The cost-effectiveness of palivizumab in the prevention of respiratory syncytial virus bronchiolitis; a systematic review

Summary Background: RSV bronchiolitis is the most common cause of infant morbidity during the winter season and is associated with a large burden of disease and high costs. The costeffectiveness of RSV immunoprophylaxis with the only available preventive treatment, palivizumab is subject of vigorous debate. It is recognised that a policy of using palivizumab for all children who meet the licensed indication is not cost-effective, but most clinicians feel that its use is justified in certain subgroups. Objective: To systematically review the literature on the cost-effectiveness of palivizumab prophylaxis in the following subgroups: 1) preterm infants born before 32 weeks gestational age (WGA), 2) preterm infants born between 32 and 35 WGA, 3) children with chronic lung disease, and 4) children with congenital heart disease. Methods: We searched Pubmed, EMBASE, and the latest versions of the DARE, NHS EED and HTA databases from inception to June 2012. Relevant studies were first selected on title and abstract and full text of the selected papers was reviewed. Results: Nineteen studies evaluating the cost-effectiveness of palivizumab performed in 13 different countries were included. The cost-effectiveness of palivizumab for the subgroups of children born before 32 WGA, children born between 32 and 35 WGA, children with chronic lung disease (CLD), and children with congenital heart disease was studied in 9, 9, 8, and 7 studies, respectively. The incremental cost-effectiveness ratios varied considerably both within and between subgroups. Sensitivity analyses showed that cost-effectiveness was mainly driven by the mortality rate due to RSV infection. Differences in hospitalisation rates, industry sponsoring and study year were also associated with differences in costeffectiveness, but these differences could be attributed to differences in mortality rates. Conclusion: The cost-effectiveness of prophylactic treatment of RSV infection with palivizumab in subgroups varies considerably. The cost-effectiveness is mainly sensitive to mortality rates of RSV infection. This systematic review indicates that future research should focus on the major uncertainties in cost-effectiveness, particularly RSV-related mortality rate, high-risk populations and long term sequelae. Interpretation of RSV cost-effectiveness studies should be done cautiously due to transferability issues.