2022 Pediatric Respiratory Surge Event #11
Healthcare Ready is ENGAGED for this event. We are monitoring potential concerns for supply chain disruptions and impacts on healthcare services.
Highlights and Key Updates
- RSV is trending downward and has peaked in most areas of the US and influenza rates are declining at the national level. However, many jurisdictions continue to experience high hospitalization rates and influenza rates. Seven-day averages of cases and hospitalizations due to COVID-19 have decreased (-22.7%) compared to the prior seven-day averages, however, experts note that COVID-19 cases and hospitalizations starkly differ regionally around the US.
- As of 1/18, states with the highest rates of in-patient pediatric bed utilization are: Idaho: 135.48% (-22.66 percentage points since 1/4), Rhode Island: 93.52%, North Carolina 88.99%, Arizona: 86.30% (+4.99), District of Colombia: 85.16% (+0.99), Texas: 81.69% (-1.38), Nebraska: 76.83% (+3.17), Oklahoma: 79.11%, Missouri: 78.47%, Delaware: 76.53%, and Oregon: 75.52%.
- Nine other states (Minnesota, Utah, Pennsylvania, Massachusetts, Maine, Connecticut, Tennessee, Nevada, and Alaska) remain at or above 70% of pediatric hospital bed utilization.
- CDC released a new dashboard tracker, Respiratory Virus Hospitalization Surveillance Network (RESP-NET), to record the confluence of RSV, COVID-19, and Influenza hospitalization rates.
- There is not yet an FDA-approved RSV vaccine on the market. However, Moderna has reported that its RSV vaccine has an 84% efficacy rate at preventing disease in adults aged 60 and older. Moderna plans to file for approval with the FDA in the first half of 2023.
- On 1/11, The COVID-19 public health emergency (PHE), which provides federal, state, and local flexibilities in regulation and funding support for the response to RSV and flu, was renewed, for another period of 90 days. If the COVID-19 PHE is not renewed before its expiration in mid-April 2023, between 5.3 and 14.2 million Medicaid enrollees could lose their coverage between April and July 2023.
- Updated as of 1/6: FDA’s list of available antiviral medications for the 2022-2023 influenza season.
- The FDA is continuing to monitor the pediatric ibuprofen and acetaminophen supplies which have experienced increased demand due to increases in respiratory illnesses. While there is not a nationwide shortage of these drugs, there are still widespread stockouts in regions of the country due to overbuying of products and the lack of ability to redistribute excess supplies to areas experiencing spot shortages.
- Healthcare Ready is regularly updating a map showing HHS data on pediatric hospital bed utilization. The map was last updated with data from 1/18.
- This is the final situation report for this event.
Assessment of Healthcare Logistics Impacts
The confluence of respiratory illnesses is creating a surge in severe clinical presentations and hospitalizations that threaten healthcare delivery systems. Influenza and RSV activities are higher than usual for this time of year, due to relaxed pandemic-related preventative measures.
Healthcare Ready is working to understand these impacts to best support communities with the greatest needs.
- Pediatric units in hospitals remain strained across the US. While there has been a considerable decrease in pediatric hospitalizations since 1/4, pediatric bed utilization remains high overall, with 6 states reporting over 80% of pediatric beds in use.
- As of 1/18, 66.54% of pediatric beds in the US are occupied (+1.4 percentage points from 1/4), with Idaho and Rhode Island being the only states reporting bed utilization above 90%. However, bed utilization estimates may be underestimated due to low participation from hospitals reporting into HHS TeleTracking. For 1/18 data, 59.34% (-3.06 percentage points compared to 1/4) of US hospitals were reporting. Local capacity may vary drastically within a given state as not all hospitals report data. As such, hospital capacity is likely more strained than reflected in the available data.
- As of 1/18, states with the highest rates of in-patient pediatric bed utilization are: Idaho: 135.48% (-22.66 percentage points since 1/04), Rhode Island: 93.52%, North Carolina 88.99%, Arizona: 86.30% (+4.99), District of Colombia: 85.16% (+0.99), Texas: 81.69% (-1.38), Nebraska: 76.83% (+3.17), Oklahoma: 79.11%, Missouri: 78.47%, Delaware: 76.53%, and Oregon: 75.52%.
- Nine other states (Minnesota, Utah, Pennsylvania, Massachusetts, Maine, Connecticut, Tennessee, Nevada, and Alaska) remain at or above 70% of pediatric hospital bed utilization.
- Healthcare Ready is regularly updating a map showing HHS data on pediatric hospital bed utilization (snapshot, below).
Confluence of Respiratory Illnesses
- RSV is trending downward most areas of the US and influenza rates are declining at the national level. However, many jurisdictions continue to experience high hospitalization rates and influenza rates.
- Seven-day averages of cases and hospitalizations due to COVID-19 have decreased (-22.7%) compared to the prior seven-day averages, however experts note that COVID-19 cases and hospitalizations starkly differ regionally around the US.
- COVID-19 cases and hospitalizations are rising on the East Coast (likely because of large and dense populations), while cases and hospitalizations are plateauing on the West Coast and Midwest.
- CDC released a new dashboard tracker, Respiratory Virus Hospitalization Surveillance Network (RESP-NET), to record the confluence of RSV, COVID-19, and Influenza hospitalization rates. RESP-NET data shows cases and hospitalizations of all three infections “based on surveillance conducted through a network of acute care hospitals in select counties in 13 states.”
Disclaimer: The following analysis is based on the limited available data from RESP-NET.
- The graph below shows that for the week ending in 1/7, the aggregate hospitalization rate for the three respiratory infections (RSV, COVID-19, and flu together) was lower than COVID-19 hospitalization rates in the same week during the 2021-2022 and 2020-2021 respiratory seasons.
- This data shows that this current respiratory season (2022-2023) is more severe in terms of RSV, Influenza, and COVID-19 all at once. Even though the rates of COVID-19 are lower than the previous two seasons, this season’s rates combine rates remain higher (more severe) than typical.
- In a regular season (2018-2019), rates of RSV and influenza were lower than the current seasons’ (2022-2023) rates; meaning that hospitalizations may not be as severe as during peak COVID-19 but remain comparatively serious.
- Children’s COVID-19 and influenza vaccination rates are remarkably low throughout the US, increasing the chances of children being infected with both illnesses (and RSV) at the same time. COVID-19, influenza, and RSV can coexist in a patient, causing coinfection, especially in children or people with comorbidities. The reason children are especially susceptible to coinfections is unclear, but experts agree that one way to prevent this is to encourage vaccination.
- As of 1/4, American Academy of Pediatrics analysis based on CDC data shows 11% of children aged 6 months to 4 years have received at least one dose of COVID-19 vaccine and 35% of children aged 5 to 11 years have received at least one dose of COVID-19 vaccine. In total, across the US, 57% of children aged 6 months to 17 years, or 41 million children, have not received any dose of the COVID-19 vaccine.
- Child vaccination rates for influenza are about 64% for at least two doses of influenza vaccine.
- On 12/22, CDC issued an initial Health Advisory to notify clinicians and public health authorities of a recent increase in pediatric invasive group A streptococcal (iGAS) infections. As the rates of Strep A rise, the concern is how it will increase/ contribute to strain on the hospital and healthcare systems.
- CDC created an advisory page for possible increase in iGAS infections in the US.
- Colorado, Minnesota, and, most recently, Pennsylvania have released advisories regarding the increase in cases. Streptococcus A is typically treated with penicillin or amoxicillin.
- If Streptococcus A infections continue to spread globally, the penicillin class of antibiotics, which includes already disrupted amoxicillin formulations, may see greater disruptions in an already strained market.
- Data shows that overall rates of RSV cases and hospitalizations are trending downward across the US and have likely peaked in most areas. RSV-NET data shows RSV cases and hospitalizations in most areas continue to trend downward (from limited data) with hospitalizations falling to more typically expected levels. A lack of comprehensive localized (smaller than state-level) data leaves gaps in national picture of when and where cases are peaking. Disclaimer: The following analysis is based on the limited available data for RSV.
- CDC National Respiratory and Enteric Virus Surveillance System (NREVSS) RSV laboratory test data show:
- RSV cases in HHS Region 8 (Montana, Wyoming, Utah, Colorado, North Dakota, and South Dakota) have likely peaked regionally. Cases in some states in the Region may not have peaked: Montana state level data shows the start of a downward trend in 3-week averages for RSV PCR test positivity, suggesting that cases have now peaked in the state. State level data shows a downward trend in 3-week averages for RSV PCR test positivity in Wyoming. However, total PCR tests in the state are relatively low, so it is possible some cases have not been captured. PCR test positivity for North Dakota and Colorado indicates cases in those states are trending downward. PCR test positivity in South Dakota has shown an inconsistent (not continuous) upward trend in PCR test positivity. Data for Utah is not available.
- Cases in Region 10 (Washington, Oregon, Idaho, Alaska) likely have peaked. PCR test positivity for Idaho, Washington, Oregon, and Alaskahttps://www.cdc.gov/surveillance/nrevss/rsv/state.html” /l “ID shows a downward trend in 3-week averages for RSV PCR test positivity.
- Most measures of cases for Region 9 (California, Nevada, Arizona, Hawaii) show RSV cases are trending downward and have likely peaked. In California, Nevada, Arizona, and Hawaii RSV PCR test positivity is trending downward.
- There is not yet an FDA approved RSV vaccine on the market. However, Moderna has reported that its RSV vaccine has an 84% efficacy rate at preventing disease in adults aged 60 and older. Moderna plans to file for approval with the FDA in the first half of 2023. Moderna is starting clinical trials on children in an ongoing early-stage trial. Pfizer is also developing an RSV vaccine, and both are in the stages of gaining FDA approval.
- Guidance for assessing and prioritizing bronchiolitis patient needs is available in resources such as East Tennessee’s Children’s Hospital’s Bronchiolitis Care Map and Spectrum Health’s Clinical Pathway: Pediatric Bronchiolitis, Inpatient.
- WRAP-EM subject matter experts released a 10-minute video “Just-in-time Bronchiolitis Pearls and Pitfalls,” which is intended to be an overview to bronchiolitis care for providers with limited pediatric experience.
- ASPR TRACIE released guidance on use of high flow nasal cannulas (HFNC) in pediatric patients, including the clinical pathways, decision support tools, and information on use of HFNC in non-intensive care unit settings and during patient transport.
- For the week ending 12/24, CDC reports that “seasonal influenza remains high but appears to be declining in some areas.”
- Influenza-like illnesses (ILI) levels are very high across the United States for the week ending in 12/24. Forty-four jurisdictions, including New York City, Puerto Rico and the District of Columbia, are experiencing high to very high levels of ILI. Seven (- 2) of the jurisdictions are reporting ILI activity level 13, the highest possible. Those jurisdictions are: Colorado, Idaho, Maine, Massachusetts, Nebraska, New Mexico, and New York City. Kentucky, Oklahoma, Tennessee, and Washington are no longer at level 13. Oklahoma, Tennessee, and Washington continue to have very high activity (levels 11-12).
- Very high ILI activity, levels 11-13, indicates that flu activity is 12-20 standard deviations present above the mean, indicating that the area’s infrastructure, workforce, and supply chain capacities might not be able to accommodate local needs without additional assistance.
- Influenza-associated pediatric deaths rose to 61 (+31) for 2022-2023 flu season as of the week ending 12/24. Region 4 (Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee) accounts for almost 1/3 of pediatric deaths with count of 19.
- HHS Region 10 (Alaska, Idaho, Oregon, Washington State) has the highest rate of pediatric mortality (2; rate is calculated as number of deaths reported per 100,000 inhabitants age 17 or younger) followed by Regions 1 & 4 (1.3).
- Region 10’s rate of pediatric mortality doubled between weeks 49 and 51.
- The number of influenza-related hospital admissions reported to HHS Protect system decreased during week 51 as compared to the previous week, marking a three-week streak, but remain high compared to recent seasons.
- CDC estimates that this season, there have been at least 20 million influenza infections, 210,000 hospitalizations and 13,000 influenza-related deaths. For comparison, CDC estimates that there were 9 million influenza infections, 4 million medical visits, 100,000 hospitalizations, and 5,000 influenza-related deaths during the entire 2021-2022 season.
- The test positivity rate decreased to 19.8% (-5.6 percentage points) compared to the week ending 12/10 (25.4%).
- For the week ending in 12/24, the 0-4 age group experienced the highest rates (14.6%; – 1.3 percentage points compared to the week ending 12/10) of outpatient visits for influenza-like illnesses.
- National-level data shows a decrease (compared to the week ending in 1/10) in new hospital admissions of pediatric patients with confirmed COVID-19. New admissions of elderly patients decreased since the week ending in 1/10. New admissions of patients with confirmed COVID-19 have shown a continuous decline since 1/04. As of 1/17, compared to the average admissions for the week ending 1/10:
- People ages 0-17: -18.8% new admissions per 100,000
- People ages 70+: -18.3% new admissions per 100,000
- National level data shows that COVID19-related patient admissions are still 82.5% lower for the age group 0-17 and 67.1% lower for those 70+ when compared to the previous year’s COVID19 admission peak of January 10-16, 2022.
- The COVID-19 public health emergency (PHE), which provides federal, state, and local flexibilities in regulation and funding support for the response to RSV and flu, was renewed on January 11, 2023, for another period of 90 days. If the COVID-19 PHE is not renewed before its expiration mid-April 2023, between 5.3 and 14.2 million Medicaid enrollees could lose their coverage between April and July 2023.
- When the Federal PHE is rescinded, measures relied upon by hospitals to manage ongoing surge, including 1135 waivers, staff redeployment flexibilities, and telemedicine flexibilities, will no longer be available. This will limit surge capacity of hospitals.
- Federal funding for COVID-19 vaccines might run out as early as this month – January 2023, at which point COVID-19 vaccines and therapeutics will become available only via the commercial market.
- According to an analysis from the Kaiser Family Foundation, “private insurers will be required to take on more of the cost of vaccines (including paying for the doses themselves once the federal supply runs out), which could have a small upward effect on premiums.”
- Implications for how these changes may affect vaccine availability and out-of-pocket costs to patients will become clearer as the commercial cost of vaccines and mechanisms for distribution and purchasing are defined.
Health Equity Concerns
- Even as RSV trends downward, childcare disruptions continue throughout the US with COVID-19 and influenza infections continuing in adults. The tenuousness of childcare is forcing parents, especially women, to miss work hours or leave the workforce entirely to provide childcare and is creating financial strain on parents and families. Financial strain may have long-term impacts on resilience of the families to withstand future emergencies.
- This has a disproportionately negative impact on women. Women are typically in the childcare role and are more likely to be in service-oriented jobs with less stability/time off.
- CDC tracks influenza vaccine uptake throughout this influenza season, including by demographic. There are disparities in vaccination coverage for children by race and ethnicity. This season so far, coverage for Black, Non-Hispanic (NH) children (39.6%) is: 9.6 percentage points lower compared with White, NH children (49.2%), 9.0 percentage points lower compared with Hispanic children (48.5%), and 11.3 percentage points lower compared with children in the Other, NH race/ethnicity group (50.9%). The “Other, NH race/ethnicity group” includes children who are Asian, American Indian or Alaska Native, Native Hawaiian or Other Pacific Islander, multiracial, and children whose parents reported their race as “Other.”
- Children with underlying conditions, especially obesity and diabetes, are more likely to experience severe COVID-19 and hospitalization. According to data from CDC’s COVID-19 Associated Hospitalization Surveillance Network (COVID-NET), during the 2021-2022 Omicron surge (December 2021 – February 2022): 70% of hospitalized children had an underlying medical condition, 19% were admitted to an intensive care unit, and children with diabetes and obesity were more likely to experience severe COVID-19.
- For the limited areas tracked by CDC’s RSV-NET* for the week ending 12/24, hospitalization rates for all races and ethnicities have fallen compared to the previous week.
- On 1/11, The COVID-19 public health emergency (PHE), which provides federal, state, and local flexibilities in regulation and funding support for the response to RSV and flu, was renewed, for another period of 90 days. If the COVID-19 PHE is not renewed before its expiration mid-April 2023, between 5.3 and 14.2 million Medicaid enrollees could lose their coverage between April and July 2023.
- On 12/30, the HHS-ASPR deployed a 14-person National Disaster Medical System (NDMS) team to the University of New Mexico (UNM) Children’s Hospital, which was operating above 100% capacity.
- The NMDS team is comprised of medical professionals from around the country, and includes a team leader, administrative specialist, a medical officer, a nurse practitioner, four registered nurses, four paramedics, and two respiratory therapists.
- Hospitals that need assistance should reach out to their local health department; Jurisdictions that need assistance should reach out to their ASPR Regional Teams.
- On 12/21, HHS increased access to Tamiflu (oseltamivir) through the Strategic National Stockpile. Jurisdictions should work with ASPR Regional Teams to evaluate any requests for Tamiflu through the SNS.
- On 12/20, CDC’s Health Alert Network (HAN) issued the alert, “Important Updates on COVID-19 Therapeutics for Treatment and Prevention.”
- The alert supplements previous advisories that emphasize that the majority of Omicron sublineages circulating in the US have reduced susceptibility to the monoclonal antibody bebtelovimab and the monoclonal antibody combination, cilgavimab and tixagevimab (EvusheldTM). Due to this resistance, as of 11/30, use of bebtelovimab is not FDA authorized for patients with COVID-19.
- Ritonavir-boosted nirmatrelvir (Paxlovid™), remdesivir (Veklury®), and molnupiravir (Lagevrio™), retain activity against currently circulating Omicron sublineages and are widely available for eligible patients.
- On 12/15, the White House announced its COVID-19 Winter Preparedness Plan. The Plan focuses on expanding access to COVID-19 testing, vaccinations, and treatments. The plan notes that HHS Secretary Becerra sent a letter to all governors regarding actions to take to prepare for COVID-19 surge and reminding them of the federal support available for their responses.
- On 12/14, CDC HAN distributed Interim Guidance for Clinicians to Prioritize Antiviral Treatment of Influenza in the Setting of Reduced Availability of Oseltamivir, where it outlines:
- General recommendations for clinicians and public health practitioners; and,
- Guidance for prioritization when antiviral supplies are limited (per medical setting, age, and condition)
- On 12/07, CDC created an advisory page for possible increase in iGAS infections in the US where it outlines what actions parents, healthcare providers, and laboratorians should do if they suspect a child might be infected with Streptococcus A.
- On 12/2, Secretary of the Department of Health and Human Services Xavier Becerra sent a letter to state governors providing guidance on how to deal with the pediatric hospitalization crisis. The letter reiterates the resources and tools that are available, including flexibilities under the COVID-19 PHE declaration, as well as funding available from the Centers for Disease Control (CDC).
- There is currently no declared federal public health emergency (PHE) for pediatric surge.
- An emergency declaration would grant waivers for certain Medicare and Medicaid programs and the Children’s Health Insurance Program (CHIP).
- PHE waivers for Section 1135 of the Social Security Act waiver would allow for easier movement or transfer of patients, use of new spaces for care, creation of offsite triage to manage capacity challenges, adaptation to workforce shortages, and licensure reciprocity to enable cross-state care, including telehealth.
- CDC issued an official Health Advisory on 11/14 about rising rates of RSV and the co-circulation with COVID-19 and influenza and its potential impact on healthcare systems.
- HHS ASPR and TRACIE Pediatric Surge Resources page.
State and Local Posture
Healthcare Ready developed a report explaining how emergency declarations can strengthen public health capabilities and surge capacities in this response. Healthcare Ready recommends that healthcare systems advocate for local declarations to access immediate resources at the state and regional levels.
The following table summarizes states with active emergency declarations or states of emergency for COVID-19 and/or respiratory surge. Six states are under a state-level emergency declaration for COVID-19. Connecticut and Kansas’s PHEs for COVID-19 have expired in the last four weeks. Two states (Oregon and Colorado) are under a state of emergency specific to respiratory surge.
Potential Threats for Pediatric Medical Surge
Several challenges are unique to managing pediatric medical surges, particularly for the healthcare workforce and supply chain. For one, pediatric hospitals require more intensive nursing resources to treat and monitor patients, especially in intensive care and neonatal intensive care units.
Additionally, pediatric supply chains can also be more vulnerable to supply chain disruptions, as some critical products have only one supplier or manufacturer capable of producing the necessary pediatric-specific equipment and supplies.
- The repeal of China’s COVID Zero policies have led to a surge in COVID cases. Pharmaceutical companies around the world rely on active pharmaceutical ingredients (APIs) and key starting materials from abroad, including China. Without reliable reporting from China’s economic partners, analysts are keeping a close eye for any warning signs of supply chain disruptions in every sector.
- The upcoming Lunar New Year holiday may exacerbate disruptions. The holiday lasts from January 21 to 27. Every year, factories are shut down for an extended period to celebrate the Lunar New Year in China and other countries in Asia, and suppliers typically take this into account in their planning and logistics. However, along with the compounding impacts of COVID-19 workforce illness in China, the supply chain may witness additional disruptions this year as production has already been delayed.
- In Shanghai, hospitals have reported a rapid surge in COVID-19 cases – especially after the revoked zero-COVID policy. Since December 8, 2022, the Chinese government has reported over 60,000 COVID-19 related deaths. The impact of COVID-19 on the workforce in China as well as the shutdown for the Chinese New Year will have compounding effects on the international supply chain.
- Amoxicillin remains in short supply.
- As of 1/19, multiple forms of amoxicillin remain on the FDA and ASHP drug shortage lists. This includes tablets, capsules, and powder for suspension. Providers and patients continue to experience impacts.
- The American Academy of Pediatrics reported on alternative therapies during the shortage.
- Tamiflu (oseltamivir)
- On 12/21, HHS/ASPR announced that Tamiflu will be released from the Strategic National Stockpile and other sources to states and territories that request it.
- Tamiflu and its generic oseltamivir remain in high demand. As of 1/19, both the oral suspension and capsule formulations of oseltamivir remain on the ASHP shortages list. Oseltamivir is not currently on the FDA shortage list.
- Updated as of 1/6: FDA’s list of available antiviral medications for the 2022-2023 influenza season.
- FDA notes that while certain variations of Tamiflu are unavailable, there are no reported shortages (as of 1/19) among many companies.
- Many over-the-counter pediatric pain relievers (ibuprofen and acetaminophen) are experiencing spot shortages locally. With the exception of ibuprofen oral suspension (prescription only), which is on the ASHP Shortages list, these products are not yet on the ASHP or FDA Drug Shortage lists. The FDA is continuing to monitor the pediatric ibuprofen and acetaminophen supplies which have experienced increased demand due to increases in respiratory illnesses. They are working closely with the manufacturers on their efforts to further increase supply in response to the increased demand.
- Johnson & Johnson, the maker of children’s Tylenol and Motrin, has said that there is not a nationwide shortage. The issue is there is no efficient way of redistributing children’s medication to parts of the country where stocks are low.
- The two largest pharmacy chains, CVS and Walgreens have started implementing limitations on purchasing children’s pain relief and fever reducing over the counter medicines. CVS purchases are restricted to two items online and in-store, and Walgreens is limiting buys to 6 items online (in-store purchases are not limited).
- ASHP’s current drug shortages list includes the following drugs that could negatively impact treatment of RSV and other respiratory illnesses:
- As of 1/17: 0.9% Sodium Chloride 10 mL, 20 mL, and 50 mL Preservative Free Vials and Syringes from Pfizer have been added. Pfizer stated that the shortage is due to an increase in demand. The 10 mL syringes are on back order and Pfizer estimates a release date of June 2023.
- As of 1/11: Oseltamivir Oral Suspension and Capsules of various sizes from 8 different companies have been added. Ajanta and Alembic have oseltamivir available to contracted customers. Alvogen has oseltamivir suspension and capsules available. Genentech has Tamiflu presentations available and is reviewing orders. Strides has oseltamivir capsules available. Lupin has oseltamivir on shortage due to the increase in demand. Alembic has oseltamivir 30 mg capsules on back order and the company estimates a release date of late-January 2023. Macleods has oseltamivir 30 mg capsules on back order and the company estimates a release date in late-February 2023.
- As of 1/13: Albuterol Sulfate and Ipratropium Bromide Inhalation Solution from Mylon and Nephron Pharmaceuticals Corporation have been added. While both companies have not provided a reason for the shortages, it is safe to assume shortages are being experienced due to the increased use of albuterol inhalers in hospitals to treat COVID-19 patients in respiratory distress. Both companies estimate a release date in mid-to-late January 2023.
- Reverified on 1/19: Albuterol Inhalation Solution from Akorn and Nephron Pharmaceuticals Corporation are still currently on the ASHP drug shortage list. Both companies estimate a release date May to June of 2023.
- As of 1/17: 0.9% Sodium Chloride Small Volume Bags (< 150 mL) of various sizes from six different companies have been added. There are a multitude of reasons for the shortage including increased demand, manufacturing delays, and labor shortages. A number of the companies have supplies on allocation as they work through this shortage while Fresenius Kabi expects a release date of mid-January 2023.
- As of 1/17: 0.9% Sodium Chloride Large Volume Bags of various sizes from five different companies have been added. The majority of companies stated that the reason for the shortage was due to an increase in demand. Additionally, a majority of the companies have product on allocation to their customers while Fresenius Kabi estimates a release date of mid-January 2023for the 250, 500, and 1000 mL bags. This was pushed back from December 2022.
- Reverified 1/19: Ibuprofen Oral Suspension (Prescription Products Only) from Teva has been added. While no reason for the shortage has been provided, we can assume it is due to or exacerbated by the surge of respiratory illnesses impacting the nation. There has been no estimated resupply date.
- As of 1/10: Bacteriostatic 0.9% Sodium Chloride Vials of various sizes from Fresenius Kabi and Pfizer remain in shortage. The shortage is likely caused by increased demand, related to the application of sodium chloride for respiratory therapy. Pfizer has 0.9% sodium chloride 10 mL and 20 mL vials on backorder and the company estimates a release date June 2023 for the 10 mL vials and March 2023 for the 20 mL vials. Fresenius Kabi estimates a release date of late-January to early-February 2023 for the 10 mL vials and the 30 mL vials.
- As of 1/17: 23.4% Sodium Chloride Injection of various formulations from Fresenius Kabi and Pfizer have been added. Both Fresenius Kabi and Pfizer have said the shortage is due to an increase in demand. Expected resupply dates are mid-January 2023.
- Reverified 1/17: Ceftazidime Injection (and its generic name Tazicef) from Pfizer, Sagent, and BBraun have been added. The shortage is due to increased demand, likely due to the fact that ceftazidime is used to treat a wide variety of bacterial infections and providers could be prescribing this drug as a remedy to respiratory symptoms.
- As of 1/10: Rocuronium injection, used during tracheal intubation, is in shortage from several manufacturers due to increased demand and manufacturing delays. Estimated resupply dates vary based on manufacturer.
- FDA’s drug shortage database lists the following updates regarding drugs that may be related to treating respiratory illness:
- Reverified on 1/11: Amoxicillin oral powder for suspension is available for current customers from Hikma pharmaceuticals. As of 12/6 most of the amoxicillin oral powder product for suspension from Sandoz is unavailable while some has limited availability. Additionally, as of 12/6, products from Aurobindo and Teva are on allocation.
- Reverified on 1/19: albuterol sulfate, a bronchodilator for oral inhalation, manufactured by Akorn Pharmaceuticals, remains unavailable and is estimated to be back in stock by Q2 2023. A 5 mL version from Nephron Pharmaceuticals is available.
- FDA’s medical device shortage database lists the following updates regarding medical devices that may be related to treating respiratory illness:
- As of 10/31: two ventilation-related products are on the FDA medical device shortage list – JOH (Tube Tracheostomy And Tube Cuff) and BTO (Tube, Tracheostomy (with and without Connector).
- Definitions for product shortage vary by organization. Healthcare Ready sources data from multiple organizations that maintain drug shortage lists, including:
- American Society of Health-System Pharmacists (ASHP), which defines a drug shortage as “a supply issue that affects how the pharmacy prepares or dispenses a drug product or influences patient care when prescribers must use an alternative agent.”
- US Food and Drug Administration (FDA), which defines a drug shortage as “a situation where the total supply of all versions of the approved product available at the user level will not meet the current demand, and a registered alternative manufacturer will not meet the current and/or projected demands for the potentially medically necessary use(s) at the user level.”
- On 11/22, the FDA issued an emergency use authorization (EUA) for the Lucira COVID-19 and influenza multiplex test for use in a point-of-care (POC) setting. This will expand the testing kit pool as well as reduce the strain on the testing kit supply chain as two tests are combined into one.
Treatments for RSV
A monoclonal antibody therapy called palivizumab is available as a precautionary measure to prevent severe RSV illness in certain infants and children at high risk for severe disease during the normal respiratory season. It cannot cure or treat children who are already suffering from severe cases of RSV; it is a preventative treatment.
- On 11/17, AAP updated its guidance: Given the known efficacy of palivizumab along with the unpredictable surge capability of RSV, AAP recommends programmatic consideration of providing more than five consecutive doses of palivizumab depending on the duration of the current RSV surge in a particular region of the country.
- Palivizumab is sold under the brand name Synagis, and is marketed by Sobi in the United States. Sobi purchased US rights to Synagis from AstraZeneca in 2018. Before COVID-19, physicians prescribed Palivizumab more frequently as a preventative measure, yet, this treatment strategy slowed during the pandemic.
- AAP says that it recommends Palivizumab in eligible infants in regions that are experiencing high rates of RSV and that it will release updated guidance as they monitor the seasonal trends.
The nursing shortage is currently being exacerbated by the rise in hospitalizations amongst the adult and pediatric population. The demand for pediatric nurses is increasing along with the surge of respiratory illnesses; at the same time, fewer nurses are entering the workforce.
Ongoing workforce shortages may threaten the ability of facilities to establish a predictable quality of care for patients. Because pediatrics is a specialty practice, there may be additional strain on the workforce with pediatric care experience. Reports indicate that pediatricians are requesting increased federal support as they deal with RSV, COVID-19, and influenza treatment in unison. Physicians state that they can only successfully handle this “tripledemic” with the assistance of a federal emergency declaration and dissemination of support. The Administration for Strategic Preparedness and Response (ASPR), Technical Resources, Assistance Center, and Information Exchange (TRACIE) team has a staffing resources section on their pediatric surge response resources page, which can be found here.
Hospitals and other healthcare facilities may need to increase surveillance for respiratory illnesses among staff to reduce the spread and the potential for staff being out sick. Practitioners’ mental health should also be considered and protected. Additional training and support for practitioners that are not used to caring for acute pediatric cases for prolonged periods should be provided whenever possible.
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