Highlights
- Nirsevimab is associated with a 62% reduction in the odds of all-cause lower respiratory tract infection (LRTI) hospitalizations in infants.
- The monoclonal antibody reduced RSV-related emergency department (ED) visits by 76%, highlighting its specific efficacy against its primary target.
- Real-world data from 11 studies across five countries corroborate the high efficacy observed in earlier clinical trials like MELODY and HARMONIE.
- While respiratory-specific outcomes improved significantly, all-cause hospitalization rates did not show a statistically significant difference, reflecting the diverse etiology of infant admissions.
Background: The Persistent Threat of RSV and LRTI
Respiratory syncytial virus (RSV) remains the leading cause of lower respiratory tract infections (LRTI), such as bronchiolitis and pneumonia, in infants worldwide. Historically, the burden of RSV on pediatric healthcare systems has been immense, leading to predictable seasonal surges that strain emergency departments and neonatal intensive care units. Until recently, the only available pharmacological prophylaxis was palivizumab, a monoclonal antibody restricted to high-risk infants due to its high cost and the requirement for monthly injections throughout the RSV season.
The landscape of pediatric preventative care shifted dramatically with the licensure of nirsevimab in 2023. Nirsevimab is a long-acting recombinant human IgG1κ monoclonal antibody designed with a triple-amino acid substitution (YTE) in the Fc region. This modification extends its terminal half-life to approximately 60 to 70 days, allowing for a single dose to provide protection for the duration of a typical five-month RSV season. While Phase 3 clinical trials demonstrated high efficacy, the transition to routine clinical practice—characterized by diverse patient populations and varying healthcare delivery models—required rigorous validation. This meta-analysis by Sumsuzzman et al. provides the most comprehensive evaluation to date of nirsevimab’s real-world impact.
Study Design and Methodology
The investigators conducted a systematic review and meta-analysis of postlicensure observational studies published between January 1, 2023, and June 20, 2025. This timeframe captures the initial global rollout of nirsevimab immunization programs. Data sources included major medical databases such as MEDLINE, Embase, and Web of Science, as well as preprint servers like medRxiv to capture the most recent data.
The inclusion criteria were strictly defined: studies had to report original data on nirsevimab effectiveness in infants and children aged 24 months or younger in routine clinical settings. Quality was assessed using the Critical Appraisal Checklist of the Joanna Briggs Institute, ensuring that the evidence synthesized was methodologically sound. The researchers employed a random-effects meta-analysis model to calculate pooled odds ratios (ORs) and 95% confidence intervals (CIs), a conservative approach that accounts for heterogeneity between studies.
The analysis eventually included 15 studies, with 11 contributing to the quantitative meta-analysis. The total cohort comprised 236,764 infants in the nirsevimab group and 27,522 in the control group across five countries, providing substantial statistical power to detect meaningful differences in clinical outcomes.
Key Findings: Quantifying the Impact of Nirsevimab
The results of the meta-analysis underscore the significant clinical benefit of nirsevimab across several key metrics of respiratory morbidity. The findings are categorized into primary outcomes related to hospitalizations and emergency department utilization.
LRTI-Related Hospitalizations and ED Visits
The primary finding of the study was a dramatic reduction in all-cause LRTI-related hospitalizations. Infants who received nirsevimab had an odds ratio of 0.38 (95% CI, 0.28-0.53) compared to those who did not. This translates to an approximately 62% reduction in the odds of being hospitalized for a lower respiratory infection. This is a critical finding for health policy, as LRTI hospitalizations represent the most significant cost and resource burden during the winter months.
Furthermore, nirsevimab demonstrated a strong protective effect against emergency department visits. For all-cause LRTI-related ED visits, the OR was 0.52 (95% CI, 0.37-0.73). When focusing specifically on RSV-confirmed LRTI, the protection was even more pronounced, with an OR of 0.24 (95% CI, 0.13-0.47), indicating a 76% reduction in the odds of an ED visit for RSV-related illness.
All-Cause Hospitalizations
Interestingly, the study did not find a statistically significant difference in all-cause hospitalizations (OR, 0.56; 95% CI, 0.14-2.20). While the point estimate suggests a trend toward reduction, the wide confidence interval crossing 1.0 indicates that nirsevimab does not significantly alter the overall rate of infant hospitalizations when all etiologies (including neonatal jaundice, surgical issues, and non-respiratory infections) are considered. This finding is biologically plausible, as nirsevimab is a highly specific antibody targeting the RSV fusion (F) protein and would not be expected to prevent hospitalizations unrelated to RSV or general respiratory distress.
Expert Commentary: Implementation and Policy Implications
The real-world effectiveness of nirsevimab, as demonstrated in this meta-analysis, matches or exceeds the efficacy reported in the MELODY and HARMONIE trials. This is particularly noteworthy given that real-world implementation often faces challenges such as storage requirements, timing of administration, and varying adherence rates. The data suggest that nirsevimab is a robust tool for public health.
However, clinicians and policy experts must consider several factors. First, the cost-effectiveness of universal versus targeted administration remains a point of debate in some jurisdictions. While the reduction in hospitalizations is clear, the high cost of the monoclonal antibody must be weighed against the savings in healthcare utilization. Second, the “all-cause LRTI” outcome is significant because it suggests that by preventing RSV, nirsevimab may also be reducing the incidence of secondary bacterial infections or complications that would otherwise lead to a non-specific LRTI diagnosis.
The lack of significance in all-cause hospitalizations serves as a reminder that while RSV is a major player, it is only one component of infant health. Nevertheless, the specific reduction in respiratory-related strain on the healthcare system is sufficient to support the continued expansion of nirsevimab programs. Future research should focus on the long-term effects of nirsevimab on childhood asthma and wheezing, as early RSV infections are known risk factors for these chronic conditions.
Conclusion
This meta-analysis provides high-level evidence that nirsevimab is highly effective in reducing the clinical and economic burden of LRTI in infants. By significantly lowering the odds of hospitalizations and ED visits, nirsevimab offers a viable path toward mitigating the seasonal crises caused by RSV. These findings support the integration of nirsevimab into routine pediatric immunization schedules and highlight its potential to improve infant health outcomes on a global scale.
References
1. Sumsuzzman DM, Shi C, Langley JM, Moghadas SM. Nirsevimab Against Hospitalizations and Emergency Department Visits for Lower Respiratory Tract Infection in Infants: A Meta-Analysis. JAMA Pediatr. 2025 Dec 22:e255280. doi: 10.1001/jamapediatrics.2025.5280.
2. Muller WJ, et al. Nirsevimab for Prevention of RSV in Healthy Late-Preterm and Term Infants. N Engl J Med. 2023.
3. Drysdale SB, et al. Nirsevimab for Prevention of Hospitalizations Due to RSV in Infants (HARMONIE). N Engl J Med. 2023.
