When two-year-old Mila began occasionally coughing in early May, her parents figured she’d caught a summer cold. But after her symptoms worsened until she couldn’t stop coughing, a visit to the pediatrician sent them straight to the emergency room. “Her oxygen levels were not even registering,” said her mother, Kalee Dionne, a meteorologist for Dallas television station WFAA.
Mila had contracted respiratory syncytial virus, a common pathogen that typically fills up children’s hospital beds each winter. Mila only needed to stay one night at the hospital, but her cough lingered for another month—until she caught it again at daycare and developed pneumonia. Though she recovered, Mila now needs to use a steroid inhaler twice a day for at least the next six months as her lungs begin recovering.
For most older kids and adults, RSV causes little more than a common cold—“a runny nose and congestion, and maybe a little bit of fever,” said Dr. Anthony Flores, chief of pediatric infectious diseases at UTHealth’s McGovern Medical School and a physician at Children’s Memorial Hermann Hospital in Houston. However, frail older adults and very young children, especially babies under six months old, don’t cope as well with RSV. They’re the ones mostly likely to end up in the ICU.
Relatively few U.S. children die from RSV infections—between one hundred and five hundred a year, according to the Centers for Disease Control and Prevention—and hospitals have come to expect the cases that start rolling in annually around late fall. Those cases tend to peak in December or January before dropping off in the spring. It’s like clockwork every year. Until 2020.
“This past winter, we saw essentially no RSV, and that was not only true for Dallas Children’s, it was true for Dallas County and for many other places in the United States,” said Dr. Jeffrey Kahn, chief of infectious diseases at Children’s Health and a professor at UT Southwestern Medical Center in Dallas. He and Flores suspect the absence of RSV, like last year’s missing flu season, is due to a combination of mask wearing, social distancing, virtual learning for many children, and other measures implemented to stop COVID-19 transmission.
“Initially, everyone was just kind of waiting, sure RSV was coming and waiting,” said Dr. Lara Johnson, a professor of pediatrics at Texas Tech University Health Sciences Center and chief of staff at Covenant Children’s Hospital in Lubbock. Then they saw data from the CDC showing few cases anywhere. RSV season never arrived.
Johnson worried that meant the upcoming winter season would be twice as severe, with two birth cohorts of kids suffering their first infections at the same time. But the virus had another surprise in store. Sometime between late May and early June of 2021, Covenant Children’s saw one RSV case come in, and then another, and then another. And it didn’t stop. “All of a sudden, we’re looking around, and we’re like, ‘Oh my gosh, this is winter,’” Johnson said. “I never imagined that we would have a true RSV season in the summer.”
That’s been the reaction in every children’s hospital in Texas—and throughout the rest of the U.S. A recent report from the CDC found several unprecedented trends in respiratory viruses during 2020. They disappeared almost entirely in March 2020, but their return was staggered in ways scientists are just beginning to try to understand.
“We didn’t see a lot of the typical fall-winter-spring illnesses, but now that we’re having our kids back out and about and socializing again, we’re certainly seeing those diseases surge, including RSV,” said Dr. Nicholas Rister, a pediatric infectious disease specialist at Cook Children’s in Fort Worth.
Dr. Jaime Fergie, director of infectious diseases at Driscoll Children’s Hospital in Corpus Christi and an RSV expert, said he thought the first small wave of RSV cases was just a fluke. “But then, wow, it overwhelmed us,” he said.
As in other hospitals throughout Texas, Driscoll’s intensive care unit is now strained by the unexpected RSV surge and “a higher rate than ever” of pediatric COVID cases. Fergie says the hospital has been trying to bring in more nurses, but it’s been difficult to recruit enough. Covenant Children’s is facing the same problem in trying to find enough nurses, respiratory therapists, and other staff to cover shortages that normally don’t occur in summer.
“It’s not dissimilar to what we see in winter, but I think it just feels a little bit worse because we weren’t anticipating it,” Johnson said. A similar trend is playing out in outpatient pediatric clinics, she adds. Her colleagues usually spend the late summer months doing well-child visits and physicals in preparation for the new school year, but instead of waiting rooms full of healthy kids, they’re overrun with runny noses and hacking coughs.
Children’s hospitals are well equipped to deal with RSV surges in the winter, but many are now running out of pediatric beds as they see a surge in pediatric COVID cases at the same time. Since RSV cases aren’t reportable by law in Texas, there are no reliable statewide numbers for its prevalence. But several of the state’s largest pediatric hospitals shared with Texas Monthly what they have been seeing. Corpus Christi’s Driscoll had no children test positive for RSV in 2020, but in the past month, the hospital has tested 963 children, and just over one third had RSV. Most of those kids weren’t hospitalized, but Driscoll’s ICU has recently been admitting four to ten patients a day with RSV. Meanwhile, Children’s Health in Dallas had 191 positive RSV cases during the week of August 8–14, and 109 of those children were admitted to the hospital. Cook Children’s in Fort Worth said it’s had upward of two hundred positive cases of RSV per week. Texas Children’s Hospital in Houston has diagnosed more than 1,600 cases of RSV during the last three months, compared with fewer than 30 cases per month during a typical summer.
Meanwhile, Texas is averaging 38 to 43 new hospitalizations every day of children with COVID-19. When Dallas ran out of pediatric ICU beds last week, Dallas County judge Clay Jenkins made clear how dire the situation was when he said any child who needed an ICU bed “will wait for another child to die.” As of August 16, children’s inpatient hospital beds in the Dallas–Fort Worth area were 93 percent full, and Texas Children’s Hospital had nearly 30 children suffering from both RSV infections and COVID-19.
“It’s like a very busy RSV season, and we’re very good at handling that,” Kahn said. “The big challenge now is that we’re starting to see a lot more COVID cases in kids, and that’s really starting to stress the system.”
Unlike the RSV surge—which has been similar at hospitals throughout Texas—pediatric COVID hospitalization rates vary across the state. In Corpus Christi, nearly all the children hospitalized at Driscoll with a respiratory virus had RSV in early June, but now the hospital has only slightly more RSV cases than COVID cases, Fergie said. In Lubbock, COVID isn’t even a distant second to RSV at Covenant, but Houston is “getting crushed by” COVID, tweeted Dr. Heather Haq, an assistant professor in the Department of Pediatrics at Baylor College of Medicine and a pediatric hospitalist at Texas Children’s Hospital in Houston. Children’s Health in Dallas is still seeing much more RSV than COVID, but the COVID cases keep climbing, Kahn said.
“This is a horrible combination of having the peak of RSV activity as we’re starting to see another wave of COVID,” he said. “There are certain things that we can do to alleviate the stress in some parts of the hospital, but for the most part, the number of beds that we have is the number of beds that we have. The big concern is that we’re going to run out of beds.”
Despite the RSV surge, COVID is the greater worry among doctors at several Texas children’s hospitals.
“COVID affects a much broader age range with disease that will get you hospitalized,” Rister of Cook Children’s said. “I worry a lot about RSV in infants, especially premature infants, because these cases can be severe and even deadly, but COVID is generally the more serious infection.”
Hospitals are already expecting the inevitable wave of multisystem inflammatory syndrome in children (more commonly referred to as MIS-C) that has followed about a month after each previous COVID surge, Kahn says. And, though RSV testing data reported voluntarily by some Texas laboratories to the CDC suggests that the peak of this latest RSV outbreak may have just passed, the start of a new school year could well reignite infection rates. Meaning that it’s not clear when things will slow down.
“We’re sending kids back to school in an environment with at least two highly transmissible viruses. It’s a potential recipe for disaster,” Rister said.
The usual pattern is that older children pick up RSV at school and bring it home to their younger siblings, especially babies and toddlers, Fergie said, so he expects that pattern to continue as the school year gets going. That worries Johnson as well, yet she emphasized the importance of keeping children in school for their well-being.
“I know parents are anxious, which I totally understand,” Johnson said, but she encourages people to focus instead on getting themselves vaccinated, vaccinating children ages twelve and older, and practicing routine infection prevention measures, including frequent handwashing, staying away from others who are sick, and having children wear masks at school.
“There’s plenty of data to say that if we adhere as best we can to masking, social distancing, hand hygiene, ventilation—all these things that mitigate the spread of COVID—we can safely keep kids in school,” Flores said. “We have all the tools to do it. We just have to be able to use them.” Even that is uncertain, however, as school districts battle Governor Greg Abbott over mask mandates.
“The question is, are we going to have like the usual season, the usual four to six months, and then die down? Or are we going to have something that began in June of this year and goes all the way to March or April next year, something that’s never happened before?” Fergie said. “What we’re seeing right now has never happened in history.”
What especially worries him is how an extended RSV season might complicate the ability to mitigate RSV symptoms among the infants at highest risk for dying. Monthly injections of the drug palivizumab—a lab-made antibody—can prevent serious illness caused by RSV. But the drug is expensive, so the American Academy of Pediatrics only recommends its use in premature babies and those born with heart disease or other serious health problems. Most insurance companies require prior authorization for palivizumab and only cover it for the five months of RSV season. The AAP recommended on August 10 that at-risk infants receive the drug now, but if this bizarre summer surge of RSV continues until next year, it’s unclear if enough of the drug is available—or if insurance will cover it—to ensure the most vulnerable infants can keep getting it until cases die down.
“The other wild card in all this is that for the last year and a half or so, we have not seen any influenza, and this would be a nightmare scenario if influenza were to raise its ugly head right now and start spreading,” Kahn said. “Fortunately, that hasn’t happened at this point, but if that were to happen now, it’d be a real catastrophe.”