Expand use of anti-RSV agent in Nunavut, thousands of petitioners say
“For the Inuit, you save money because of the high rate of RSV”
When Dr. Anna Banerji and her fellow alumni from the University of Toronto medical school class of 1989 first posted their petition on change.org at the end of September, they hoped to attract 1,000 signatures.
But at the time this article was written, they had gathered 23,322 names—and they now hope to reach 25,000.
Their petition says the Government of Nunavut could prevent multiple needless deaths and admissions to hospital of infants by extending the use of an antibody called palivizumab to all babies under the age of six months.
Palivizumab is an immunization agent, though not a vaccine, and is marketed under the brand name Synagis.
It’s been proven effective in preventing lower lung infections in infants caused by RSV, short for “respiratory syncytial virus,” which attacks the lower part of the lung, causing a frightening disease called bronchiolitis.
But Dr. Michael Patterson, the chief medical officer of health in Nunavut, told Nunatsiaq News in an interview that the GN only gives palivizumab to about 11 to 12 per cent of all children younger than two years of age.
“We do it selectively, for children that are at the greatest risk of severe complications from RSV, and groups where there is demonstrated real-world benefit in giving them palivizumab,” he said.
That includes children born prematurely, at fewer than 35 weeks’ gestation, or children with chronic lung or heart disease.
Banerji, an associate professor of pediatrics at the University of Toronto’s faculty of medicine, has published multiple studies over the past decade and a half on the prevalence and cost of RSV in the Arctic.
And, based on that research, she disagrees strongly with Nunavut’s current policy and says all Nunavut infants should get the antibody.
Nunavut’s staggering costs make it worthwhile
She said her studies have shown the prevalence of RSV in Nunavut can reach staggering levels and produce staggering medevac and hospitalization costs for Nunavut’s Department of Health.
The antibody is expensive: about $5,600 per dose. But even at that price, Banerji and many others believe it’s a bargain.
That’s because Nunavut’s high infection rates and high emergency evacuation costs make it economical to use, they argue.
“We did several cost analyses that shows that in most parts of the Arctic that if you give palivizumab, it saves money,” she said in an interview.
One cost analysis, published in 2013, found a big rate of lower respiratory tract infection in Kitikmeot babies: calculated at 389 per 1,000.
During that study period, which ran from Jan. 1, 2009, to June 30, 2010, the average cost of admission to hospital per infection ran to $57,535.
For the Qikiqtani region, lung infections in infants occurred at a rate of 202 per 1,000 live births and in the Kivalliq region, at a rate of 230 per 1,000 live births.
This meant the GN spent about $5.9 million to care for gravely ill Qikiqtani infants and about $5.7 million for sick Kivalliq infants during the study period.
The Kivalliq region racked up the highest average cost per lower respiratory tract infection admission: $63,686.
“For the Inuit, you save money, because of the high rate of RSV,” she said.
Head of Ontario physicians group supports petition
The president of the Ontario Medical Association, Dr. Sohail Gandhi, endorses Banerji’s position.
“Inuit infants have 10 times the rates of admission with RSV than the “high-risk” infants and the symptoms are often more severe. Despite this disparity, Inuit infants in Nunavut do not get the antibody,” Gandhi wrote in his endorsement.
That position is also endorsed by professionals at the Northern School of Medicine, the Canadian Medical Association and the Canadian Institutes of Health Reseach Institute of Indigenous Peoples’ Health.
But healthy babies in Nunavut whose mothers carry them to full term don’t get the antibody—even if they’re from high-risk communities outside Iqaluit with historically high levels of RSV infection.
Banerji says that’s the wrong approach.
“I’ve done my due diligence. I’ve shown my data to everyone. Carolyn Bennett, Jane Philpott, they’ve seen the data and they say yeah, it’s really convincing,” she said.
Nunavik immunizes all babies
And she points out that, unlike Nunavut, health authorities in Nunavik have given palivizumab to all infants for about three years now.
In the Nunavut legislature on Oct. 18, Health Minister George Hickes said, in response to questions from Iqaluit-Niaqunngu MLA Pat Angnakak, that the GN is taking a close look at the Nunavik example.
“We are following the progress of that program,” he said.
Angnakak said that RSV can have a devastating impact on families.
“Recently, somebody who I know had their baby medevaced because of RSV and it really has an impact on the family, especially when the baby is so young.
But Hickes defended the GN’s current approach and denied that his government is trying to save money by restricting the antibody to only pre-term babies.
“It’s not a political or a policy decision based on cost. It’s following best medical practices,” Hickes said.
Patterson acknowledged that Nunavik went ahead three years ago with blanket immunizations of all infants under six months.
“We are waiting for some analyses on those numbers, and if we can find demonstration that there’s significant cost savings to administering palivizumab, we would probably adopt it as quickly as we could,” Patterson said.
But he said that in his opinion, there isn’t enough evidence to justify extending its use in Nunavut.
“There’s a couple of things that I disagree with in the petition and one of them is the presentation that this is a done deal, or that there’s a scientific consensus on this issue. There are still a lot of people with questions,” he said.
The controversy over the use of palivizumab in Nunavut dates back many years.
In 2008, the GN refused to even participate in one of Banerji’s studies on RSV, even though officials in Greenland, Nunavik and the Northwest Territories agreed to participate in it.