After two winters of mask-wearing and social distancing, pediatric respiratory viruses have returned with a vengeance, and pediatric hospitals, emergency room doctors and pediatricians are lobbying Congress and the Biden administration to provide more support.

Pediatric hospitals deal with a wave of respiratory syncytial virus, also known as RSV, every year. But this year, the wave of RSV is more like a tsunami because COVID-19 mitigation measures have driven down immunity among many children. For most children, RSV is mild and does not require hospitalization, but it can be severe, especially in infants and toddlers. There is no vaccine.

“This is our March 2020. This truly is an overwhelming wave,” Daniel Rauch, chair of the American Academy of Pediatrics Committee on Hospital Care, said of the current surge of respiratory illnesses.

Coupled with an earlier-than-usual flu season and a cold-weather uptick in COVID-19 cases, the RSV outbreak has children’s hospitals on the brink. Pediatric hospitals are seeing the highest influenza hospitalization rate going back a decade, said Jose Romero, director of the Centers for Disease Control and Prevention’s National Center for Immunization and Respiratory Diseases. Across the United States, hospitals have run out of room as pediatricians pull long hours and face burnout, with many states reporting more than 90 percent of pediatric beds occupied.

This week, the Children’s Hospital Association and the American Academy of Pediatrics asked the Biden administration to declare a public health emergency to respond to the respiratory virus trifecta: RSV, flu and COVID-19. 

The pediatric care organizations argue that significant capacity issues in hospitals can only be solved by a federal emergency declaration from the White House and Health and Human Services secretary — like the ongoing COVID-19 public health emergency.

An emergency declaration would allow for more telehealth flexibilities and waive certain Medicare, Medicaid and Children’s Health Insurance Program requirements that make it difficult for providers to share resources.

“We also hope that an emergency declaration will galvanize federal response,” Mark Del Monte, CEO and executive vice president of the American Academy of Pediatrics, and Mark Wietecha, CEO of the Children’s Hospital Association, wrote in the letter to President Joe Biden and HHS Secretary Xavier Becerra.

Emergency departments are so overwhelmed and gridlocked with patients waiting for admission, waiting to be seen or waiting for a bed that it’s nearly impossible to function, the American College of Emergency Physicians said in a Nov. 7 letter to the White House. 

The term for admitted patients being held in the emergency department when no inpatient bed is available is known as “boarding,” and it’s worse than it’s ever been, ACEP said, because of the “triple threat” of flu, COVID-19 and pediatric RSV.

“Patients with nowhere else to go are being held in emergency departments for days, weeks, or even months in some cases. Boarding is straining our system, accelerating emergency physician burnout, and putting patients’ lives at risk,” ACEP President Christopher S. Kang said in a press release. 

During the early days of the COVID-19 pandemic, doctors of all medical specialties helped staff COVID-19 units and treat patients in overflowing emergency departments. But it’s not as easy for pediatric RSV, said Aaron Glatt, chief epidemiologist at Mount Sinai South Nassau, because pediatricians are a smaller group with more specialized training. Existing physicians need to be cross-trained to treat young kids.

“In pediatrics, one of our sayings is that kids are not small adults. And it’s very hard if you’re used to taking care of adults to take care of a 2-month-old or even a 2-year-old,” Rauch said.

Addressing physician shortage

The Children’s Hospital Association, which represents 220 pediatric hospitals across the United States, is lobbying Congress to provide $718.8 million for the Children’s Hospitals Graduate Medical Education program for fiscal 2023 as well as a $200 million one-time increase for the fiscal year to immediately strengthen and grow the pediatric workforce.

The Children’s Hospitals Graduate Medical Education program funds freestanding children’s hospitals’ programs to train resident physicians and grow their workforce. Just 1 percent of all hospitals receive funding from the program, but they train roughly half of all pediatric residents and fellows, according to data from the Children’s Hospital Association.

But hospitals say the program is underfunded compared with other federal graduate medical education programs. Funding for a pediatric resident is only about half of the federal funding for Medicare graduate medical education — $79,813 per pediatric resident, compared with $156,128 per resident trained with support from Medicare graduate medical education.

The House included $200 million to boost the pediatric workforce in its 2021 reconciliation bill, but the Senate stripped out the provision in its slimmed-down version of the legislation, which was eventually signed by Biden. 

Federal effort

On Nov. 4, the CDC issued a Health Alert Network communication to clinicians about diagnostic testing, treatments and vaccination for respiratory diseases, including RSV, flu and COVID-19. The administration is working with hospitals on load levels to ensure that hospitals within the same coalition accept patients for one another when a hospital runs out of beds, said Dawn O’Connell, the assistant secretary for preparedness and response in the Department of Health and Human Services.

The agency also recommends that physicians do initial RSV assessments via telehealth rather than having patients immediately go to the hospital.

New England, the mid-Atlantic and Washington state are currently experiencing the most hospital strain, O’Connell said.

Public health officials are currently partnering with hospital systems throughout the country to increase capacity in pediatric hospitals and address workforce shortages. But they say this isn’t enough on its own. State and territorial public health officials are urging Americans to stay up to date on vaccinations, including flu and COVID-19, to help keep hospital beds open for pediatric RSV patients.

“Even if you reduce the hospitalization rate by some small amount, that’s going to be highly significant when you’re in the peak of a surge,” said Louisiana State Health Officer Joseph Kanter.

On Tuesday, the Biden administration detailed a $10 billion supplemental funding request to Congress to help pay for the government’s response to COVID-19 and other infectious diseases. It did not specifically request money for RSV or influenza.

It’s unclear what the rest of the winter will look like when it comes to RSV and other respiratory viruses. Just because RSV has surged earlier in the year than usual does not necessarily mean virus levels will drop earlier than usual. Hospital capacity issues are dependent on what the winter COVID-19 wave looks like, experts say.

“We did not see the virus for two years,” Romero said of RSV. “And this increased number of cases is to be expected given the number of individuals that are susceptible to the virus at this time.”