2022 Pediatric Respiratory Surge Event #4
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
- Nationwide, pediatric bed utilization has increased from last week (35 states have increased bed occupancy on 11/16 compared to 11/10). This correlates with increased rates of RSV and influenza across age groups and ethnicities compared to previous seasons.
- As of 11/17, states with the highest rates of in-patient pediatric bed utilization are: Arizona: 99% (+3.14%), Rhode Island: 94% (-4.29%), Utah: 94% (+8%), District of Colombia: 92% (-5.67%), Texas: 91%, and Minnesota: 91% (+1.12%).
- Nationally, 76% of pediatric beds are occupied, down 2% from 78% on 11/10.
- RSV case rates for some racial minorities (Hispanic, Alaskan/Native American) are rising much faster compared to Whites.
- RSV cases have become more prevalent in the Midwest and parts of the West compared to last week where cases were largely concentrated in the Southeast.
- Physicians should be aware of alternatives for amoxicillin which is in short supply. Some manufacturers have placed limits on amounts of amoxicillin pharmacies can order to respond to this shortage.
- As of 11/15, the American Academy of Pediatrics (AAP) and the Children’s Hospital Association (CHA) have called for government officials to declare a public health emergency in response to this RSV surge.
- As of 11/15, Oregon became the first state to declare a public health emergency in response to RSV case and hospitalization rates.
- On 11/14 California reported the first RSV and influenza related death of a child under 5 years old.
- Several manufacturers are reporting limited or no supply of certain oseltamivir formulations (an influenza antiviral).
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. Influenza and RSV activity are higher than usual for the time of year, perhaps due to pandemic related preventative measures being relaxed. 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 for case identification and first-line treatment.
Healthcare Ready is working to understand these impacts to best support in communities with highest needs.
Confluence of RSV, COVID-19, and Influenza
- Vaccine-preventable illnesses are experiencing rises in case rates. This follows a trend of decreasing childhood vaccination rates for routine vaccinations during the COVID-19 pandemic, including for influenza, which is believed to have made some groups of children more susceptible to preventable viral infections, such as measles, mumps, rubella, influenza, chickenpox, polio, etc. The decline in vaccination rates have left children unprotected and trends have shown a struggle to catch up to pre-pandemic vaccinations rates.
- Without a vaccine for RSV, the influenza vaccine becomes more critical in limiting respiratory-related hospitalizations this flu season. Officials note that hospital capacity could rapidly decline, especially because there are far fewer pediatric beds. In some cases, it can take as few as 9-10 new hospitalizations for a hospital to reach pediatric bed capacity. Anecdotally, hospitals and healthcare workers are stressed from the high rates of RSV and influenza.
- Studies on coinfection of influenza and RSV reveal that interaction between respiratory viruses might impact virus pathogenesis and make viral infections more difficult to treat.
- On 11/14, California reported the first death of a child due to RSV and influenza. The child was under five years old and living in Southern California. Missed vaccinations may be a contributing factor that has led to an increase in influenza cases and coinfections with other illnesses.
- According to data from RSV-NET, as of 11/18, RSV hospitalization rates are higher than they were two weeks ago, and slightly lower than last week when rates peaked.
- According to CDC RSV Census Regional Trends, as of 11/15, cases of RSV are trending higher in the Midwest with about a 30% positivity rate and over 4,762 PCR detections.
- The West follows closely behind with about a 23% positivity rate and 2,917 PCR detections.
- RSV in adults often presents like a common cold and does not typically result in high numbers of hospitalizations. RSV in young children, the elderly, and the immunocompromised are at higher risk of hospitalization and negative impacts from RSV. RSV does not typically threaten healthcare infrastructure the way it is this year. Testing for RSV is not administered unless patients present with intense symptoms or other comorbidities.
- Flu-like respiratory illness levels have increased across the United States with five new states increasing to moderate high levels of flu-like activity. Compared to last week, 30 (+7) states, plus Puerto Rico, are experiencing high to very high levels of ILI. Overall, flu-like respiratory illnesses are increasing across the nation.
- For week ending 11/5, the 0-4 age group experienced the highest rates (15.4) of outpatient visits for flu-like illness, which is 1.5 times higher than the 5-24 age group. This is in-line with larger data that the youngest populations are disproportionately contracting respiratory illnesses.
- The overall rate of new US COVID-19 hospitalizations for all age groups is lower than the beginning of the year, however pediatric admissions are increasing slightly.
- National-level data shows a decrease of 2.7% from the prior week. As of 11/16, trends are as follows for the following age groups:
- People ages 0-17: 0.2 (+0.02 from 11/06) new admissions per 100,000
- People ages 70+: 4.78 (-0.2 from 11/06) new admissions per 100,000
Epidemiology Updates for Respiratory Illnesses of Concern
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, which may make it more difficult for jurisdictions to predict surges for each condition.
CDC tracks cases in three ways, by: State, HHS Region, and census region.
From CDC’s RSV-NET* for week ending 11/11:
- The youngest populations continue to experience the highest hospitalization rates.
- The hospitalization rate for children aged 0 to <6 months was 171 per 100,000 (- 14.2 compared to the previous week, but still almost triple the rate of last year).
- Hospitalization rates for all ages remain high for:
- Hispanic individuals (3.5 hospitalizations per 100,000)
- American Indian/Alaska Native (3 hospitalizations per 100,000)
- Compared to White individuals (1.9 hospitalizations per 100,000)
- *RSV-NET data represents only the aggregated data from participating states (8% of the US). Hospitalizations may be higher due to the high likelihood of non-laboratory confirmed RSV cases, and lack of data for potentially vulnerable populations.
- CDC maintains the Respiratory Virus Hospitalization Surveillance Network (RESP-NET) for laboratory-confirmed COVID-19, RSV, and influenza-associated hospitalizations.
- The RSV-NET Interactive Dashboard shows preliminary data for 58 counties in 12 participating states. RESP-NET uses three sets of surveillance data:
Health Equity Concerns
From CDC’s RSV-NET* for the week ending 11/11:
- Hispanic individuals are being hospitalized at a higher rate (3.6 per 100,000) than other races and ethnicities and are experiencing a higher rate of hospitalization than the national rate (3.5 per 100,000).
- Similarly, Alaska Natives (AN) have historically been a particularly vulnerable group to RSV; some studies have found that AN children in Southwest Alaska were hospitalized for RSV at a rate three times higher than the general US pediatric population. In general, AN children experience one of the highest rates of hospitalization for lower respiratory tract infections and RSV among children in the US.
- A study found that multi-generational households and general “crowding” in the household were associated with an increased rate of RSV in high-risk children under the age of five. This may be why Hispanic individuals have been experiencing higher rates of hospitalization this season.
- Nationally, RSV-related hospitalization rates are declining across all races and ethnicities, which may result in the reduction of burden on healthcare systems if cases continue to trend down. Despite this downward trend, the current hospitalization rate is still high compared to previous years.
- Infants aged 0-<6 months continue to experience the highest hospitalization rates with 171 hospitalizations per 100,000 (-14.2). Though this data shows sharp declines in hospitalizations across race and ethnicities and age groups, this data only accounts for about 8% of the US and could misrepresent actual trends of hospitalizations.
- Infants younger than six months, especially those born premature, are at an especially high risk of contracting RSV. Other populations vulnerable to worse impacts to RSV, including higher hospitalization rates, include black children, pregnant people, older adults, older adults with comorbidities, the uninsured, and those living below the poverty line. A study published in 2021 found that those living in census tracts with higher rates of poverty were more likely to be hospitalized with RSV.
- Another concern is the disruption of non-influenza-like illness (ILI) medical appointments for children as pediatric clinics and hospitals face large amounts of sick patients.
- 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.
- As of 11/15, the American Academy of Pediatrics (AAP) and the Children’s Hospital Association (CHA) have called for government officials to declare a public health emergency in response to this RSV surge. They are reporting that pediatricians and healthcare professionals need federal support to allow flexibility in care.
- As of 11/4, CDC issued an official Health Advisory about rising rates of RSV and the co-circulation with COVID-19 and influenza and its potential impact on healthcare systems. CDC is continuing to monitor the increase in RSV and the effect on hospitals. HHS ASPR and TRACIE developed a Pediatric Surge Resources page highlighting resources to help address the response.
State and Local Posture
- As of 11/15, according to the Oregon governor’s office, Governor Kate Brown issued an executive order under ORS Chapter 401 to support hospitals during the pediatric RSV response and Oregon declared a public health emergency. Oregon is the first state to issue an emergency declaration for the pediatric surge event.. Oregon is likely to exceed its previously recorded peak weekly hospitalization rate of 9.5 per 100,000 children imminently.
- Los Angeles County Public Health may reinstate indoor masking requirements if COVID-19 case counts reach 100 per 100,000 residents. Los Angeles COVID-19 case counts are at 86 per 100,000.
- If cases continue to increase nationally, we expect additional jurisdictions to allow for emergency measures in the coming weeks.
- Jurisdictions with emergency measures:
- On 11/12, Oklahoma State Department of Health allowed hospitals to designate adult beds .
- On 10/31, Orange County, CA issued a Declaration of Health Emergency in Orange County.
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.
- Physicians should be aware of alternatives for amoxicillin when prescribing it to their patients as remains in shortage. The rise in amoxicillin demand is likely related to viral infections as well as bacterial infections that can occur with RSV. Medication transaction data for October and November shows amoxicillin is being prescribed at much higher rates than typical months, with especially high rates for children aged 0-2 and aged 3 to 12. Some manufacturers have placed limits on amounts of amoxicillin pharmacies can order to respond to this shortage.
- ASHP and FDA are tracking this issue. There are alternative medications to prescribe considering the shortage, such as oral cephalosporins that can address many of the same bacteria as amoxicillin, or antibiotic amoxicillin-clavulanate. However, this these alternative treatments options can cause more side effects, are more costly, and if relied on too heavily could cause a shortage.
- The American Society of Health-Systems Pharmacists’ current drug shortages list includes the following drugs that could negatively impact treatment of RSV and other respiratory illnesses:
- As of 11/15, Sodium chloride solution of various formulations for injection from Fresenius Kabi and Pfizer. Reasons for shortage are manufacturing delays. Resupply dates are anticipated at the end of November for Pfizer and early December for Fresenius Kabi.
- As of 11/14, Rocuronium injection, used during tracheal intubation, is on shortage from several manufacturers due to increased demand and manufacturing delays. Estimated resupply dates vary from manufacturers.
- As of 11/9, certain formulations of Oseltamivir, commonly known as Tamiflu, has been reported in short supply by several manufacturers. The FDA has not yet reported a national shortage of this drug as they believe other manufacturers can meet demand. As this antiviral is used to treat influenza, physicians may need to prescribe other medications if their patients are unable to find Tamiflu in pharmacies.
- The Food and Drug Administration’s drug shortage database list the following updates regarding drugs that may be related to treating respiratory illness:
- As of 11/14, Amoxicillin oral powder for suspension is available for current customers from Hikma pharmaceuticals. However, as of 11/1 amoxicillin oral powder for suspension is not available from Sandoz.
- As of 10/25, Albuterol sulfate inhalational solution, manufactured by Akorn Pharmaceuticals, remains unavailable and is estimated to be restored by Q2 2023.
According to some pediatric clinics, RSV, flu, and COVID-19 testing kits have been on backorder.
ASPR received inquiries regarding the Strategic National Stockpile (SNS) and cribs. They responded noting that the SNS inventory contains primarily medical countermeasures supplies as prescribed by law. As of 11/8, ASPR encourages organizations to first try to acquire cribs through commercial supply chain channels. If that supply is insufficient or unsuccessful, then the need should be communicated to the ESF-8 representative consistent with that jurisdiction’s emergency management policies. Needs that are not met at the state or territory level, then public health preparedness officials are advised to consult with ASPR Regional Emergency Coordinators to explore federal options
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. Palivizumab is prescribed to prevent RSV in high-risk children, however it has not been shown to help patients once they are already infected with RSV. Before COVID-19, physicians were prescribing Palivizumab more frequently as a preventative measure, however this treatment strategy slowed during the pandemic. Due to the increase in RSV, the AAP updated guidance. The 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.
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.
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. 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.
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.
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