2022 Pediatric Respiratory Surge Event Situation Report #6

2022 Pediatric Respiratory Surge Event #6

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

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 communities with the greatest needs.

Pediatric Hospitalizations
  • As of 11/30, 75.47% of pediatric beds are occupied (-2.23 percentage points from 11/22), with six states reporting bed capacity above 90%. Bed utilization estimates may be underestimated due to low participation from hospitals reporting into HHS TeleTracking.  
  • As of 11/30, states with the highest rates of in-patient pediatric bed utilization are: Idaho: 104.50% (+15.41 percentage points), Arizona: 98.31% (-0.56), Utah: 97.20% (+1.30), Nevada; 96.63%, Rhode Island: 93.69% (+2.48), Kentucky: 93.41% (-1.95), Oregon: 89.61% (-0.51), Minnesota: 88.54% (-1.85), Texas: 86.99% (-2.04), and District of Colombia: 86.82% (-8.93).
  • Healthcare Ready is regularly updating HHS data on pediatric hospital bed utilization (snapshot, below).
Confluence of RSV, COVID-19, and Influenza
  • Following post-holiday trends during the COVID-19 pandemic, travel and gatherings for Thanksgiving and winter holidays are expected lead to a rise in observed cases for COVID-19, influenza, and RSV.
  • The uptake of COVID-19 and influenza vaccines will be a crucial factor for limiting respiratory-related hospitalizations throughout the winter months.
    • As of 11/16, American Academy of Pediatrics analysis based on CDC data shows only 10% of children aged 6 months to 4 years old have received at least one dose of the COVID-19 vaccine. 38% of children aged 5 to 11 years and 68% of children aged 12 to 17 years have received at least one dose of COVID-19 vaccine.
    • As of 11/5, about 1 in 3 children (35.4%) between the ages of 6 months and 17 years have been vaccinated for influenza for the 2022-2023 season. This is similar to the rate compared with the same week in the 2021-2022 (35.3% of children).
    • Alabama, Maryland, Montana, and West Virginia have relatively low influenza vaccination uptake in children 6 months to 17 years old when compared to the 2021-2022 season. Children in these states may be at greater risk for severe illness due given reduced influenza vaccine coverage.
    • Only 22.4% of children living in rural areas are vaccinated for influenza. This is lower than the previous year (29.2%).
  • Data shows that rates of RSV cases and hospitalizations may have peaked in some areas of the US. However, lack of comprehensive localized (smaller than state-level) data leaves gaps in the national picture of when and where cases are peaking. Disclaimer: The following analysis is based on the limited available data for RSV.
  • CDC stated in a webinar that “for RSV, some HHS regions (3, 4, and 6) are seeing decreased test positivity and may have peaked” as of 11/29. These regions include New Mexico, Texas, Oklahoma, Arkansas, Louisiana (region 6); Kentucky, Tennessee, Alabama, Mississippi, Georgia, Florida, South Carolina, North Carolina (region 4); and West Virginia, Virginia, District of Columbia, Maryland, Delaware, and Pennsylvania (region 3).
  • The data from CDC’s RSV-NET* for the week ending 11/26 shows a decrease of RSV-related hospitalization rates in most demographics, including children ages 6 months to 4 years. The non-representative dataset shows declines in hospitalizations across race and ethnicities and age groups (data accounts for about 8% of the US and actual trends may be higher).
  • For the areas reporting to RSV-NET: As of the week of 11/26, the youngest populations continue to experience the highest hospitalization rates. The hospitalization rate for children aged 0 to 4 years was 17.9 per 100,000 (-26.7 compared to the previous week, but greater than the rate for the same time last year [12.0]).
Source: CDC RSV-NET Interactive Dashboard. Accessed: December 1, 2022
    • *RSV-NET data represents only the aggregated data from participating states (8% of the US). Hospitalizations may be higher due to the increased likelihood of non-laboratory confirmed RSV cases and lack of data for potentially vulnerable populations.
  • 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.
  • 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.
  • Influenza season usually lasts from October to May and peaks between December and March.
    • This season, a significant increase in cases was noted 6 weeks earlier than normal, with the rate twice as high as usual.
    • The 2022-2023 influenza season is the most severe in terms of hospitalizations for the time of year in 13 years. According tCDC, “the cumulative hospitalization rate… is higher than the rate observed in week 46 during every previous season since 2010-2011.”
  • Influenza-like illnesses (ILI) levels are high across the United States. Thirty-three states and the District of Columbia are experiencing high to very-high levels of ILI. The test positivity of tests grew by 10.06 percentage points between the week ending 11/12 (8.16%) and the week ending 11/19 (18.22%). The highest levels are reported from Texas, New Mexico, and Tennessee. Influenza-like respiratory illnesses are increasing across the nation on a uniform trajectory.
    • For the week ending 11/19, the 0-4 age group experienced the highest rates (15.4%) of outpatient visits for influenza-like illnesses, which is 1.5 times higher than the 5-24 age group. Aggregated data of all age groups demonstrates that the youngest populations are disproportionately contracting respiratory illnesses.  
Source: CDC Outpatient Respiratory Illness Activity Map. Accessed November 30, 2022
  • Federal funding for COVID-19 vaccines might run out as early as in January 2023, at which point COVID-19 vaccines 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.
  • National-level data shows an increase in new hospital admissions of pediatric patients with confirmed COVID-19 compared to the prior week. New admissions of elderly patients also increased since the week ending in 11/20. New admissions of patients with confirmed COVID-19 have shown a continuous upward trend that began in late October. As of 11/27, compared to the average admissions for the week ending 11/20:
    • People ages 0-17: +14.6% new admissions per 100,000
    • People ages 70+:  +14.1% new admissions per 100,000
  • If the upward trend of COVID-19 hospitalizations continues into the respiratory season, healthcare institutions might end up dealing with compounded crisis conditions and surge, putting further strain on healthcare infrastructure and workforce of these multiple populations.
Health Equity Concerns
  • For the limited areas tracked by CDC’s RSV-NET* for the week ending 11/26, hospitalization rates for all races and ethnicities have fallen compared to the previous week.
    • Hispanic individuals of all ages have the highest rates of RSV hospitalizations for the week ending 11/26 (2.1 [-1.3] hospitalizations per 100,000). Hispanics had the greatest cumulative rates of RSV-related hospitalizations for the 2021-2022 season.
    • American Indian/Alaska Native individuals are also experiencing relatively high hospitalization rates (1.4 [-0.7] hospitalizations per 100,000).
Source: CDC RSV-NET Interactive Dashboard. Accessed:December 1, 2022
  • 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 childrenpregnant peopleolder adultsolder 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.
  • 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.
  • Alaska Natives (AN) have historically been a particularly vulnerable group to RSV. In general, AN children experience one of the highest rates of hospitalization for lower respiratory tract infections and RSV among children in the US.
  • 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.

Government Response

Federal Posture
State and Local Posture

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.

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.
  • 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.

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.

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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