TLP:GREENLimited disclosure, recipients can spread this within their community, but not via publicly accessible channels.
Note: Greentext indicates new or updated content in this report compared to the previous report.
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 utilizationare: 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.
Healthcare Ready is ENGAGED for this event. We are monitoring potential concerns for supply chain disruptions and impacts on healthcare services on ourPediatric Surge in Respiratory Illness response page, as well as listing resources and previous situation reports.
Assessment of Healthcare and 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.
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 hospitalizationsfor a hospital to reach pediatric bed capacity. Anecdotally,hospitals and healthcare workers are stressed from the high rates of RSV and influenza.
On 11/14, California reported thefirst 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 Midwestwith 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.
Flu-like respiratory illness levelshave increased across the United Stateswith 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) ofoutpatient 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 newUS COVID-19 hospitalizationsfor 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.
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.
TheRSV-NET Interactive Dashboardshows 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 aparticularly vulnerable groupto 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 studyfound 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.
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.
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. Therise in amoxicillin demandis likely related to viral infections as well as bacterial infections that can occur with RSV. Medication transaction data for October and Novembershowsamoxicillin 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 shortageslist includes the following drugs that could negatively impact treatment of RSV and other respiratory illnesses:
As of 11/15, Sodium chloride solutionof 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 databaselist 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.
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.
Healthcare Ready leverages unique relationships with government, nonprofit and medical supply chains to build and enhance the resiliency of communities before, during and after disasters.
Healthcare Ready is approved by the Internal Revenue Service as a 501 (C)(3) tax-exempt organization, and all donations are tax deductible to the extent provided by law. Healthcare Ready's Federal Identification Number (EIN)