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.

Product Availability

• 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. FDA mentioned that this authorization expands the availability of multiplex tests for COVID-19 and influenza. The new test kit availability could ease clinic testing constraints as well as they become available.
• Amoxicillin remains in short supply.
  • As of 11/29, amoxicillin remains on FDA and ASHP drug shortage lists. Providers and patients continue to experience impacts. Alternatives to amoxicillin are being used, but pharmacists are searching for more alternatives in case of future surge.
  • In Ohio on 11/9, the State of Ohio Board of Pharmacy issued guidance allowing pharmacies to compound amoxicillin by combining it with other drugs or via dilution.
  • On 11/7, USAntibiotics, the sole American manufacturer of penicillin-based Amoxicillin, noted that they reached out to the Biden Administration to inform them that they are able to manufacture and store Amoxicillin to meet demand levels over the next five years.
  • Amoxicillin remains on allocation to protect supply until more product is available.
• Tamiflu, the nation’s most popular influenza prescription drug, remains in high demand with a current fill rate nearly double compared to the same time last year. As of 11/29 it remains on the ASHP shortages list. The generic alternative, oseltamivir, has been in short supply since the beginning of November.
  • Other alternative influenza antivirals include Xofluza, Rimantadine, Zanamivir.
  • Updated as of 11/3: 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 a no current shortages (as of 11/3) among many of other companies.
    • There are no current shortages for Relenza, Rapivab, and Xofluza.  
• ASHP’s current drug shortages list includes the following drugs that could negatively impact treatment of RSV and other respiratory illnesses:
  • As of 11/28: Bacteriostatic 0.9% sodium chloride vials of various sizes from Fresenius Kabi and Pfizer have been added. The shortage is likely caused by increased demand, related to the application of sodium chloride for respiratory therapy. Pfizer has bacteriostatic 0.9% sodium chloride 10 mL and 20 mL vials on backorder and the company estimates a release date of March 2023 for the 10 mL vials, and December 2022 for the 20 mL vials. The 30 mL vials are available in limited supply. Fresenius Kabi has bacteriostatic 0.9% sodium chloride 30 mL vials on backorder and the company estimates a release date of mid- to late-December 2022.
  • As of 11/28: 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 11/29: Sodium chloride solution of various formulations for injection from Fresenius Kabi and Pfizer. The reasons for the shortage are manufacturing delays. Resupply dates are anticipated at the end of November for Pfizer and early December for Fresenius Kabi.
  • As of 11/29: 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.  
  • As of 11/29: certain formulations of Oseltamivir, commonly known as Tamiflu, have been reported in short supply by several manufacturers. The FDA has yet to report 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 cannot find Tamiflu in pharmacies.
• FDA’s drug shortage database list the following updates regarding drugs that may be related to treating respiratory illness:
  • As of 11/29: Amoxicillin oral powder for suspension is available for current customers from Hikma pharmaceuticals. As of 11/29, most of the amoxicillin oral powder product for suspension from Sandoz is unavailable. Additionally, as of 11/29, product from Aurobindo and Teva is on allocation.
  • As of 11/29: 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.
• 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.”

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.

Workforce Shortages

Workforce Shortages continue to impact access to care in hospitals around the country.

• Resident physicians, doctors, hospitals staff are advocating for increased federal support.
• In Washington, D.C., resident physicians staged a demonstration on 11/16 in response to the increasingly stressful work environment in light of the “tripledemic.” At this demonstration, doctors called for compensation, mental health care, paid sick leave, and more to better reflect the burden of work they are providing. One resident stated that it is not uncommon to have a single resident physician caring for 36 premature babies overnight.
• Hospitals around California are noting that RSV, influenza, and COVID-19 are straining the systems of care delivery and asking for federal support to address needs in hospitals.
• To accommodate the surge in cases, some Boston area hospitals are canceling scheduled surgeries and calling neighborhood hospitals asking for additional beds and staff. While reported needs across facilities vary widely, hospital staff and physicians agree there is persistent need for space and staff.

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.