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Highlights and Key Updates
Nationally, 77.7% of pediatric beds are occupied, up 1.7% from 76% on 11/16. As of 11/20, 30 states show increases in in-patient pediatric bed utilization, with highest rates in: Arizona: 98.87% (-0.13%), Rhode Island: 96.17% (+2.17%), Utah: 95.90% (+1.90%), District of Colombia: 95.75% (+3.75%), Kentucky: 93.41%, Maine: 90.43%, Minnesota: 90.39% (-0.61%), Oregon: 90.12%, Idaho: 89.09%, and Texas: 89.03% (-0.97%).
Amoxicillin remains in short supply. At least one US based company has reached out to the White House to indicate greater capacity for manufacturing and storage.
Massachusetts and Colorado have joined other states or jurisdictions in expanding or amending COVID-19 policies and emergency measures to address the surge.
There are reports of rising rates of pertussis (a vaccine-preventable respiratory illness) in parts of California, New York, and Texas.
COVID-19 vaccination rates for children vary widely across states, ranging from 2% to 37% having received their first dose according to analysis of CDC data by AAP. Policies and messaging aimed at increasing COVID-19 vaccination rates for eligible infants could be a powerful way to reduce their risk of severe illness and hospitalization, which could mitigate additional surge.
As of 11/23, there is no response to AAP and CHA’s November 15 letter calling for government officials to declare a public health emergency for RSV.
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
Background
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
Nationally, 77.7% of pediatric beds are occupied (up 1.7% from 11/16).
As of 11/20, states with the highest rates of in-patient pediatric bed utilization are: Arizona: 98.87% (-0.13%), Rhode Island: 96.17% (+2.17%), Utah: 95.90% (+1.90%), District of Colombia: 95.75% (+3.75%), Kentucky: 93.41%, Maine: 90.43%, Minnesota: 90.39% (-0.61%), Oregon: 90.12%, Idaho: 89.09%, and Texas: 89.03% (-0.97%). See below for a map of pediatric hospital bed utilization.
30 states and territories show increased rates of pediatric bed utilization compared to 11/16. States with the greatest increases compared to 11/16, include: North Carolina: 78.53% (+21.53%) and Vermont 76.74% (+17.74%).
24 states and territories experienced decreases in pediatric bed utilization. Of note, Delaware’s pediatric bed utilization rate fell 8.56%, from 88% on 11/16 to 79.44% on 11/20.
Certain US jurisdictions, such as Louisiana, have had up to a 30% decline in Tdap (Tetanus-Diphtheria-Pertussis) vaccinations in 2020 compared to previous years. Tdap is an essential public health countermeasure, particularly for adolescents who are less likely to receive preventative care.
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 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.
AAP notes that “child [COVID-19] vaccination rates vary widely across states, ranging from 2% to 37% receiving their first dose.”
Policies and messaging aimed at increasing COVID-19 vaccination rates for eligible infants could be a powerful way to reduce their risk of severe illness and hospitalization, which could mitigate additional surge. Low COVID-19 vaccination rates for children aged 6 months to 4 years are not only due to the relatively recent authorization of the vaccine for that age group. Uptake of COVID-19 vaccine in this age group is much lower at comparable stages following authorization of the vaccine. At 21 weeks following vaccine authorization: 10% of children aged 6 months to 4 years received at least one dose compared to 34% for those 5 to 11 years and 48% ages 12 to 15.
Influenza vaccination data for the 2022-2023 season is not yet available. For the 2021-2022 season CDC reports 57.8% of children 6 months through 17 years received at least one dose of flu vaccine. This was a decrease of 0.8 percentage points from the prior season. Also for the 2021-2022 season, 66.7% of children aged 6 months to 4 years received at least one flu vaccine. While this is higher than other pediatric groups, it is relatively low compared to past years, in which coverage for the age group was typically around 70.0%.
RSV
Data for RSV cases and hospitalizations for the week ending 11/18 will be updated by CDC on 11/25 or 11/28. As a result, RSV case and hospitalization data reporting in this document remains the same as last week.
Adults presenting with any respiratory symptoms should adhere to pandemic precautionary measures, including masking, to protect the populations at highest risk of RSV-related hospitalization, such as older adults, and individuals who are immunocompromised.
RSV is the most common cause of bronchiolitis and pneumonia in children younger than 1 year of age in the US. Bronchiolitis is a leading cause of pediatric intensive care unit (PICU) admission.
Treatment for RSV-related bronchiolitis cases may vary depending on individual patient and available supplies. 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.
Bronchiolitis care options include non-invasive ventilation (NIV) to improve delivery of oxygen to a patient’s lungs. There are two NIV modalities widely available, continuous positive airway pressure (CPAP) and high-flow nasal cannula (HFNC).
ASPR TRACIE released guidance on use of 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
Influenza season data from CDC has not updated since the previous report last updated on 11/16.
Influenza-like illnesses (ILI) levels are high across the United States. 30 states, plus Puerto Rico, are experiencing high to very-high levels of ILI. Overall, influenza-like respiratory illnesses are increasing across the nation.
For the week ending 11/5, the 0-4 age group experienced the highest rates (15.4%) of outpatient visits for influenza-like illness, 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.
The overall rate of new US COVID-19 hospitalizations for all age groups is lower than at the beginning of the year.
National-level data shows a very slight increase in new hospital admissionsof pediatric patients with confirmed COVID-19 from the prior week. New admissions of elderly patients also increased slightly. As of 11/20:
People ages 0-17: +0.4% new admissions per 100,000
People ages 70+: +1.4% 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.
Data for RSV cases and hospitalizations for the week ending 11/18 will be updated by CDC on 11/25 or 11/28. As a result, RSV case and hospitalization data reporting in this document remains the same as last week.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.
TheRSV-NET Interactive Dashboardshows preliminary data for 58 counties in 12 participating states. RESP-NET uses three sets of surveillance data:
Past research shows that patients of color and those from low-income or limited English proficiency families are more likely to experienceworse hospital outcomes compared to other children.The same socio-economic factors increase the likelihood for hospitalization due to RSV.Clinicians should be aware of the potential of implicit bias due to structural racism to impact treatment of pediatric patients of color and interactions with their families.A recent Health Affairs article by a primary care pediatrician calls for fellow clinicians to advocate for and practice equity and antiracism in their work.
Systemic racism not only impacts the quality of care that people of color receive, but also likely reduces their likelihood to seek care for fear of mistreatment.
Black patients and hospital visitors are much more likely to have hospital security called on them, and Black patients are much more likely to have negative descriptors (such as “aggressive”) appear in their electronic health records.
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).
Infants aged 0-<6 months continue to experience the highest hospitalization rates with 171 hospitalizations per 100,000 (-14.2). Though this data shows 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.
Source: CDC RSV-NET Interactive Dashboard. Accessed: November 18, 2022.
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
As of 11/22, there has been no response from the White House to the letter from the American Academy of Pediatrics (AAP) and the Children’s Hospital Association (CHA) calling for government officials to declare a public health emergency in response to the RSV surge. An emergency declaration would waive certain Medicare, Medicaid, or Children’s Health Insurance Program (CHIP) requirements to allow hospitals, physicians, and other healthcare providers to share resources in a coordinated effort to help manage capacity challenges. The letter requests for the federal government to “support the increased costs associated with the growing needs and capacities, in particular escalating workforce costs required to meet care demands,” and to mitigate drug shortages.
On 11/21, Massachusetts Governor Baker extended a COVID-19 related policy allowing acute care hospitals to use alternative spaces to help facilities manage pediatric medical surge associated with RSV.
As we get further into the influenza season, and as colder weather increases gatherings indoors, we can expect more emergency declarations to be issued as pediatric hospitals continue to experience surge. Additionally, we expect to see more states extending and/or expanding their COVID-19 disaster declarations or policies to address the RSV surge.
On 11/11, Governor Polis in Colorado signed an executive order amending and extending the current COVID-19 disaster declaration to include RSV, influenza, and other respiratory illnesses. This would allow agencies to continue to access state and federal funding for recovery efforts, to rapidly respond to changes in the public health environment, and to support the healthcare system to remain appropriately staffed and prepared to respond to public health.
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, assome critical products have only one supplier or manufacturer capable of producing the necessary pediatric-specific equipment and supplies.
Product Availability
Definitions for product shortage varies 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.”
Amoxicillin remains in short supply.
On November 7, USAntibiotics, the sole-licensed American manufacturer of penicillin-based Amoxicillin and Amoxil Clavulanate (Augmentin), noted that they have reached out to the Biden Administration to inform them that every dose of Amoxicillin that will be needed in the US over the next five years can be manufactured and stored at their facility in Tennessee.
Physicians should be aware of alternatives for amoxicillin when prescribing it to their patients. Some manufacturers have placed limits on the amount of pharmacies can order to respond to this shortage.
ASHP’s current drug shortages list includes the following drugs that could negatively impact treatment of RSV and other respiratory illnesses:
As of 11/21, 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 11/21, 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 11/21, 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 11/21, Amoxicillin oral powder for suspension is available for current customers from Hikma pharmaceuticals. However, as of 11/21, most of the amoxicillin oral powder product for suspension from Sandoz is unavailable.
As of 11/21, 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.
According to some pediatric clinics, RSV, influenza, and COVID-19 testing kits have been on backorder.
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.
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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.
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