs. A meta-analysis of the RSV-related hospitalization rate from 5 randomized placebo-controlled trials yielded an overall odds ratio of 0.41 (95% CI, 0.31-0.55) in favor of palivizumab prophylaxis over placebo (P < 0.00001). Low rates of RSV-related hospitalizations were observed in palivizumab recipients consistently over time in more than 42,000 pediatric subjects across 7 RCTs, 4 open-label non-comparative trials, and 8 observational studies/registries conducted in 34 countries. In addition, among palivizumab-prophylaxed subjects with breakthrough RSV LRTI, rates of intensive care unit admission and mechanical ventilation from RSV hospitalization also were low and consistent across studies. With respect to safety, no differences were observed between palivizumab and placebo in the blinded RCTs.

Conclusion: Rates of RSV hospitalizations and RSV hospitalization-related endpoints in pediatric subjects who received prophylaxis with palivizumab were low and constant over time and across RCTs, open-label non-comparative trials, and observational studies/registries.

Keywords: Efficacy; Palivizumab; Respiratory syncytial virus; Safety; Serious lower respiratory tract infection; Systematic review.

Fig. 1

Study selection diagram. Asterisk indicates three articles reported results on different time periods and subject populations from the same registry. RSV Respiratory syncytial virus

Fig. 2

RSV-related hospitalization rates in the large randomized controlled trials: a IMpact-RSV [24], b Carbonell-Estrany et al. [70], c MAKI [30], d Tavsu et al. [31], e Cardiac [23], and f Feltes et al. [71] studies. Relative reduction rate compared with placebo is shown as ↓%. Asterisk indicates without BPD/CLDP. BPD Bronchopulmonary dysplasia, CHD hemodynamically significant congenital heart disease, CLDP chronic lung disease of prematurity, GA gestational age, mo months, RSV respiratory syncytial virus, wk weeks, y years

Fig. 3

Meta-analysis of RSV-related hospitalization in the randomized, placebo-controlled trials. M–H Mantel–Haenszel method, RSV respiratory syncytial virus