Enterovirus, rhinovirus and RSV on the rise

A September surge in requests for pediatric intensive care unit beds as a result of rhinovirus and RSV respiratory illness has regional pediatric care systems in Maryland at a breaking point, according to Dr. Jennifer Anders, a Johns Hopkins Hospital physician and Maryland’s Critical Care Coordination Center pediatric medical director.

“The fall surge shows no signs of slowing yet – with the past weekend being among the busiest (for our Pediatric Critical Care Coordination Center) on record,” Anders, a physician board certified in pediatrics and EMS medicine, told me. “Pediatric care all over the U.S. is in a state of retraction, with fewer and fewer community hospitals maintaining pediatric capacity. Large studies have demonstrated the disproportionate need for children to be transferred from one hospital to another to receive acute care several times the rate that is required for adult patients … and that is certainly true here in Maryland.”

Most medical centers are exclusively set up to provide care for adults, and while every emergency department can provide outstanding stabilization of critically ill pediatric patients, few have built the infrastructure to provide definitive care.

And children present a unique challenge to healthcare providers. “Interpreting vital signs, not being able to provide their own history, interpreting physical exam findings based on age-appropriate developmental stages and weight-based medication dosing is complicated,” Anders said. “To care for children effectively, hospitals must not only have an array of equipment in different sizes, but also a core of trained staff that are comfortable with all these challenges.”

The pediatric bed crunch has been further exacerbated during COVID with staffing shortages and increased financial pressures on hospitals. Pediatric care is a smaller portion of revenue, leading it to be cut first, according to Anders.

MARYLAND’S CRITICAL CARE COORDINATION CENTER

On October 1, 2021, the Maryland Institute for Emergency Medical Services Systems’ cutting-edge and award-winning Adult Critical Care Coordination Center added pediatric services. Maryland’s Critical Care Coordination Center began operation in December 2020 to aid with critical care consults and assistance with placement during the COVID pandemic.

“Our call volume for C4 (Maryland Critical Care Coordination Center) Pediatrics has gone up and down dramatically around respiratory viral flares,” Anders reported. “Increasingly, high flow nasal cannula respiratory support is being used for these children. The use of high flow nasal cannulas has dramatically increased (the) requests for PICU beds.”

Anders said that since September 1, 2022, the center has received nearly 200 calls. Approximately 30% of these calls required “out-of-state” transfers to Virginia, Delaware and Pennsylvania pediatric hospitals due to a lack of pediatric capacity in the hospitals which geographically serve our children in Maryland and Washington D.C.

The adult coordinators and physicians evaluate and monitor the critical care requests in the state. The pediatric coordinators and physicians evaluate and monitor all pediatric requests, including PICU, intermediate care and floor-level patients. The only service that C4 Pediatrics currently doesn’t assist with is psychiatric care.

“C4 Pediatrics continues to work 24/7 to assist with bed placement inside Maryland and D.C. and to neighboring states,” Anders said. “C4 Pediatrics also provides management advice to ED physicians and community-based sites to help them care for the children who wait multiple shifts for PICU transfer and those who are never transferred.”

NEIGHBORING NEW JERSEY

In nearby New Jersey, the state is reporting a surge of viral infections bringing pediatric patients to emergency departments. The most critically ill of these patients are admitted to facilities for severe respiratory distress.

The last several weeks, hospital emergency departments and in-patient pediatric units have seen an influx of children with enteroviruses and rhinoviruses, according to Dr. Uzma Hasan, director of the division of pediatric infectious disease at Cooperman Barnabas Medical Center, in Livingston.

“The ICUs in most hospitals in the state have a hefty burden of kids who have respiratory illness,” Hasan told reporters, adding that the EV-D68 enterovirus accounts for about 80% of the children in ICUs.

These viruses commonly cause symptoms like the common cold in adults, however, are much more severe in children with pre-existing conditions such as asthma and other lung conditions. Hasan added that shortness of breath, coughing and wheezing can progress rapidly, and some children require high-flow oxygen or frequent albuterol treatments to help them breathe.

Common signs and symptoms of EV-D68 virus include:

• Cough
• Shortness of breath
• Wheezing

In New Jersey, rhinovirus and enterovirus activity has been higher over the past few weeks and higher this year compared to the previous three years.

State officials told the media that the wave of virus infections is expected to be worse this year than the last two years, following relaxation of mask mandates and other preventive measures against COVID-19. This year’s surge is particularly concerning because it appears to be dominated by a type of enterovirus that is associated with acute flaccid myelitis, a condition marked by a sudden weakness in the arms or legs and loss of muscle tone and reflexes.

Nancy Kearney, from the New Jersey Health Department and Hasan agreed that increased vigilance for acute flaccid myelitis in the coming weeks will be essential, because these cases are typically preceded by respiratory illness caused by EV-D68.

Although no cases of acute flaccid myelitis have been reported in New Jersey as of a September 14 report, 40 cases are under investigation nationwide. According to the report, cases usually peak in alternate years, for unknown reasons, and a spike is expected in 2022 after a lull in 2020. This directly correlates to the spread of many viruses being interrupted by pandemic precautions and remote schooling.

“The one thing I want to make sure of is that everybody has touched base with their pediatrician to make sure children are caught up with routine vaccinations, Kearney said. “Children can be infected with multiple viruses simultaneously, so it makes sense to vaccinate against influenza and COVID-19 to limit the number of possible causes of illness.

PHYSICIAN OFFERS A SOLUTION

Anders said that she strongly encourages facilities to implement surge capacity plans to increase statewide ability to serve ill and injured children.

“Recent guidance on this topic was published by the American Academy of Pediatrics,” Anders said. “One potential solution is to ‘unload’ tertiary care facilities by pushing patients with low-acuity hospital needs to community-based sites.

Anders added that the C4 Pediatric Center is positioned and willing to assist with such transfers in the Maryland area if desired. The Critical Care Coordination Center was recently awarded the 2021 CRISP Patty Brown Innovation Award. The award recognizes an individual or team that contributes to advancing health care in Maryland. Recipients of this award demonstrate innovation in how they engage and collaborate with people and organizations across the healthcare continuum. They are strategic thinkers and have led others in adopting pragmatic solutions with health information technology. Above all, their approaches are mission-driven and always aim to support better health outcomes for our patients and communities.