Confluence of RSV, COVID-19, and Influenza

• Vaccine-preventable illnesses, including those that affect the respiratory system, such as influenza and whooping cough (pertussis), are exhibiting a rise in case rates. The COVID-19 pandemic contributed to a trend of decreasing routine childhood vaccinations, which has made some groups of children more susceptible to other preventable viral infections, such as measles, mumps, rubella, chickenpox, and polio.
• 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.
• US counties with relatively low vaccination rates for preventable diseases, such as Taylor County, TX, San Diego County, CA, and Rockland County, NY, are seeing an increase in pertussis cases.
• 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.  

Source: CDC Weekly US Influenza Surveillance Report. Accessed 11/18/2022.  

COVID-19  

• 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 admissions of 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.

CDC tracks cases in three ways, by: State, HHS Region, and census region.

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)

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

• 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.
• 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 11/1, Pfizer announced that they would seek FDA approval for their RSV vaccine by the end of 2022.

Workforce Shortages

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.