Infants in low- and middle-income countries bear the greatest burden of deaths from respiratory syncytial virus (RSV), yet access to prevention remains limited. Research by UMC Utrecht PhD candidate Neele Rave shows how local clinical and economic evidence can guide affordable immunization programs. Her findings highlight opportunities to protect young infants while reducing the financial burden on families and pressure on overstretched healthcare services.
Infection with the respiratory syncytial virus (RSV) is responsible for 3.6 million hospitalizations and >100,000 deaths each year among young children. The vast majority of these deaths occur in low- and lower-middle-income countries (LMICs) where there is limited access to supportive medical care. Maternal vaccination and long-acting preventive antibodies have recently emerged and now offer opportunities to prevent severe RSV infection. However, countries with limited healthcare budgets must weigh the benefits of these interventions against their costs and other competing priorities.
In her PhD thesis, Neele Rave, MSc (Department of Pediatric Infectious Diseases, UMC Utrecht) combined clinical research, cost-of-illness studies capturing both health system and household costs and health economics analyses from low- and middle-income countries (LMICs) to support these decisions.
In many LMICs, access to intensive care and RSV prevention remains limited, making severe RSV particularly dangerous for young infants. In the RSV GOLD-ICU Network Study across 12 hospitals in 10 LMICs, almost one-third of 2,118 children under two admitted with severe respiratory illness tested positive for RSV. Among 608 RSV-positive children with clinical records, 30 died; their median age was only 1.8 months.
For maternity and child healthcare teams, these findings reinforce the need to protect infants before they become severely ill. Where available, timely maternal RSV vaccination or infant immunization should therefore be integrated into routine care, with particular attention to ensuring protection from the first months of life.
As part of the RSV GOLD – Health Economics Study, studies by Neele Rave in Nepal and Mozambique revealed substantial costs for the healthcare system as well as the families related to RSV infection in children <2 years of age. In Nepal, average out-of-pocket household expenses reached approximately USD 200 for an RSV-related hospital admission and USD 472 for ICU admission, compared with a monthly minimum wage of USD 118. In Mozambique, public healthcare covered more treatment costs, but families still faced considerable expenses.
These differences show why prevention decisions must account for local healthcare financing as well as household costs as hospital expenditure alone does not capture the full burden of RSV.
Rave also modelled maternal vaccination and long-acting monoclonal antibodies for infants over ten years in both countries. In Mozambique, assuming a hypothetical price of USD 5 per dose, these strategies could prevent approximately 4,700 and 5,100 deaths, respectively. However, substantial health benefits did not automatically make either program cost-effective under the study’s main economic threshold. It is therefore crucial that RSV vaccines or antibodies are offered at affordable prices.
Results were more favorable in Nepal, which illustrates why findings cannot simply be transferred between countries. It should be noted that these estimates are modelled projections, not observed program outcomes.
Neele Rave summarizes: “For healthcare practitioners, our research highlights the importance of documenting disease severity, patients’ ages, seasonal patterns, costs and resource use. These data help countries to select appropriate interventions, plan delivery and evaluate impact. In addition, affordable pricing must go together with programs adapted to local services, ensuring that preventive measures reach infants before severe illness develops.”
Neele Rave, PhD (1992, Osnabrück, Germany) defended her PhD thesis on October 9, 2026 at Utrecht University The thesis is titled “From evidence to implementation: the added value of health economics for RSV immunization implementation in low- and middle-income countries.” Supervisor was Prof. Louis Bont, MD PhD and co-supervisor was Joanne Wildenbeest, MD PhD (both Department of Pediatric Infectious Diseases, UMC Utrecht). In May 2026, Neele started working as an international project manager at the Institute of Virology of the Medical University of Innsbruck, Austria. In that role, she coordinates the European-African Vaccine Initiative.
