2022 Pediatric Respiratory Surge Event #3
Healthcare Ready is ENGAGED for this event. We are monitoring potential concerns for supply chain disruptions and impacts on healthcare services.
Summary
- ASPR has released the following response in response to inquiries regarding the Strategic National Stockpile (SNS) and cribs: The SNS inventory consists primarily of medical countermeasures as prescribed by law. Organizations should first attempt to acquire cribs through the commercial supply chain. If the need cannot be met by the commercial supply chain, or through another local source such as a healthcare coalition partner or health system partner, the need should be communicated to the ESF-8 representative consistent with the established emergency management policies for that jurisdiction. For needs that cannot be met at the state or territorial level, state and territorial public health preparedness officials should consult with ASPR Regional Emergency Coordinators regarding potential federal options to meet unmet health and medical needs.
- Albuterol sulfate inhalation solution has been added to the FDA drug shortage list.
- There is a shortage of tracheostomy tubes that is likely to impact pediatric patients because of the lack of alternative tubes with similar functionality. The FDA has released guidance on reusing tracheostomy tubes for patients and caregivers.
- On November 4, the CDC issued an official Health Advisory about early, elevated respiratory disease incidence caused by multiple viruses occurring especially among children and placing strain on healthcare systems.
- Cases of RSV requiring hospitalization decreased this week compared to last, but infection and hospitalization rates remain much higher than the norm, especially for this time of year. Babies aged 0 to <6 months have a significantly higher hospitalization rate compared to other age groups.
- The RSV-associated hospitalization rate of American Indian or Alaska Native, non-Hispanic individuals rose greatly compared to the previous week. The hospitalization rate for this group is 2.9 per 100,000 for the week ending 11/5.
- Southeastern and southcentral US are experiencing very high case rates of flu-like respiratory illnesses. In the US for the week ending 11/5, 12.8% of lab tests were positive for influenza.
Assessment of Healthcare Logistics Impacts
The confluence of RSV, influenza, and COVID-19 is creating a surge in severe pediatric respiratory illnesses and hospitalizations that threaten healthcare delivery systems. Flu and RSV activity are higher than usual for the time of year, and pediatric COVID-19 hospitalizations are also rising. According to HHS data, as of 11/8, the following states have more than or close to 90% of inpatient pediatric beds occupied: Rhode Island (98.29%), the District of Columbia (97.67%), Arizona (95.86%), and Minnesota (89.88%).
Hospitalizations and case rates for COVID-19 and influenza are tracked separately from RSV cases. This makes it difficult to discern the number of hospitalizations caused by each virus in each state. This may make it more difficult for jurisdictions to predict surges for each condition.
It is not yet clear how the surge in respiratory illnesses will impact the capacity of facilities, such as community health centers, free and charitable clinics, urgent care, or pharmacies. These facility types will be critical in case identification and triage of cases, which could reduce patient surge in hospitals. Healthcare Ready is working to understand these impacts so that support is situated where most needed within communities.
RSV
Rates of RSV have been surging since August, which is weeks earlier than during a typical season. There is some concern that the surge in RSV and other respiratory cases could have the potential to disrupt supply for treating hospital-admitted patients. There are reports of hospital admissions as high as triple the typical number of hospitalizations due to RSV, and other areas reporting that all pediatric beds are occupied.
Based on RSV spread and progression, current trends indicate that more states will experience strain on their healthcare systems because of this surge. RSV is common and usually harmless for most individuals, and predominantly manifests with cold-like symptoms during the winter. However, RSV infection can be severe for children under two years, the elderly, and the immunocompromised. Still, it does not typically threaten healthcare infrastructure the way it has this year. People will not be tested for RSV unless they are experiencing intense symptoms or other comorbidities.
Influenza
Southeastern and southcentral US are experiencing the highest case rate of flu-like respiratory illnesses. In the US for the week ending 11/5, 12.8% of lab tests were positive for flu (compared to test positivity rates of 0.3% in 2021 and 0.1% in 2020).
According to the latest World Health Organization (WHO) report, an increasing trend of influenza A was observed in the northern hemisphere. Influenza A is the dominant type in the US. The dominant subtype circulating is A(H3N2). Globally, influenza trends during the southern hemisphere’s respiratory season showed a significant increase in cases compared to the previous year – a possible predictor for what’s to come in the US. Australia’s number of recorded influenza cases doubled their previous record in May. In Australia, 60 percent of flu-related hospitalizations were for children 16 and under.
Pediatric impacts from flu might reach pre-pandemic levels, if not surpass them, due to pediatric population’s sensitivity to respiratory infections and lack of immunity. During the 2019-2020 respiratory season, 199 influenza-associated pediatric deaths were recorded in the US compared to 1 death in 2020-2021 and 44 deaths in 2021-2022. Two pediatric deaths have been recorded for the 2022-2023 season so far.
COVID-19
While the overall rate of US COVID-19 hospitalizations for all age groups shows a decline, the data for age groups 0-17 in November shows a recent increase in pediatric hospitalizations over the past month.
Health Equity Concerns
Infants younger than six months, especially those who are premature, are at and especially high risk for contracting RSV and are affected by typical symptoms of this illness. Other vulnerable populations to worse impacts to RSV, including higher hospitalization rates, include black children, older adults, older adults with comorbidities, the uninsured, and those living beneath the poverty line. A study published in 2021 investigating the relationship between socioeconomic status and the incidence of RSV found that those living in census tracts with higher rates of poverty were more likely to be hospitalized with RSV. The concern is that already underserved populations will face worse circumstances from the RSV surge.
Another concern is the disruption of non-ILI medical appointments for children as pediatric clinics and hospitals face large amounts of sick patients. In Boston, pediatric surgeries are being canceled to make room for more patients with respiratory distress. Likewise, pediatric primary care clinics, facing a surge in sick patients, are having to cancel and postpone routine medical exams.
At the center of Healthcare Ready’s work is building equity into our preparedness, response, and recovery resources, including this report. To learn more about Healthcare Ready’s core belief of why it is important to highlight vulnerable populations during disasters, read our Equity Framework.
Epidemiology Updates for Respiratory Illnesses of Concern
CDC maintains a Respiratory Virus Hospitalization Surveillance Network (RESP-NET), which is designed to “conduct population-based surveillance for laboratory-confirmed COVID-19, RSV, and influenza-associated hospitalizations.” RESP-NET is composed of three sets of surveillance data: Respiratory Syncytial Virus Hospitalization Surveillance Network (RSV-NET), Coronavirus Disease 2019 (COVID-19)-Associated Hospitalization Surveillance Network (COVID-NET), and Influenza Hospitalization Surveillance Network (FluSurv-NET).
CDC is tracking case detection trends state by state. CDC is also tracking case trends by Department of Health and Human Services (HHS) Region and Census Region.
RSV-NET includes data by age, sex, race and ethnicity, and county of residence. The RSV-NET Interactive Dashboard shows preliminary data for 58 counties in 12 participating states.
Disclaimer: The following RSV-NET data represents only the aggregated data from participating states; trends likely differ by geography. While it does not represent “the true burden of RSV-associated hospitalizations” (which may be higher due to the high likelihood of non-laboratory confirmed RSV cases) and covers around 8% of the US population, it may be useful for extrapolating impacts to different, potentially vulnerable populations. For the areas tracked by RSV-NET as of the week ending 11/5/2022:
- Overall hospitalization rates have fallen somewhat compared to the past week (3.0 per 100,000 individuals the week ending 11/5 compared to 3.4 per 100,000 individuals the week ending 10/31).
- The youngest populations continue to experience the highest hospitalization rates.
- The hospitalization rate for children aged 0 to <6 months was 145.2 per 100,000 (- 12.2 compared to the previous week, but still more than double the rate last year).
- Hospitalization rates for all ages remain high for:
- Hispanic individuals (2.7 hospitalizations per 100,000)
- Black, non-Hispanic individuals (1.6 hospitalizations per 100,000)
- Compared to White individuals (1.4 hospitalizations per 100,000)
- The hospitalization rate of American Indian or Alaska Native, non-Hispanic individuals rose greatly compared to the previous week. The hospitalization rate for this group is 2.9 per 100,000.
Government Response
Federal Posture
On November 4, the CDC issued an official Health Advisory about early, elevated respiratory disease incidence caused by multiple viruses occurring especially among children and placing strain on healthcare systems. Co-circulation of RSV, influenza viruses, COVID-19, and others could place stress on healthcare systems this fall and winter. This early increase in disease incidence highlights the importance of optimizing respiratory virus prevention and treatment measures, including prompt vaccination and antiviral treatment.
The CDC continues to monitor the increase in RSV, RSV-associated emergency department visits. and hospitalizations in all but two HHS regions (4 and 6). Some regions are already nearing the seasonal peak levels which are typically observed during the winter season.
The HHS Administration for Strategic Preparedness and Response (ASPR) Technical Resources, Assistance Center, and Information Exchange (TRACIE) has developed a Pediatric Surge Resources page highlighting resources to help address the response. ASPR will also be developing an email inbox to collect and answer requests for information about the surge.
Connecticut Children’s Medical Center in Hartford reported they are working with FEMA and the National Guard to potentially set up medical tents on the hospital lawn because of the increased need for beds. If hospitalization rates continue to rise, it is likely that there will be an increase in requests for state or Federal aid.
State and Local Posture
No updates on state or local health emergency declarations as of 11/9.
A small number of states and local jurisdictions have instituted emergency measures to expand ability to care for children. The Oklahoma State Department of Health will temporarily allow hospitals to designate adult beds for children amid a surge in RSV cases in children statewide.
Only one jurisdiction has issued an emergency declaration for this event thus far. On October 31, the County Health Officer of Orange County, California, issued a Declaration of Health Emergency in Orange County due to rapidly spreading virus infections – especially RSV – causing record numbers of pediatric hospitalizations and daily emergency room visits.
If cases continue to increase, we expect additional jurisdictions to allow for emergency measures in the coming weeks.
Global Response
Richard Peabody, head of the WHO High Threat Pathogen team, has shared report of low-level circulation of RSV in Europe, with no major surges observed as of yet.
Potential Threats for Pediatric Medical Surge
There are several challenges unique to managing pediatric medical surge, particularly for the healthcare workforce and supply chain. Pediatric hospitals require more intensive nursing resources to treat and monitor patients – especially patients in intensive care and neonatal intensive care. 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.
Product Availability
As of November 1, tracheostomy tubes are in short supply. The shortage of tubes is likely to impact the pediatric population the hardest because of the lack of alternative tubes with similar functionality. The FDA has released guidance on reusing tracheostomy tubes or switching to appropriate substitutes. The FDA is working with manufacturers and HHS to help manufacturers obtain the raw materials necessary to expedite supply of tracheostomy tubes.
Albuterol sulfate inhalation solution was added to the FDA drug shortage list on 10/25.
According to some pediatric clinics, RSV, flu, and COVID-19 testing kits have been on backorder.
The oral powder form of amoxicillin remains on the FDA drug shortage list. Other forms of amoxicillin are not on the shortages list.
Products of concern for this event include supplies and equipment that are commonly used to treat respiratory illnesses, and that may have limited numbers of manufacturers. Products that should be tracked for disruptions due to increased demand, include:
- Nasal cannulas (for which pediatrics has multiple sizes)
- Antivirals
- Fluids
- Pediatric ventilators
- Treatments like palivizumab
- Oxygen
- Pediatric intubation supplies
- Desitin and diapers
- Pediatric personal protective equipment (PPE), including N95s
Guidance for obtaining products and equipment that might be in shortage: organizations should first attempt to acquire them through the commercial supply chain. If the need cannot be met by the normal supply chain channels; or through another local source, such as a healthcare coalition partner or health system partner, the need should be communicated to the ESF-8 representative consistent with the established emergency management policies for that jurisdiction. For needs that cannot be met at the state or territorial level, state and territorial public health preparedness officials should consult with ASPR Regional Emergency Coordinators regarding potential federal options (such as the Strategic National Stockpile) to meet unmet health and medical needs.
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. Since the RSV season started earlier than anticipated, as it has the past two summers, hospitals may not be able to keep up with assuring an adequate supply of palivizumab.
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. We are working to determine considerations for the availability of this treatment in future assessments.
While there is not yet a vaccine for RSV, on Tuesday, November 1, Pfizer announced that they will seek FDA approval for their RSV vaccine by the end of 2022.
Workforce Shortages
Ongoing workforce shortages may threaten the ability for 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.
Hospitals and other healthcare facilities may need to increase surveillance for respiratory illnesses among staff to reduce spread and the potential for staff being out sick. Practitioner mental health should also be considered and protected. Additional training and support for practitioners that are not used to caring for acute pediatrics cases for prolonged periods should be provided whenever possible.
Preparedness Considerations for Healthcare Facilities
Several steps can be taken to enhance regional preparedness. Healthcare facilities and pediatric hospitals can prepare communication and resource-sharing networks to be poised for response by:
- Reviewing crisis standards of care that include pediatric strategies to avoid reaching crisis;
- Coordinating with healthcare coalitions, especially to review pediatric surge annexes;
- Training non-pediatric practitioners to be able to care for pediatric patients;
- Refreshing and reviewing transfer agreements with other children’s’ hospitals or adult hospitals with pediatric bed capacity;
- Refreshing and reviewing transfer agreements with other children’s hospitals or adult hospitals with pediatric bed capacity;
- Refreshing contacts with distributors and vendors to alert them of potential needs;
- Confirming contacts with county or city public health departments in case assistance needs to be requested;
- Reviewing and restocking pediatric and NICU Critical Supply Lists;
- Following the latest guidance from key institutions, such as: American Academy of Pediatrics, CDC, NIH.
As the US healthcare system prepares for influenza season this fall and winter, it will be essential that pediatric hospitals have beds available and access to the necessary medical supplies. Regional facilities should engage and enhance existing partnerships to ensure pediatric hospitals are armed with needed supplies (including via state caches, regional supplies via local healthcare coalitions, or other strategies in place to support surge or alternatives to existing supply sources). State and local public health departments may disperse information on the safety and efficacy of influenza vaccines to aid in communication needs around this event, along with providing additional guidance to support clinical diagnosis or helping parents and caretakers understand when to seek medical attention.
About Healthcare Ready
Healthcare Ready is a 501(c)(3) nonprofit organization that works to ensure patient access to healthcare in times of disaster, emergency, and disease outbreaks. We leverage unique relationships with government, nonprofit and medical supply chains to build and enhance the resiliency of communities before, during and after disasters. Learn more about Healthcare Ready
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