The Fight to End Childhood RSV in Indian Country
American Indian and Alaska Native infants experience the highest rates of RSV-related hospitalization in the U.S., but a breakthrough immunization is helping to close the gap
This article is part of “Innovations In: RSV,” an editorially independent special report that was produced with financial support from MSD, Sanofi and AstraZeneca.At first, Ethel Branch thought her two-year-old son, Patro, had a cold or maybe the flu. But on a chilly day in November 2022, a seemingly common childhood ailment took a hairpin turn that nearly sent him into respiratory failure.That day, fever, congestion and lethargy set in to the point that Branch took Patro to an emergency room in Winslow, Ariz., where he was diagnosed with croup, given steroids and released.On supporting science journalismIf you're enjoying this article, consider supporting our award-winning journalism by subscribing. By purchasing a subscription you are helping to ensure the future of impactful stories about the discoveries and ideas shaping our world today.But the following day, his temperature climbed and his chest began to cave in with each breath. Frantic, Branch rushed Patro to the larger Flagstaff Medical Center, where he was diagnosed with respiratory syncytial virus (RSV), placed on oxygen and admitted to the pediatric intensive care unit.“My son got COVID, and it was not that bad,” Branch recalls. “In fact, he didn't even really present symptoms. But with RSV, I couldn’t have waited any longer before taking him into the ER because his chest was depressed.”Patro left the hospital after four days, but his recovery was far from over. Three years later, he still goes to the emergency room for oxygen and breathing treatments every winter.For Branch, a Harvard-trained lawyer and former attorney general of the Navajo Nation, her son’s encounter with RSV was eye-opening. She realized that the dangers of RSV were largely unrecognized—not just by her or the health care workers who initially misdiagnosed him but across her tribal community as well.Over time, she also learned that her son’s experience was shockingly common among Native Americans, especially those on reservations, where lack of infrastructure and multigenerational households make them uniquely vulnerable to this and other illnesses. As a result, American Indian and Alaska Native infants bear the tragic distinction of experiencing the highest rates of RSV-related hospitalization in the country.After Patro contracted RSV, he spent four days in the pediatric intensive care unit at Flagstaff Medical Center in Arizona in 2022.But one year after Patro’s RSV scare, scientific breakthroughs emerged that have begun to bend the RSV curve among young children in Native communities: a monoclonal antibody and a maternal vaccine that can dramatically cut RSV-related hospitalizations among infants.Disease and Resilience on Navajo LandsWith a population of more than 400,000, the Navajo Nation (whose people are known as the Diné, pronounced Din-EH, in their language) is the largest federally recognized tribe in the U.S. And its reservation—home to more than 165,000 residents—is the largest in the country, encompassing roughly 27,000 square miles in northeastern Arizona, northwestern New Mexico and southeastern Utah. With a rich heritage, a distinct language and cultural traditions rooted in family and ties to their land, the Diné remain one of the strongest, most vibrant Indigenous communities in the world.Throughout their history, the Diné—like many other tribes—have endured devastating epidemics, including smallpox, mumps and pneumonia in the 17th and 18th centuries, which decimated their population. Their forced removal from their lands in 1864, known as the Long Walk, led to deadly outbreaks of measles, dysentery and pneumonia at the Bosque Redondo internment camp at Fort Sumner, N.M. The 1918 influenza pandemic killed an estimated 3,000 Diné, roughly one quarter of the tribe, according to the Navajo Times.In his seminal history on the pre-Columbian Americas, author Charles C. Mann noted that none of the major infectious diseases—including smallpox, measles, typhoid, leprosy, bubonic plague, tuberculosis, scarlet fever, diphtheria, influenza and cholera—existed in the Western Hemisphere prior to European contact.Recognizing the lethality of these diseases, the Europeans turned to biological warfare to destroy and subjugate Native communities by giving them smallpox-infected blankets, clothing and other “gifts,” deliberately spreading the deadly illness among Indigenous populations, according to medical researchers at the National and Kapodistrian University of Athens in Greece.Because of their lack of exposure and immunity to these pathogens, scientists and geographers estimate that by the beginning of the 1600s, infectious disease brought to the Americas killed more than 56 million Indigenous people, representing roughly 10 percent of the entire global population at the time. This was one of the deadliest demographic collapses in human history. In some cases, entire tribes became extinct, and their languages, histories and cultural ways died with them.When COVID arrived in early 2020, tribal nations across North America immediately understood the threat and implemented strict prevention measures, including lockdowns, checkpoints, temperature checks, masking and other methods to protect their communities.When vaccines became available, tribes became national public health leaders by testing and vaccinating their own members and opening their clinics and hospitals to the general public.Despite these efforts, tribal communities from Alaska to Maine still experienced some of the highest rates of COVID infection and death in the country. As of January 1, 2025, the Navajo Nation has recorded 93,980 confirmed cases and 2,334 deaths, according to the Navajo Epidemiology Center, and at one point it claimed the highest per capita infection rate nationwide.But even as COVID captured global attention, a quieter but relentless virus continued to stalk tribal communities, striking Native American infants and toddlers with unmatched severity: RSV.Battling RSV amid Social ChallengesRSV hospitalization rates among Indigenous infants and toddlers are up to 10 times higher than the rate in the general population.RSV has been a persistent threat among all tribes. Among them, its effect has been devastating in Alaska’s Yukon-Kuskokwim Delta, the Navajo Nation and the White Mountain Apache Reservation in Arizona, where pediatric hospitalization rates are among the highest in the world.RSV spreads rapidly through droplets, which can be transmitted from person to person via coughing or sneezing, direct human contact such as touching or kissing or contact with a contaminated surface. RSV can survive on hard surfaces for hours.The virus’s spread is often accelerated by living conditions and other socioeconomic factors on Native lands, such as overcrowded housing, limited access to health care and clean water, environmental hazards and barriers to transportation.These stark disparities have been driven largely by generations of displacement, broken treaties and systemic neglect. As tribes were forced by the federal government into isolated and under-resourced reservations in the late 1800s, these conditions became the norm.The legacy of those policies continues to shape the health of their communities, resulting in higher rates of infectious diseases such as RSV, according to public health experts and tribal epidemiologists.“Water alone is a huge public health issue for us because roughly 30 percent of the households on our reservation have no running water,” Branch says. “And it’s very expensive for our people to haul their own, and they have to ration, which has had a direct impact on the health of the Navajo Nation.”Access to basic resources and challenging living conditions have created environments where infectious diseases thrive—which highlights how health outcomes are tied to social inequities, says Laura Hammitt, director of Infectious Disease Programs at the Johns Hopkins Center for Indigenous Health.Laura Hammitt, director of Infectious Disease Programs at the Johns Hopkins Center for Indigenous Health, guided the Indigenous research portion of a worldwide nirsevimab study. American Indian and Alaska Native children have some of the highest rates of RSV transmission, hospitalization and mortality in the country.“Social determinants of health are really the root cause of the elevated RSV disease burden among Native American children,” Hammitt says. “This is a disease of poverty.”Even though the disparity has been well documented in medical research over many years, that information has rarely reached Native families themselves. That’s partly because the symptoms of RSV are similar to those of other respiratory illnesses, such as the flu and the common cold. And there haven’t been culturally relevant public health campaigns about RSV on Native lands, according to public health experts.“I was doing a lot of advocacy relating to COVID at the time [of the pandemic], because I was leading the Navajo and Hopi Families COVID-19 Relief Fund, a mutual aid nonprofit,” Branch explains. “So I had a hyperawareness of things like this. But even so, I had no idea what RSV was.”After her son’s hospitalization, Branch began researching RSV and was shocked to learn that high transmission rates on the Navajo Nation reservation had been a serious problem for years.As COVID cases began to decline and lockdowns eased on the reservation, she realized a public health crisis was emerging as people began to gather again, spreading germs. RSV surged among the tribe’s children, so Branch penned a column in the Navajo Times about her son’s experience and began educating other parents and caregivers about the risks and warning signs of RSV.Meanwhile frontline health workers, armed with experience from COVID, were building better systems to track and fight infectious diseases, laying the groundwork that continues to shape the Navajo Nation’s response to RSV and other medical threats.How COVID Shaped the RSV ResponseWhen pediatrician Amanda Burrage arrived at the Tuba City Regional Health Care Corporation on the Navajo Nation reservation in 2018, the facility had no coordinated effort to track and monitor RSV cases and admissions. But the emergence of COVID served as a catalyst for transforming the public health apparatus.Burrage led the efforts at Tuba City’s hospital by organizing a comprehensive response, including data collection, contact tracing, community outreach, disease surveillance, testing, vaccination campaigns and staff training. Once that infrastructure was in place, Burrage and her team could apply these same tools to other infectious diseases such as RSV.“Prior to COVID, we did not have anybody on staff at Tuba City focused on the data or tracking the RSV tests that were positive and cases that were hospitalized,” says Burrage, who serves as the facility’s medical director of public health. She splits her time between her clinical practice and public health efforts aimed at improving disease surveillance, prevention and response across the region.Amanda Burrage, a pediatrician and public health expert, is leading the efforts at Tuba City Regional Health Care Corporation on the Navajo Nation reservation to ensure children receive nirsevimab immunizations against RSV.As COVID cases began to recede, RSV transmission and hospitalizations started to spike at Tuba City, signaling the virus’s aggressive return after people stopped isolating.RSV primarily attacks the respiratory tract, inflaming the small airways and making it difficult for infants and children to breathe. The virus can cause a severe buildup of mucus that blocks airflow, reducing oxygen levels in the blood. For some children, this can quickly spiral into pneumonia or bronchiolitis, requiring hospitalization and sometimes intensive care. Because young children have more fragile immune systems and lungs, RSV can overwhelm their bodies quickly, making it one of the most dangerous respiratory viruses for infants and toddlers, according to the Centers for Disease Control and Prevention.“Once RSV is present, there is only supportive care,” Burrage says. “There is really no treatment, and it becomes about management of symptoms and monitoring for complications.”A Breakthrough Years in the MakingIn 2019, before COVID emerged in the U.S., a multidisciplinary team of physicians, epidemiologists, public health professionals and national research institutions joined forces in a monumental global effort to study the efficacy of a new immunization that helps to prevent severe RSV infections in infants and children.Nirsevimab, under the commercial name Beyfortus, is a monoclonal antibody that provides infants passive immunization from RSV. Developed jointly by AstraZeneca and Sanofi, it’s not technically a “vaccine” but an immunization that works by delivering antibodies that target the RSV-F protein, offering the strongest protection in the weeks after it is administered.Native Americans played a small but crucial role in a clinical trial of nirsevimab known as the MELODY study. Hammitt, who served as the lead investigator for the Indigenous portion of the trial, worked closely with the Navajo Nation to recruit participants and monitor the outcomes, ensuring the research was conducted in a culturally respectful and collaborative way.The initial phase of the trial was postponed during the first year of the pandemic but started again in 2021, according to Hammitt. Out of 1,490 global participants in that phase, approximately 83 Navajo infants were enrolled at Fort Defiance, Ariz., and at Shiprock and Gallup in New Mexico.The study’s integration of Indigenous communities provided critical data on the immunization’s efficacy in a high-risk group. The CDC’s Advisory Committee on Immunization Practices subsequently endorsed nirsevimab for all infants under eight months born during or entering their first RSV season. The committee made a special recommendation that American Indian and Alaska Native children aged eight months to 19 months receive a second dose for their second RSV season.When the trial began, prior to COVID, “we had pretty comprehensive data on what RSV looked like in a prepandemic setting,” Hammitt says. “We found that the Navajo Nation’s rate of serious RSV infection and hospitalization was about five times higher than the general U.S. numbers.”The results from the first phase of the trial were dramatic and immediate and showed that nirsevimab was about 75 percent effective at preventing RSV illness that required medical attention, says Hammitt, who has spent decades partnering with tribes in the U.S. Southwest and Alaska to study the impact of infectious disease on their communities.“We were a small but important part of the MELODY trial because of the need to really demonstrate that immunizations that are licensed and recommended work in the populations that need them the most,” she explains.After nirsevimab’s approval in 2023 by the Food and Drug Administration, public health officials at the Navajo Nation set their new public health apparatus in motion, reaching out to parents with eligible babies. Pfizer’s RSV vaccine for pregnant people, Abrysvo, was also approved that year and offered parents another option to protect their babies. A single dose administered between 32 and 36 weeks of gestation confers protection to the fetus through the placenta and lasts for about six months after birth.“We were very proactive in reaching every family who had a child that was eligible,” says Burrage, whose staff worked overtime on parent outreach at Tuba City. “We sent letters, made phone calls. And whenever a parent is in for a well-child visit or at prenatal checkups, we certainly offer it.”Burrage reports there has been a small increase in the number of parents who are hesitant to accept the shot because of the influence of antivaccine groups and misinformation. But given the risks and high prevalence of RSV among Navajo children, she says, the vast majority are choosing to immunize their children. A second antibody injection, Enflonsia, was approved by the FDA for infant use in June 2025. “We certainly recognize this to be a game-changer for us in our community,” Burrage says. “Many people know somebody who’s had severe illness that was admitted [to a hospital] with RSV—an older sibling, a niece or nephew. People recognize that it can be severe for young children and have almost universally accepted it.”After Patro’s hospital stay, Branch began educating other parents and caregivers about the risks of RSV in the Navajo Nation. She encourages all Indigenous parents to get their children immunized against the virus.Branch, who now serves as deputy county attorney for the Coconino County Attorney’s Office in Flagstaff, Ariz., hopes her son’s story will serve as a wake-up call regarding the dangers of RSV.Patro fell ill before any prevention measures were available. Every winter she has to whisk him to the emergency room if he shows signs of wheezing or labored breathing, a vestige of his serious brush with RSV in 2022.“You don't want your kid to get RSV—ever,” Branch says. “So get that vaccine so you can save yourself and your child the trauma of having it in the first place, which is a horrible experience for everyone. There are long-lasting effects, and you don’t want to have to go into the ER every winter with your child.”
