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Published Date: 2011-03-17 19:00:14
Subject: PRO/EDR> Respiratory syncytial virus - Canada: (NT)
Archive Number: 20110317.0851

RESPIRATORY SYNCYTIAL VIRUS - CANADA: (NUNAVUT)
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Date: Wed 16 Mar 2011
Source: CMAJ News [edited]
<http://www.cmaj.ca/earlyreleases/16mar11_nunavut-government-assailed-over-outbreak.dtl>

An estimated half of Nunavut's 26 communities have been affected by
an outbreak of respiratory syncytial virus (RSV) infection. The
remoteness of communities is believed to be a risk factor for RSV
infection.

Dr. Anna Banerji, professor of pediatrics at the University of
Toronto in Ontario, says: "I would find it very surprising if the
recent deaths are not related to RSV." Banerji urges that the
government of Nunavut immediately adopt universal antibody coverage
among Inuit infants and estimates that more than half of Nunavut's 26
communities have already been affected by the outbreak. RSV is the
leading cause of lower respiratory tract infections in infants and
young children. Nunavut suffers from the highest rate of RSV in the
world.

But the territory's chief medical officer of health says that those
infants who need treatment are receiving it. RSV is carefully managed
in the territory using monthly injections of palivizumab, a [humanised
monoclonal] antibody that is provided to premature babies and infants
with chronic heart or lung problems, says Dr. Isaac Sobol, adding that
the territory's decision not to adopt universal coverage to all
full-term Inuit infants younger than 6 months of age at the onset of
the RSV season is based on an "internal review."

Moreover, Sobol adds that "we've seen RSV in Nunavut every year," and
that case loads have been dropping in number in recent years. "Our
goal is to provide protection for those kids most vulnerable."

But Banerji says the government's management of RSV ignores both
scientific evidence and a recommendation from the Canadian Pediatric
Society. The controversy erupted as a consequence of a trio of recent
infant deaths, prompting Louis Tapardjuk, the member of the Nunavut
legislature for Igloolik, to demand a public inquiry into the cause of
the outbreak. "I am asking whether or not they will try to get to the
bottom of this," he told the legislature.

Nunavut Health Minister Tagak Curley has rejected calls for a public
inquiry, in accordance with Sobol's advice that the government await
the results from the coroner's office. Banerji says the government's
failure to proceed with universal antibody coverage on the grounds
that there are a diminishing number of RSV cases is unjustified. "RSV
fluctuates in waves from year to year, and universal antibody coverage
would reduce the risk of hospitalizations and deaths in the worst
years, such as this one." She also argues the diminishing number of
RSV cases is a reflection of the impact of antibody usage among the
most vulnerable infants and should be grounds for universal coverage
rather than limitations on availability.

Banerji has linked RSV to such risk factors as smoking during
pregnancy, rural residency, full Inuit Status and high levels of
overcrowding among Inuit families in the Canadian Arctic (See: Pediatr
Infect Dis J. 2009; 28[8]:697-701). The study also indicated that
non-breastfed adopted children had a 4.4-fold increased risk over
their breastfed, non-adopted counterparts.

In a separate study, Banerji established that universal antibody
treatment for rural Inuit children would be more cost effective than
the current practice of selective treatment alongside extensive usage
of air evacuations for sick children (see: J Med Econ
2009;12[4]:361-70).

Similarly, a 2009 Canadian Paediatric Society position statement
asserts that "consideration should be given to administering
prophylaxis to all full-term Inuit infants younger than 6 months of
age at the onset of the RSV season in northern remote communities (for
example, children who require air transportation to hospital
facilities)."

The position statement adds that there are insufficient data to "make
recommendations for other First Nations and Metis full-term infants
living in remote communities. This is identified as an urgent research
priority, and in the interim, some experts may recommend prophylaxis
in these populations based on local epidemiology."
(<http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2780968/?tool=pubmed>)

Banerji says Nunavut's refusal to provide new RSV data on RSV in
Baffin Island, which is the only region in the territory with its own
hospital, is compromising follow-up studies. Co-investigator Dr.
Michael Young of the IWK (Isaak Walton Killam) Health Centre in
Halifax, Nova Scotia, says the data would be useful. "I cannot
understand their reasons for denying this data." But Sobol says the
request for data was denied "because we were already underway with our
internal review."

[Byline: Paul Christopher Webster]

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[Nunavut's 26 000 inhabitants live in 28 communities widely scattered
across 2 million square km. All communities are accessible by air and
by sea. The Inuit have occupied the region for thousands of years and
form almost 85 percent of the current population. Their language,
Inuktitut is spoken by 80 per cent of the population.

Nunavut's society is the youngest in Canada, with half the population
under 21. Possibly, this is the reason why Nunavut suffers from the
highest rate of RSV infection in the world. RSV infection affects all
ages but has its greatest impact during infancy and in the elderly.

The most effective treatment of bronchiolitis in infancy as a result
of RSV infection is the administration of the humanised monoclonal
antibody Palivizumab. Routine administration of Palivizumab to the
entire infant population, as suggested in this report, seems hardly
feasible. RSV circulates globally, and it is unlikely that a strain of
virus of enhanced virulence is prevalent in Nunavut. (For a recent
analysis of the "Molecular Epidemiology and Evolution of Human
Respiratory Syncytial Virus and Human Metapneumovirus," see R.G. Gaunt
et al., PLoS ONE 6(3): e17427.
<http://www.plosone.org/article/info:doi/10.1371/journal.pone.0017427>).

Improvement in general living conditions may gradually reduce the
problem of RSV infection.

A map showing the location of Nunavut can be accessed at:
<http://atlas.nrcan.gc.ca/site/english/maps/peopleandsociety/nunavut/people/communities>.
The HealthMap/ProMED-mail interactive map of Canada is available at:
<http://healthmap.org/r/007x>. - Mod.CP]

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