Analysis of Beyfortus® (Nirsevimab) Immunization Campaign: Effectiveness, Biases, and ADE Risks in RSV Prevention

Respiratory infections with RSV account for an important part of hospital admissions for acute respiratory infections. Nirsevimab has been developed to reduce the hospital burden RSV (respiratory syncytial virus) infections: Compared with the product previously used, it has a stronger binding capacity to RSV F protein and a high affinity for FcRn (neonatal receptor for the Fc fragment of IgG), which extends its lifespan. Nirsevimab has been shown to be highly effective in reducing hospitalization rates for RSV infections but a large or unknown number of treated subjects have been excluded in clinical and post-marketing studies. However, analysis of these studies cannot exclude that in rare cases, nirsevimab facilitates and worsens RSV infection (or other respiratory infections). This could be attributable to ADE (antibody-dependent-enhancement) which has been observed with RSV F-protein antibodies in inactivated vaccine trials. This risk has been incompletely assessed in preclinical and clinical trials (incomplete exploration of nirsevimab effector functions and pharmacokinetics). ADE by disruption of the immune system (not studied and due to FcRn binding) could explain there is no reduction in all-cause hospital admissions in treated age groups. Given the high price of nirsevimab, the cost-effectiveness of mass immunization campaigns may therefore be debated from an economic as well as a scientific point of view.