Cost of childhood RSV management and cost-effectiveness of RSV interventions: a systematic review from a low- and middle-income country perspective

Abstract

Background: Approximately 97% of global deaths due to RSV occur in low- and middle-income countries (LMICs). Until recently, the only licensed preventive intervention has been a shortacting monoclonal antibody (mAb), palivizumab (PVZ) that is expensive and intensive to administer, making it poorly suited for low-resource settings. Currently, new longer acting RSV mAbs and maternal vaccines are emerging from late-stage clinical development with promising clinical effectiveness. However, evidence of economic value and affordability must also be considered if these interventions are to be globally accessible. This systematic review's objective was to summarise existing evidence on the cost-of-illness (COI) and cost-effectiveness of RSV prevention interventions in LMICs.

Methods: We conducted a systematic literature review using the Embase, MEDLINE, and Global Index Medicus databases for publications between Jan 2000 and Jan 2022. Two categories of studies in LMICs were targeted: cost-of-illness (COI) of RSV episodes and cost-effectiveness analyses (CEA) of RSV preventive interventions including maternal vaccines and long-acting mAbs. Of the 491 articles reviewed, 19 met the inclusion criteria.

Results: COI estimates varied widely: for severe RSV, the cost per episode ranged from $92 to $4114. CEA results also varied-e.g. evaluations of long-acting mAbs found ICERs from $462/DALY averted to $2971/DALY averted. Study assumptions of input parameters varied substantially and their results often had wide confidence intervals.

Conclusions: RSV represents a substantial disease burden; however, evidence of economic burden is limited. Knowledge gaps remain regarding the economic value of new technologies specifically in LMICs. Further research is needed to understand the economic burden of childhood RSV in LMICs and reduce uncertainty about the relative value of anticipated RSV prevention interventions. Most CEA studies evaluated palivizumab with fewer analyses of interventions in development that may be more accessible for LMICs.

Keywords: Cost-effectiveness; Cost-of-illness; Low- and middle-income countries; Respiratory syncytial virus; Systematic review.

Fig. 1

PRISMA flow diagram of included studies. Abbreviations: LMIC, low- and middle-income countries; RSV, respiratory syncytial virus

Fig. 2

Findings from cost-effectiveness studies. Notes: ⁺ Study reports results in two subgroups: infants born at < 29 weeks ($19,307) vs. born 29–32 weeks (22,863); ⁺⁺ Study reports results in four subgroups: those without BPD and with siblings ($10,456), those with BPD and with siblings ($16,837), those with BPD and without siblings ($34,088), and those without BPD and without siblings ($71,226). Currency is reported in 2020 USD. Abbreviations: BPD, bronchopulmonary dysplasia; DALY, disability-adjusted life year; GDP, gross domestic product; ICER, incremental cost-effectiveness ratio; LIC, low-income country; LMIC, low- and middle-income countries; mAb, Long-acting monoclonal antibody; MI, maternal immunisation; NR, not reported; PI, paediatric immunisation; PVZ, pavilizumab; QALY, quality-adjusted life year; UMIC, upper-middle-income country; USD, United States dollars

Fig. 3

Findings from cost-of-illness studies. Notes: + Comparison groups are for full-term infants vs. pre-term infants, which are included in the Ward and ICU categories, respectively, for comparison by disease severity; # Study evaluates the cost of nosocomial RSV infections. Currency is reported in 2020 USD. Abbreviations: COI, cost-of-illness; ICU, intensive care unit; LIC, low-income country; LMIC, low- and middle-income country; NR, not reported; UMIC, upper-middle-income country; USD, United States dollars