Health-care burden related to respiratory syncytial virus in a resource-constrained setting: a prospective observational study

Abstract

Background: Respiratory syncytial virus (RSV) is a leading cause of paediatric hospital admissions worldwide, straining health systems. A lack of data on the burden of RSV infections and the impact on health systems in resource-limited settings hinders evidence-based policy decisions. Here, we aimed to assess RSV's burden on the health system in Bangladesh.

Methods: From January to December, 2019, we conducted a prospective study at Bangladesh's largest paediatric hospital among children aged 0-59 months admitted with a possible respiratory infection, as guided by the WHO RSV hospital-based surveillance case definition. Outcomes for RSV-positive children younger than 5 years were analysed. We also followed up outcomes of children denied hospitalisation due to bed shortages. Adjusted hazard ratios for children denied admission versus admitted were estimated using survival analysis. Monte Carlo simulations with a queueing model were used to estimate the effects of RSV prefusion F maternal vaccine or nirsevimab on admission denials and mortality.

Findings: Of 40 664 children admitted, 31 692 were younger than 5 years; 19 940 were in study wards. Among 7191 admitted with possible respiratory infections, 6149 (85·5%) had nasopharyngeal swabs taken, with 1261 (20·5%) testing RSV-positive. The median age of children who tested positive for RSV was 3·0 months (IQR 1·0-8·0), with a median hospital stay of 5 days (IQR 4-8); 24 (1·9%) of 1261 died in hospital. 8274 (5·5%) of 151 110 bed days were for children who were positive for RSV. Additionally, of 9169 children denied admission, outcomes were tracked for 3928 and compared with 2845 admitted. The hazard ratio for death was 1·56 (95% CI 1·34 to 1·81) for children denied versus admitted, being highest for neonates at 2·27 (1·87 to 2·75). RSV prefusion F maternal vaccine or nirsevimab could have reduced denials by 677 (95% prediction interval 63 to 1347) and 1289 (684 to 1865), respectively, potentially preventing 130 (-60 to 322) and 258 (32 to 469) deaths.

Interpretation: RSV strains health care in Bangladesh, increasing mortality risks. Preventive interventions could lessen its impact, boosting health-care capacity and child health in resource-limited settings.

Funding: The Bill & Melinda Gates Foundation.

Figure 1

Flowchart of sample collection and patient follow-up The figure illustrates the process of sample collection and subsequent patient follow-up for children younger than 5 years admitted to Bangladesh Shishu Hospital and Institute or denied admission due to the unavailability of beds. *Reasons why samples could not be collected are given in appendix 1 (p 25).

Figure 2

RSV infections and bed occupancy in Bangladesh Shishu Hospital and Institute in 2019 (A) The total number of patients meeting the eligibility criteria of the study each month, and the number of samples collected from these patients. (B) The percentage of occupied beds that were RSV cases. (C) The percentage of beds occupied by children with RSV across different months. The dip in bed occupancy seen in mid-August is likely because of the Eid-ul-Adha holidays. RSV=respiratory syncytial virus.

Figure 3

Survival analysis of patients followed up (A) Survival probabilities of patients denied admission (blue line) and those admitted (orange line). Cases were censored at discharge if there was no follow-up or at the last successful follow-up. (B) Survival curve for only RSV-positive cases: the 24 cases that resulted in in-hospital deaths, alongside the additional 205 cases that were followed up, of whom 18 subsequently died. Numbers at risk at different timepoints are provided below the graphs.

Figure 4

Effect of RSV preventive interventions on hospital use and 90-day mortality rates of all children who require admission at Bangladesh Shishu Hospital and Institute Effects of RSVpreF and nirsevimab on RSV admissions, showing its impact on the proportion of hospital denial (A), 90-day mortality proportion (B), total hospital denials (C), and total deaths at 90 days (D) among children younger than 5 years. The plots C and D compare mortality against the effective increase in available beds, showing how reducing RSV cases is akin to increasing bed capacity. Solid lines in (A) and (B) and shaded areas in (C) and (D) represent prediction intervals. The dotted line in (C) and (D) represent the current bed number at Bangladesh Shishu Hospital and Institute. RSV=respiratory syncytial virus. RSVpreF=RSV prefusion F maternal vaccine.