The study, led by Shaolong Ren and colleagues working with the World Health Organization, is the first to quantify how the uneven introduction of nirsevimab, a long-acting monoclonal antibody licensed in 2022, and RSVpreF, a maternal vaccine licensed in 2023, could reshape global inequalities in infant RSV disease. The researchers built a static deterministic model that combined comprehensive epidemiological data on RSV burden, seasonality, and hospitalisation risk by birth month and age in months with country-level information on licensing and uptake as of June 2025. They then compared two futures: a world in which no country had introduced the products, and the world as it actually stood in mid-2025, with implementation frozen at that moment.

The baseline picture for 2019 revealed stark regional contrasts. The WHO African Region carried the highest incidence of RSV-associated acute lower respiratory infection, at 117.4 episodes per 1000 person-years, and the highest attributable mortality, yet paradoxically recorded the lowest hospital admission rate, just 12.6 per 1000 person-years. The Eastern Mediterranean Region, by contrast, had the highest admission rate at 29.9 per 1000. The African Region also showed the highest in-hospital case fatality ratio at 1.54 percent, closely followed by the South-East Asia Region at 1.49 percent. Crucially, in-hospital deaths accounted for only about 21 percent of RSV-attributable deaths in the African Region, meaning roughly four in five infants who died of RSV did so without ever reaching a hospital bed. Together, the African, South-East Asia and Eastern Mediterranean regions accounted for 88 percent of all infant RSV deaths.

The authors argue that the low hospitalisation rates in the highest-burden regions do not reflect milder disease. Instead, they point to barriers of affordability, distance and time to reach care. Severe RSV illness is treatable with supportive measures such as supplemental oxygen and intravenous hydration, but children in resource-limited settings often cannot access these in time. A recent study in Bangladesh underscored the point: 18.4 percent of children requiring hospitalisation were denied admission because of insufficient bed capacity, and those turned away faced a hazard ratio for death of 1.56 compared with children who were admitted. This pattern also implies, the researchers note, that preventive interventions could deliver even greater absolute benefit in poorly resourced settings, by averting the out-of-hospital deaths that currently dominate the mortality toll.

Against this backdrop, the implementation landscape as of June 2025 was strikingly skewed. Nirsevimab had been licensed in 54 countries and RSVpreF in 64, but only 16 and 12 countries respectively had incorporated them into their national immunisation programmes, and the overwhelming majority of those were high-income countries. The European Region accounted for 34 nirsevimab and 35 RSVpreF licences, and the Region of the Americas for 8 and 12, while the African Region had zero nirsevimab licences and just two for RSVpreF, and the South-East Asia Region only two of each. Of the countries that had licensed nirsevimab, 53 of 54 were high- or upper-middle-income; for RSVpreF the figure was 59 of 64. No low-income country had licensed either product.

The projections that followed were sobering. Under the June-2025 scenario, an estimated 4.64 million doses of nirsevimab and 1.96 million doses of RSVpreF would be administered annually, averting roughly 91,000 infant RSV hospital admissions and about 300 deaths worldwide. That translates to reductions of just 3.7 percent of global infant RSV admissions and 0.4 percent of deaths. The benefits were overwhelmingly concentrated in wealthy nations: high-income countries, which received about 90 percent of averted admissions and over 70 percent of averted deaths, saw reductions of 33.2 percent in hospitalisations and 29.1 percent in mortality. Middle-income countries saw relative reductions below 5 percent, and low-income countries, with no uptake at all, saw none.

The model’s assumptions were grounded in real-world evidence. Nirsevimab was assigned 83 percent effectiveness against RSV-associated hospital admission and 81 percent against attributable death, drawn from meta-analyses of real-world data; RSVpreF was assigned 71 and 77 percent respectively, informed by a test-negative study in Argentina. The model accounted for seasonal immunisation strategies with birth doses and catch-up doses for nirsevimab, year-round maternal vaccination in most countries, and mutual exclusivity between the two products to avoid double-counting protection. Uncertainty was propagated through 1000 simulation draws for each input parameter, and sensitivity analyses varying uptake, effectiveness, and alternative mortality data from the Global Burden of Disease Study 2023 all produced trends consistent with the main findings.

Most striking was what happened to measured inequality. The researchers ranked countries by RSV-attributable infant mortality and divided the global population into quintiles, then calculated the ratio of deaths between the highest- and lowest-risk fifths. Under no implementation, that ratio stood at 18.3, already a staggering expression of inequity. Under the June-2025 scenario it rose to 20.8, meaning the rollout of these lifesaving products is projected to make global RSV mortality inequality worse, not better. Within WHO regions, the increases were most pronounced where several countries had introduced the products: the ratio in the Region of the Americas climbed from 5.8 to 10.4, and in the European Region from 12.7 to 22.1. The authors warn that, drawing on the history of pneumococcal and rotavirus vaccines, coverage disparities between rich and poor countries can persist for years after initial introduction, so the true widening could exceed even these projections over the next five years.

There are signs that access may eventually improve. The WHO’s Strategic Advisory Group of Experts recommended infant RSV passive immunisation in late 2024, the WHO prequalified the maternal vaccine in March 2025, and Gavi’s board approved a funding window for RSV maternal immunisation programmes in July 2025. Yet the Gavi programme is not expected to introduce vaccines until 2028 and will initially reach only a handful of eligible countries. The study’s authors point to pooled procurement through UNICEF- and PAHO-led initiatives, the Gates Foundation-supported development of multi-dose vial formulations of the maternal vaccine, tiered pricing, technology transfer and stronger national immunisation advisory capacity as routes to accelerate adoption. At this juncture, they conclude, coordinated action by international agencies, governments, manufacturers and researchers is essential to ensure that the tools now transforming infant RSV outcomes in wealthy countries reach the infants who bear the greatest burden of the disease.

Subject of Research: Global regional inequality in infant RSV morbidity and mortality under expanded passive immunisation

Article Title: Regional inequality in infant RSV morbidity and mortality burden in the era of expanded RSV passive immunisation: a global projection modelling study

Article References: Ren, S., Cong, B., Zou, J., Guo, L., Nair, H., Sparrow, E., Feikin, D. R., & Li, Y. (2026). Regional inequality in infant RSV morbidity and mortality burden in the era of expanded RSV passive immunisation: a global projection modelling study. eClinicalMedicine, 100, Article 104219. https://doi.org/10.1016/j.eclinm.2026.104219

Image Credits: AI Generated

DOI: 10.1016/j.eclinm.2026.104219

Keywords: RSV, nirsevimab, RSVpreF, infant health, global health equity, modelling study, low- and middle-income countries, hospitalisation, maternal vaccination, monoclonal antibodies, WHO, vaccine access

The research team, led by analysts at the York Health Economics Consortium and clinicians at Manchester University NHS Foundation Trust, built a cost-effectiveness model aligned with the National Institute for Health and Care Excellence reference case. They simulated four distinct patient populations: people with early-stage lung cancer (stages 1 to 3a), people with late-stage head and neck cancer (stages 3 and 4), people with kidney cancer at any stage, and an exploratory general cancer population mixing several diagnoses. In every population examined, offering cessation support at diagnosis proved cost effective against the standard threshold of £20,000 per quality-adjusted life year, or QALY, gained.

The technical machinery behind the analysis is considerable. The model tracked a cohort of adults aged 18 and over who had recently been diagnosed with cancer and currently smoked, splitting them into those who quit and those who continued based on natural quit rates, service uptake, and five-year relapse rates. Each group then moved through a partitioned survival model with three health states: progression-free disease, progressed disease, and death. Survival trajectories were derived from published Kaplan–Meier curves, which the team digitised and converted into pseudo-individual participant data using the Guyot algorithm, before fitting six standard parametric distributions — exponential, Weibull, Gompertz, log-normal, log-logistic, and generalised gamma — to extrapolate long-term overall and progression-free survival beyond the observed follow-up periods.

Beyond cancer itself, the model accounted for seven smoking-related comorbidities: chronic obstructive pulmonary disease, coronary heart disease, myocardial infarction, type 2 diabetes, stroke, dementia, and asthma. Age- and gender-specific prevalence estimates for non-smokers were multiplied by smoking-status relative risks to generate weighted comorbidity risks for quitters and continuing smokers alike. Costs and QALYs were discounted at 3.5 percent per annum over a lifetime horizon — 25 years for the lung cancer cohort and 30 years for the others — with monthly cycles capturing clinical events, treatment costs, and health-related quality of life.

The headline numbers are striking in their asymmetry. In the lung cancer population, median time to death rose from 4.08 to 4.25 years, at an incremental cost of just £292 per person, yielding an incremental cost-effectiveness ratio of £2,606 per QALY. For head and neck cancer, median survival improved by four months at an additional £1,074 per person, an ICER of £5,495. Kidney cancer delivered the most emphatic result: the intervention was dominant, meaning it both saved money — £189 per person — and added 0.45 QALYs, driven by reduced spending on second-line treatment and end-of-life care. The general cancer population gained 0.10 QALYs at £392 extra per person, an ICER of £4,055.

Probabilistic sensitivity analysis, run across 1,000 iterations, reinforced confidence in these findings. Smoking cessation at diagnosis remained cost effective in 99.70 percent of iterations for lung cancer, 99.90 percent for head and neck cancer, 100 percent for kidney cancer, and 97.80 percent for the general cancer population. In the kidney cancer scenario, the intervention was outright dominant — cheaper and better — in 70.40 percent of simulations. Threshold analyses identified the boundaries of the result: the intervention stops being cost effective only if uptake falls below roughly 12 to 14 percent, or if the per-person implementation cost climbs above £2,000 to £6,600 depending on the population. Both boundaries sit comfortably away from realistic estimates, since uptake of cessation support offered during lung cancer screening in the UK has been measured at around 74 percent.

The biological rationale for the survival gains is well established. Smoking during treatment impairs overall survival, raises cancer-specific mortality, and increases treatment-related complications such as surgical site infections and pulmonary problems after surgery. Tobacco alters the biological characteristics of cancer cells and speeds the metabolism of anticancer drugs, meaning chemotherapeutic agents are cleared faster in smokers. Conversely, quitting after diagnosis has been shown in prospective cohort studies to reduce the risk of progression, cancer-specific death, and all-cause mortality compared with continued smoking. The model’s assumption that treatments themselves do not differ by smoking status is therefore conservative, since patients who quit may in fact be eligible for more treatment options, including surgery.

Scaled across the population, the implications are substantial. Around 57,000 cases of cancer are attributed to smoking in the UK each year, and the authors estimate that rolling out cessation services at diagnosis could generate a net monetary benefit upwards of £88 million based on the general cancer population. The cost of the cessation package itself — an estimated £257 per person, including an e-consultation proxy cost of £45.98 to cover NHS system restructuring and the pharmacological and behavioural treatments — represents between 0.34 and 0.53 percent of the total costs the NHS incurs during cancer care. By comparison, NICE-recommended immunotherapies such as durvalumab for limited-stage small cell lung cancer cost an estimated £141,335 per person, and nivolumab for head and neck cancer around £31,693.

The study is not without limitations, and the authors are candid about them. Survival data for the lung and kidney cancer populations came from a Russian cohort, an assumption judged reasonable by consulting oncologists who found no genetic or population characteristics that would materially alter outcomes in a UK setting. The Kaplan–Meier studies were predominantly male — roughly 80 percent across the three cancer-specific populations, against 50 to 70 percent in the wider cancer population — and natural quit rates and relapse rates were drawn from non-cancer populations due to data scarcity. The general cancer analysis required averaging costs and utilities across tumour types, and the authors caution that its results should be treated as exploratory. Several assumptions, such as equal relapse rates in each year after the first and identical treatment regardless of smoking status, deliberately bias the model against the intervention.

Beyond the immediate clinical economics, the findings carry broader significance. Tobacco smoking remains the largest single cause of health inequalities in England, and cancer mortality is almost 60 percent higher in the most deprived areas compared with the least; prior distributional cost-effectiveness work suggests cessation interventions reduce absolute health inequality. Reducing smoking would also cut second-hand smoke exposure, which is linked to ischaemic heart disease, COPD, respiratory infections, and stroke. The authors note that embedding cessation at diagnosis aligns squarely with the NHS 10-year plan’s stated shift from treating sickness to preventing it, and that effective first-line cancer treatment in non-smokers should reduce demand for costly second-line care. The remaining challenge, they conclude, is practical: delivering integrated services will require initial investment in staff and capacity, and policymakers must weigh rollout against the demonstrated value for money that this analysis makes abundantly clear.

Subject of Research: Cost-effectiveness of integrating smoking cessation services into NHS cancer care pathways in England

Article Title: Economic and health impact of integrating smoking cessation services into NHS cancer care pathways in England: a modelling study

Article References: Green, M., Harper, S., Telfer-Thomas, E., Agrawal, S., Callister, M. E., Lane, J. L., Warren, G., Murray, R. L., Evison, M., Sheikh, M., & Malcolm, R. (2026). Economic and health impact of integrating smoking cessation services into NHS cancer care pathways in England: a modelling study. The Lancet Regional Health – Europe, 71, Article 101869. https://doi.org/10.1016/j.lanepe.2026.101869

Image Credits: AI Generated

DOI: 10.1016/j.lanepe.2026.101869

Keywords: smoking cessation, cancer care, cost-effectiveness, NHS, health economics, QALY, lung cancer, head and neck cancer, kidney cancer, tobacco, modelling study, health inequalities