Protecting the most vulnerable

Program aims to protect young children from respiratory syncytial virus (RSV)

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Winnipeg Health Region
Wave, January / February 2014

Just shy of six months of age, Logan Howson hasn't quite figured out why he is lying on the examination room bed of a clinic at Health Sciences Centre Winnipeg's Children's Hospital this morning.

Unlike some of the other kids who are visiting the clinic today, he remains blissfully unaware that his presence here can only mean one thing: he's about to get a needle.

That makes things a bit easier for nurse Kris Sneesby as she manoeuvres into position to deliver the injection to her unsuspecting patient.

"Look at Mom," Sneesby whispers to the infant lying before her, trying to distract his attention from the syringe in her right hand. "Look at Mom."

As Logan turns his head, the nurse gently pokes his leg, provoking a mild howl of protest.

"Ah, you're okay," Sneesby reassures him in a soothing voice. "You're okay."

In a few seconds, the momentary discomfort seems all but forgotten as Logan disappears into the arms of his mother, Chantal Gagnon, content once more.

"Short-term pain for long-term gain," says Sneesby. "They cry for three seconds, but this will keep them safe all winter," she says in reference to the injection.

And keeping these children safe is what this clinic is all about. Over the next three hours, 11 more children will receive an injection from Sneesby or nurse Diane Schultz. They are among 200 children currently enrolled in a little-known but highly successful program that uses a drug called palivizumab to help protect vulnerable children against a virulent cold virus called respiratory syncytial virus (RSV).

Dr. Aaron Chiu is a neonatologist at Children's Hospital and Medical Director of the Manitoba RSV Prophylaxis Program, which operates the clinic.

As he explains, RSV is a common cold virus that infects most kids by the time they turn two years of age. In the vast majority of cases, children can overcome the effects of RSV, which usually amounts to a runny nose or a cough, with little or no trouble.

But in some cases - particularly those involving children under the age of two who were born premature or have a heart condition - the virus can be much more serious, especially if it morphs into a form of bronchiolitis, a severe infection of the small airways of the lungs. In these cases, children can end up in hospital and spend weeks on a respirator because they are unable to breathe on their own.

Logan is one of the vulnerable ones. He was born July 5 at 28 weeks, weighing in at two pounds, seven ounces. As a result, he is particularly susceptible to RSV because his immune system is not yet fully capable of warding off attacks from the virus.

"He still needs that time for his lungs to mature," says Chiu. "What happens with this infection is that it makes a lot of secretions in the lungs, which makes it hard for these infants to breathe, and, in some cases, they actually forget to breathe. But as they get older, they are able to cope much better."

The RSV clinic operates weekly and is led by Rose Paulley, nurse clinician for the program. Her involvement with RSV prevention began when it started as a research project more than 15 years ago.

At the time, infants who were born premature or with a heart condition would spend some time in the neonatal ward before being released to go home. Then, in winter, some of these infants would develop a cold and have to come right back to hospital. The research project demonstrated that these vulnerable kids could benefit from receiving palivizumab. The drug is not a vaccine, rather it is a "passive immunization," which provides the child with antibodies against the RSV virus.

"We found that in certain populations, this (drug) was effective in preventing kids from coming back into the hospital," says Chiu, explaining that the numbers suggested the drug would only have to be given to as few as 13 children in order to prevent one from coming back to hospital. That's pretty good when you consider that 100 adults with a risk for heart disease would have to receive lipid-lowering drugs for three years to prevent one from having a heart attack or stroke, says Chiu.

Once the research project ended, the permanent program was established in 2009. Under the program, all children born in Manitoba are entered into a database. Family members of these children are then notified if their child is eligible for an injection at various clinics located throughout the province, northwest Ontario or Nunavut.

"Pretty much wherever babies are delivered, there is somebody at that centre who helps us collect information and lets us know that there may be a (child) who is eligible."

Children enrolled in the program receive a monthly dose of palivizumab between November and March. Most kids will receive injections for one year. But some will continue with the program for two or three years, depending on their situations.

Chiu says since the prevention program was implemented, the number of cases of vulnerable children hospitalized because of RSV has dropped significantly. Last year 14 of the 217 infants admitted for RSV were at risk infants in the program. The year before, only one out of 136 infants admitted for RSV was an at risk infant in the program.

That means that in addition to sparing these children the risks associated with severe RSV, the program also eliminates the costs associated with having these children in intensive care for extended periods of time. "It's an excellent prevention program," says Chiu. "It's not common to see (an infant) who has underlying risk factors admitted because they are being tracked and offered this program."

That's not to say that RSV still doesn't take a toll on young children. The difference is most of these kids have none of the underlying health risks that would put their lives in serious jeopardy. "You talk with physicians and pediatricians who have practiced for 20 years or more, and before this program came along, they remember these infants coming back to the hospital, how sick they were on the ventilator and the time they had to spend in hospital.... That doesn't happen as much anymore."

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