Dr. Nicole Radziminski has seen members of the same family flown out of her community to a hospital because they’d been hit with RSV or other viruses.
The pediatrician, who works in the Northwest Territories and treats patients from the Kitikmeot region in northwest Nunavut, recalls an “unusually large number” of infants and older children being sick during the 2022 viral season — the most she’d ever seen.
“I recall sending at least a couple of kids a week on a medevac to Edmonton ICU, which maybe doesn’t sound like a lot, but it is actually quite a lot for us to do that,” Radziminski said, adding that this doesn’t include the other Nunavut patients that would have been flown to Yellowknife.
Respiratory syncytial virus is a common cause of bronchiolitis, which causes inflammation and congestion in the small airways of the lung.
It shot to prominence in recent months in Ontario, as a combination of RSV, COVID-19 and the flu ripped through communities, and left pediatric hospitals overwhelmed.
But in the North, it had exacted a harsher toll for years. In the Arctic, peak RSV season usually occurs in February/March to June.
Radziminski said the “significant RSV activity” last year was between June and October.
“Every day our wards were full of kids with bronchiolitis,” Radziminski said. “We have an eight-bed unit with capacity up to 10 and it’s a shared pediatric-adult unit, but it was basically all full of children for about five months.
Dr. Anna Banerji, a pediatric infectious disease specialist, said that in typical seasons, “the rate of RSV hospitalization for an average baby in Toronto is about one per cent. In the Arctic, it can be up to 30 per cent of the babies or even more in remote communities. Thirty per cent of the babies (with RSV) end up in the hospital.”
The Toronto-based doctor is calling on the federal government to expedite a review of a single-dose drug that she said could help Inuit and other Indigenous infants who are at high risk of severe RSV.
Sanofi, the company developing the drug with AstraZeneca, said Health Canada has accepted a submission for nirsevimab, sold as Beyfortus, the first investigational long-acting antibody to help protect infants from RSV. Sanofi said it expects a decision in the last three months of the year.
While RSV is a common infection and almost all babies are infected by the age of two, those living in the Arctic and remote communities are at higher risk due to overcrowded housing and exposure at a younger age.
Inuit babies also get sicker and stay in the hospital longer. They also tend to have more complications.
“We’ve known for a long time that Inuit babies have four to eight times the rate of hospital admission due to RSV, compared to the premature babies or the cardiac babies” with RSV, Banerji said.
A study that Banerji was involved in compared sick and healthy Inuit babies. It found that overcrowding increases the risk, as does cigarette exposure in pregnancy and at home. The study also found that those sick enough to be hospitalized would need to wait for a medical evacuation team, and that could take a couple of days depending on weather.
“In the meantime, the baby that needs to be hospitalized gets sicker during that wait,” Banerji said.
Banerji added that Nunavut’s Kitikmeot region has an “extremely high rate of RSV admissions,” higher than documented rates in other places including India, Africa and other parts of the Arctic.
Radziminski said one of the biggest factors in how RSV affects babies more in the North compared to the South is how long it takes them to get increased care if they need it.
The first point of contact is the community health centre, usually staffed by nurses “who are generally very good and adept at dealing with bronchiolitis,” and can provide oxygen, Radziminski said. But kids requiring more care often must go to Yellowknife or Edmonton.
Being transported out of the community is stressful for families, too. Radziminski said often, unless the child is quite unwell, only one parent can travel with the child on the medevac plane. Child care for other kids in the family is another challenge and decisions have to be made “at a moment’s notice.”
Radziminski said depending on the child’s condition they could be away in hospital anywhere from a few days to a month or longer.
Palivizumab — a monoclonal antibody, a protein that is injected externally and wears off over time — is approved by Health Canada and given to babies in monthly doses at the start of RSV season, to reduce complications of RSV. But Banerji says it’s expensive and restricted to higher-risk babies, such as those born premature or with a significant heart or lung issues.
Banerji said several studies have also shown that it’s cheaper to give palivizumab to Inuit babies than to pay for the extra cost of transporting sick babies to regional and children hospitals for further treatment.
In a statement to the Star, Nunavut’s department of health said a recent study in Nunavik in northern Quebec, “which followed the recommendation of universal palivizumab administration, further supports Nunavut’s approach after it found that, amongst healthy term infants, palivizumab was not effective at reducing hospitalizations.”
Banerji said the single-dose nirsevimab could be approved and made available to northern communities, hopefully at a lower cost than palivizumab. She started a petition on Change.org to raise awareness about the issue.
Radziminski said it’s hard to know what the upcoming season may look like.
“Having this past year under our belt definitely makes us a little bit apprehensive and hopeful that the same thing won’t be repeated” this year and next, Radziminski said.
Data provided by Nunavut’s Department of Health shows 223 RSV infections in children two years old and under from August 2021 to July 2022. The department noted there was a spike at that time that was seen across the country after COVID-19 public health measures ended. So far this year, there have been 27 children two or younger diagnosed with RSV.
In a statement, Health Canada said that as with all drug submissions, it will review nirsevimab “based on scientific rigour and medical evidence.”
“The timing for the completion of Health Canada’s review depends on many factors, including but not limited to a need for additional data, discussions with the sponsor, and requirements for updates to safety information. Given the ongoing public health considerations, Health Canada is committed to reviewing the nirsevimab submission as quickly as possible without compromising safety.”
Health Canada added that all provinces and territories have programs that make palivizumab available for high-risk infants, including premature Inuit babies and infants with certain medical conditions.
Nunavut’s department of health said when nirsevimab is approved in Canada, the territorial government will look into how best to use it.
Nirsevimab was approved last fall in the European Union. Before that, the European Medicines Agency recommended that nirsevimab, sold as Beyfortus, be authorized based on advanced research that showed the drug reduced the chances that babies with RSV needed medical attention and appeared to be safe, compared to infants who got a placebo.
Nirsevimab was also recently approved by the U.K. regulator.
In November, Pfizer announced preliminary research showing that a new vaccine given to pregnant women could help protect their babies against RSV, after decades of failure to develop an effective shot. Moderna is also testing an mRNA vaccine and plans to seek approval from regulators this year.
Banerji is also calling on the public to help the cause by signing the petition and by reaching out to their local MP and minister of health as well as the minister of Crown-Indigenous relations, asking them to fast-track approval of nirsevimab and designate Indigenous infants in northern communities as high-risk for RSV.
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