COVID-19, Influenza, Respiratory Syncytial Virus in Pediatrics
In this podcast, John Harrington, MD, speaks about the “triple threat” of viral respiratory infections in children during the winter of 2022-2023, including COVID-19, influenza, and respiratory syncytial virus (RSV). He also addresses the children’s medicine shortage happening in some communities across the country and how he is advising the parents/guardians of his sick pediatric patients.
- Seitz A. As flu rages, US releases medicine from national stockpile. Associated Press. Published online December 21, 2022. Accessed January 11, 2023. https://apnews.com/article/health-flu-c9567822f5b409beacf1ac60f7729b0a
For more pediatric influenza content, visit the Resource Center.
John W. Harrington, MD, is the Vice President of Quality, Safety, and Clinical Integration a General Academic Pediatric Practice Co-Director at Children’s Hospital of the King’s Daughters, and a professor of pediatrics at Eastern Virginia Medical School (Norfolk, VA).
Hello everyone and welcome to another installment of Podcast360, your go-to resource for medical news and clinical updates. I'm your moderator, Jessica Bard with Consultant360, a multidisciplinary medical information network. An early start to the annual flu season in the United States, plus a spike in other respiratory illnesses created a surge in demand for some over-the-counter medications and other products, according to the associated press.
Dr John Harrington is here to speak with us today about pediatric viral respiratory infections during the winter of 2022-2023. Dr Harrington is the Vice President of Quality, Safety, and Clinical Integration and the Co-Director of the General Academic Pediatrics Practice at Children's Hospital of the King's Daughters, and a Professor of Pediatrics at Eastern Virginia Medical School in Norfolk, Virginia. Thank you for joining us today, Dr Harrington. What are you seeing in your office, and what are you hearing from your colleagues this winter regarding viral respiratory infections?
Dr John Harrington:
So, I think many offices are attacking this as a healthcare system in many ways. So our office is associated with a bunch of children medical practices, but we're also associated with urgent cares and we also have an emergency room. So, the system is actually responding to it because we can't see all the kids in our offices and the urgent care can't see all the kids in the Urgent Care and the ED can't. So, we are all taking pieces of that population and essentially the urgent care volumes are up one and a half times to two times what they usually are. The EDs are up one and a half to two times what they usually are.
The outpatients, fortunately or unfortunately, we can only see what we can see because of staffing. And so generally you can't overwhelm your staff with more sick patients when we still have a lot of well patients to see from the backlog of COVID-19. So turned into this push and pull. So if we have openings, we take them in, when we're full, we say, "You need to go to Urgent Care if you need to be seen and if you're really sick then you maybe need to go to the ED."
So we've had a triage system throughout the whole system, which is helping it sustain itself. But I'll tell you, there's fatigue, there's a lot of fatigue in terms of the staffing issues related to each department, ED, the urgent cares, the hospital, the outpatients, and everybody's dealing with that staffing, which is also causing burnout, which is all causing all this healthcare fatigue.
And really, the viral illnesses are surging after the holidays, so we're probably going to see another surge after the Christmas and New Year's Eve season and stuff. So, we're bracing for that again. So, hopefully, once that all goes through things will sort of die down. I look at the numbers every day in our practice and in our system, and we were well over a thousand patients in the urgent care, well over 300 kids in the ED. And then just over the last two days, it was down to 250 in the ED, maybe 750, 800. So there's a little bit of a blip of going down, but then we may see it pop back up again after the holidays.
So we're seeing these blips and surges that are going on with people getting together and then spreading the virus. And they're three viruses that everybody talks about, the triple threat: RSV, flu, and COVID-19. So right now flu was winning handily over the last few weeks and now COVID-19 is making a comeback, which probably happened after the holidays. So, flu and Covid are really the main players right now. RSV is still out there and still causing some degree of illness, but the two winners right now are Covid and flu. And I'm just talking about Virginia, it may be a little bit different in different areas of the country based on how the surges are moving across the country.
What would you say is new in pediatric influenza vaccination in 2022 to 2023?
Dr John Harrington:
Well, it's interesting. Different people are saying different things. I'm trying to say, "Listen, if you can protect yourself against something, at least protect yourself against the flu if you didn't get the COVID-19 vaccine. If you've always gotten the flu shot, why not get the flu shot this year?" And some people are saying there's a little bit of fatigue about vaccines as well. They're, "Well, I got the Covid vaccine and I still got Covid and I got the flu vaccine, and I still got the flu."
We try to message that if you get the flu or you get Covid and you have the vaccine, you're much less likely to die. And so we really try to emphasize that issue that the vaccine prevents death. It doesn't necessarily prevent you from getting the illness, it just makes the illness less likely to cause death. And so a lot of times when I use or I message it that way, parents get a different tone and a different idea about, "Well, I guess." So, when they say, "My aunt had the flu vaccine and still got the flu." And I said, "Is your aunt still with us?" And they're like, "Yes, she didn't die."
So, therefore, the flu vaccine worked. And so a lot of times the parents were like, "Well, I didn't know that was why you give it." And I said, "Yeah, well, the Covid vaccine was protective against death and so that's why we're pushing the Covid vaccine and pushing the flu vaccines." Not only for their child but also for the people at home who may more likely have chronic illnesses and chronic diseases.
Now, I know you just touched on this a little bit now, but is there anything else that you'd like to add about what's new in pediatric Covid-19 vaccination, and what has the Covid-19 vaccine uptake been like in pediatrics?
Dr John Harrington:
So, it was very interesting at the beginning of the pandemic. Everybody's like, "Well, there's no vaccine for the kids. They don't have any vaccine for the kids." And we were able to vaccinate most of the adults because they were high-risk, especially the ones over 65. And many of the people who were elderly were dying. But as we saw, as you move down the age categories, they were less and less likely to die from Covid. So there was less and less uptake from the vaccine, and plus, the vaccine was coming out in stages, "Okay, now it's ready for the 12 to 17. Now it's ready for the 6 to 12 age group, and now it's ready for the under fives."
And so what happened was there was more and more fatigue giving out the vaccines and now you had to give two vaccines or three vaccines as the initiation. And then as we had the vaccines out longer, then there were boosters. And then that's also when we had our staffing issues. And so you had to go to a certain place to get your vaccines, you could go to the pharmacies, or you could go to the pop-up places for vaccines. Then, the vaccine schedule got really complex.
My belief is that it's so complex that it's not happening. And so in some issues, we're getting rates of 10% or 5% vaccination for kids under 5 or maybe upwards of 20%. I don't know what the newest stats are saying, but I'm betting it's not more than 30 or 40%. And so you really can't get a caring capacity of usefulness to the vaccines if you can't get them up to a certain level. And so I'm guessing, and if I was a guessing person on the vaccine front, I would say they're going to do some meetings that the vaccine committees are probably going to say, "Listen, we've got to simplify this. It's too complex. We've got to come up with a way that allows us to give the Covid vaccines in a way that can be managed in the outpatient world and even in any place."
And so I'm guessing they'll probably do it just like the flu vaccine because everybody understands that: you get two doses in your naive season and then you get a booster dose in the next season. But I think we're moving into that phase because it's been 3 years now or two and a half years of this Covid, Covid, Covid. And we've not been good about vaccinating the younger kids because of the way it longitudinally came out. So I am not a betting person, but I basically think that we're going to have to do something to improve our vaccination. And that's probably to simplify the process.
It seems like where we've gotten to that point where either we vaccinate or don't vaccinate because parents are like, "So how many do I need, and when do I have to come back?" And we really don't have the front staff to try and do this unless we start automating a lot more. A lot of offices are looking at having automated systems in terms of moving things forward: automate, and have everybody get text messages to come to your office to get your shots. But then there may not be somebody there to give the shot because they're seeing patients.
So, it's becoming a bit of a catch-22 because we'd love to be able to do all of this, but you need staff to do that. So that becomes the bigger issue in having staff available to do some of the healthcare issues that we've been able to handle before but now are struggling to maintain.
A big hot-button topic as we enter 2023, there is a children's medicine shortage happening in some communities across the country. What is happening? What are you seeing?
Dr John Harrington:
So, as are politics, all things are local. So you have local shortages, amoxicillin liquid 400 milligrams per 5 MLS is in short supply. So people say, "Well try the 250 per 5 or the 125," and that's all gone too. So we're actually listing for our local groups, which pharmacies have the medicines available. And then when amoxicillin is out, then you can use cephalosporin, or if the cephalosporins out then you know could use a third generation, or whatever's available, essentially. Our infectious disease people are trying to keep abreast of this as well to provide some advice for people not to use antibiotics that don't make any sense.
So it is one of these things where we are patently seeing things that all of a sudden you send something to the pharmacy and then they can't get it. And so then you're, "Okay." We're seeing this with ADHD medications, "Well, this child's been on this medicine for two years and now there's none of it." No Concerta, there's no Focalin, there's no whatever. And so you try to use another medicine and then the insurance company turns around and says, "You need prior authorization for that because that one's much more expensive." I said, "But there's none of it, so I can't give it if there's none of it."
And so it turns into patients just not getting their medications, or delays in medications, or getting only partial prescriptions filled. They'll be like, "Well, we can give you 20 pills, not 30." And so if you want to take the 20... So it's these types of things and doctors are trying to make decisions based on these shortages. So it's becoming a bit of a catch-can. You're like, "Okay, so I heard Walgreens has it but maybe some of the other pharmacies don't have it," or whatever. So you wind up sending people to different pharmacies to try and find the medication that you're trying to get them.
So it's been somewhat of a difficult route. Even something as simple as liquid Motrin is in short supply and that becomes a big issue in the hospital when you're trying to not give narcotics to kids. And we want to give liquid Motrin, but the child's too young to take a pill. So you're, "I don't want to give a narcotic, so then I give Tylenol that doesn't work as well and Tylenol's in short supply, or liquid is," or whatever. And the IV stuff is, and we've had shortages of albuterol for inhalation to give to kids who have asthma and stuff.
So then we have to use some other medication and stuff, or use a pump when the parent's like, "Well, he won't take the pump." Or, "He's not using the pump well. He's under six months." Or, "How am I going to do that?" And stuff. So there are lots of things like that that are causing consternation amongst our EDs and urgent cares and offices and hospitals actually that are suffering under these supply shortages and supply chain issues.
And what are you advising parents and guardians to do if they see empty store shelves?
Dr John Harrington:
Most of the things for most of our colds and most of our illnesses and stuff like that just require rest, fluids, and just rest. So a lot of times we don't do that. We want to continue doing what we're doing or we want them to feel better now. So a lot of times it's probably better for them to just stay at home, rest, take plenty of fluids and let it run its course. So the medications that they're getting at the stores are usually for the stuffy nose or for the cough or whatever.
But generally, coughs are not a bad thing. You just wear your mask or make sure you're not in front of someone else or you let them rest in their own room. And so a lot of times if there is no medicine at that store, you could go to another one if you really feel you need that medicine. The prescriptions are different. If it's an antibiotic or if it's something that's really for the benefit of that disease, or that disorder like asthma or, pneumonia, or ear infection. Then yeah, you probably have to call the pediatrician and say, "It was not available at this pharmacy, is there any other way I can get another medicine or can you try and send it to another pharmacy that's near me?"
Usually, that can be done electronically now, so you don't have to come back to the office or anything like that. So, it's done electronically and then we can search for the other pharmacy and then send it there. But that's why I'm saying we're usually getting lists probably every week of which pharmacies have which medications so that we can send the patients to the right place. Again, a systems issue, we need to have those systems in place in order for these things to work for parents.
So we know rest is very important, but what are you advising the parents and guardians of sick children when to see a doctor or when to get kids tested, things like that?
Dr John Harrington:
It's all relative. In some situations, sometimes the adult at home may need to know whether or not their child is positive, and that gets tricky too. Healthcare workers are sometimes obligated to test themselves so that they don't come to work with an infection. And if they do, we need to know which one it is, in some cases, so we know how to put them into the system and where they can be located... if they should wear a mask, if they don't have a fever, they can work here. It really is tricky.
A lot of times, though, if you feel ill but you're not super ill, you probably could stay home and rest, drink fluids and keep away from other people. If you are sicker and having trouble breathing or breathing more quickly or not drinking, not eating well, we probably do need to see you either in the office, the urgent care, or the ED.
Most of us are triaging as best we can. You're calling on the phone, we're getting that information, and then we try and get that triage call back to you. And again, because of staffing, sometimes it's hard to triage because that person calling you may have 100 calls that they have to get through and you may have called and now it's two hours later and that person's calling and you're like, "I already went to the Urgent Care." And it's like, "Well, you didn't need to, you could have stayed home." "Well, I already went and they told me the same thing." And it's like, "Okay." So it is one of these things where people want to have things right at that time.
But again, if people understood about staffing issues and understood we're trying to take things in the order in which they come, but sometimes you have to triage that.. this sounds really sick, "I need to call them first. This one doesn't sound that sick." I wish we could have some way to do that faster, but sometimes you just can't do it as fast as the patient would like. And that becomes somewhat problematic in terms of overwhelming different systems. So, everybody shows up at the ED because the office is closed, or everybody shows up at the urgent care because nobody answered the phone because your staff was busy with something else, and they let the phone ring for two minutes and the person couldn't wait those two minutes.
I'm like that too. After two minutes I just hang up. I try again. But it is one of these things where that happens and we monitor that, "How long does it take to pick up the phone in your office?" And once it starts getting elevated, then we have to add more people to the phones because you are, you're going to start getting people just saying, "Forget it, I'll just go to the urgent care or the ED."
Those are things that we monitor closely, and I think that's another systems issue. You got to keep track of those things and make sure they don't get overwhelming because then you'll overwhelm your system. And these are things that throughout the country we're going through and trying to manage well. Not to mention even for ourselves, if we call and say, "Hey, I'd like to have a well visit for myself." "Well, how's 2024 looking?" So they're booked out completely. And so when we say there's nobody available in two to three months, people are like, "Two to three months. How's that...?" Some places go further out. So it is one of these things that we don't see until the virus season calms down. I'm not sure how we're going to do it and the catch-up stuff, but we're trying. We're definitely pushing and trying to come up with inventive ideas on how to do things faster and more efficiently but also safely.
Is there anything else that you'd like to add regarding the viral respiratory infections in kids?
Dr John Harrington:
So pediatric influenza, you have to see it as kids under two are the ones that are more likely to die from the flu. We see that every year. And kids who have any sort of pneumonia or respiratory problems, they were premature, those are the children that really need the flu vaccine and need to be protected against the flu. Obviously, everybody else around them cocooning them is also important as well. And if people are going to be somewhat vaccine-hesitant or just vaccine-fatigued, however, you want to call that, they should at least consider the fact that if it is preventative of death and the most likely kids to die are the ones under age two, or with some significant chronic illness, then please, please, please, get those kids immunized and make sure they're up-to-date with their vaccines.
We are not going to see everything go away right after January. It started early and it's probably going to continue to March, maybe even April. And so if you haven't protected them yet, you should protect them now. And kids who have never had a flu vaccine need two if they're under the age of nine. If you never vaccinated them then you need to give two doses. So you're going to have to do that pronto. If they've had the vaccine before then they only need one dose, just get it in them. Either go to your doctor's office, or go to the healthcare clinics, or the pharmacies that have the flu and get your vaccine.
But if you have a child under age two or an infant at home who can't get it, then make sure you are immunized so that you do not give it to your child.
Well, thank you so much for your time Dr Harrington. We appreciate it.
Dr John Harrington:
You're welcome and happy to talk you here today, Jessica. Thank you very much.
For more pediatric influenza content, visit the resource center at consultantthreesixty.com.