Pitting society’s lack of concern over the crisis in pediatric infectious disease

The BBQ Pit
41

@BigT,

I’m not sure what you or that ill informed writer are trying to argue against, and frankly I don’t think either you or she does either.

This is not at all a mystery.

Levels of protection against specific infections fall over time without boosting (by immunization or by having, frequently mild, re-infection). The rate of fall varies greatly depending on the germ, the exact mechanism of protection for that germ, and the nature of previous infections. Three years of few with any boosting of protection from RSV, and of those born just before to after Covid having a first infection with RSV, has increased the pool of those susceptible to infection by huge amounts, in children of all ages and adults both. Large pool of susceptible individuals leads to very rapid spread.

Reasonably healthy adults and older kids who have had past infection a few years back and are susceptible to infection because protection has waned still have protection, just not enough to prevent infection. They also have fairly large lower airways. Their infections are almost always mild or even asymptomatic. But they spread it and almost of the pool of those under three who have not yet had a first infection are almost all getting exposed. They have not had past infections. They have small airways. Many more of them get more sick some seriously so.

No new science required. And blaming past Covid infections for this large number of young children getting significantly ill while older children and healthy adults continue to get mostly just cold symptoms and mild cough, is beyond idiotic.

@Darren_Garrison, yes RSV has always been a significant problem. This is just the fact that pretty much everyone under three is being exposed to a first infection this year, while usually the dynamics spread out that first exposure over four or five years, including more getting that first infection at a point when their airways are larger, a big deal when the disease causes inflammation of the lower small airways (the bronchioles, hence RSV bronchiolitis). Of those who get RSV bronchiolitis about a third will also get inflammation and bronchospasm in response to many other viruses during preschool years. Some have thought that infection predisposes to such but most believe that it is more selection bias.

Yes.

Oh doubling back!

I certainly encourage patients to be fully immunized against Covid. That said, yes many kids were exposed to Covid for the first time last winter with the more transmissible variant, and as a result hospitalizations went up from very very few to very few. To put it into perspective - my six doc site had I think a total of two patients admitted with Covid over the whole pandemic; none in the ICU. Yesterday I saw four kids (all under three) in follow up from ICU admissions, three who had had RSV and one with the first Influenza B I know of in our area. It is certainly not impossible for a future variant to have greater morbidity even after past infection. Even if not, infrequent serious illness is worth preventing with the current very safe vaccination.

42

They aren’t really arguing against anything. What they are claiming is that the number of kids getting seriously ill from rsv is larger than can be explained by 3 years of little rsv. That’s part of it, but not enough to account for all the increase. And they hypothesize that the rest of the increase is a side effect of kids having had covid. Specifically, because covid can damage the immune system.

I’m not sure of the mechanism (i thought it was more likely lung damage than immune-system damage) but i know a couple of adults who have been incredibly prone to respiratory bugs since “recovering” from covid. It’s not that they had covid again, but that they’ve had a lot of bacterial and viral pnemomia from non-covid pathogens since having covid. So it doesn’t sound crazy to me that the same thing might sometimes happen to kids.

43

“Experts” claim that the number of those seriously ill doesn’t fit having several years worth of susceptible high risk young children all being infected in one season by an unprecedented amount of exposures? I love bullshit lines like that. Yes you can find some professor somewhere who thinks that, but no, experts in general do not think that. Normal epidemiology models with a huge group in the susceptible pool are completely adequate. See below May ‘21 Pediatric Infectious Disease Group position paper for how this eventuality was expected by the experts (who, despite the objections of some have long used the phrase “immune debt”). Meanwhile how exactly does covid induced immune damage explain the routine mild disease in healthy older children and adults and severe disease being mostly concentrated in younger children, as always?

44

I sympathize with your position. There are many problems with any health care system. It is hard to address what is unmeasured, and even this basic data is not always reported, acted upon, available or consolidated in Canada. Yet even our threadbare system - with burned out physicians, minimal beds, divided responsibilities, significant bureaucracy and enormous resistance to needed change do not have the problems inherent to maximizing profit. Canada is probably slightly more functional than the US and most Canadians value universal care, which does not cover some of what it might. But it helps.

I’ve been an emergency doctor, occasional family doctor and hospitalist for almost two decades. Between 1/2 and 3/4 of Canadian physicians say they are burned out, and 1/4 of family physicians plan on retiring within five years. Almost twenty percent of Canadians do not have a family doctor at all. This is a huge problem and generally required to see a specialist unless one goes to the ER, which Canadians do in droves. Being an emergency doctor is more dangerous in Canada than being a cop and prison guard combined, according to a recent Maclean’s article. I don’t know anyone who works emerg who has not been punched or struck, sometimes many times per year. I’ve seen colleagues beat to a pulp after they failed to resuscitate a patient. We are expected to simply suck it up. Finish the shift. Work a double shift to cover. Find no one has your back after you make sacrifice after sacrifice.

I have personally talked down several people with weapons. ERs deal with the most stressful and unstable situations and patient populations, often with too little backup, fickle collegial support, and work terrible hours, do tremendous work - often with minimal resources, no tolerance for error, little prestige and considerable bullying, obstinacy and worse. Some of this is politics, some is frustration from burned out staff, some is expecting people to deal with unreasonable things merely since this has been the status quo in the past, some is more shocking. I’ve worked in ERs with a permanent population of dozens of patients who must be seen and cared for in some hallway, even though some really require monitoring not always available when requested. In some of these places, sometimes more than half the nurses don’t show up or stay, and one often deals with agency nurses not fully used to the environment.

Emergency nurses have a lot of skills and knowledge, and suffer even more from patients and politics. After a government bill limited future pay increases to 1%, they quit ERs in droves to work for agencies which pay them much more. Small ERs have closed intermittently. Bigger ERs are understaffed, though visits are up by 70% in some cases. Hallway medicine leads to mistakes, poorer care, loss of dignity and privacy and yet the standards and expectations are the same.

The government has always limited ICU beds in Canada, which may be there but unstaffed, so in practice are unavailable, and ICU beds are so few they were sometimes hard to access before Covid. Canada has fewer acute beds and ICU beds and surge capacity than most countries. Fortunately, most Canadians are reasonable and compliant with masks and we weathered Covid adequately. I was involved in making recommendations following SARS, following which massive stockpiles of protective gear were kept. This was kept up for a decade, but was deemed too costly and stopped a few years before Covid, where it would have been an enormous help, as inferior items at enormous prices were still slow to be made available.

There are pediatric ICU beds in Canada, still at a premium, and mainly because hospitals have cancelled elective surgeries, already much delayed with a backlog of a million procedures. In a normal year, 1/3 of children get RSV bronchiolitis. Most have been exposed before in typical years, but it is still the most common reason for admitting those between 12-24 months. Usually 1-3% of children require admission, with this number increasing even before Covid. This ad is soon percentage number is much higher this year but I do not know what it is.

RSV is self limited and treatment is mainly fluids and oxygen since most other treatments are of limited efficacy. Many are in hospital for two or three days, some longer: in my city, emergency wait times are as high as twenty hours. It’s not nearly as safe as it should be. But at least profit is not a major motive and the system has been able to adjust, though at the expense of surgeries.

I disliked school closures given the data on Covid, and test scores suggest remote learning has had real (and pernicious) effects. Bronchiolitis will be manageable at the expense of cancelled procedures, enormous wait times and due to the personal efforts of many people. Covid has taught some to disrespect medicine. If Covid resurges and flu is severe this year, things will be even less fun. There has been much concern that the supply of children’s antipyretic medicines have often been unavailable, but much less education on whether these are always needed or how to make these at home (possibly due to liability concerns). The system will cope, but barely. For now. Lessons won’t be learned. Already doctors do not choose family medicine, or stay very long in emergency medicine.

45

I can’t put it as well as this guy. I hope your problems sort themselves out and more resources are made available to you. It’s hard to fight the good fight without support. Thanks for doing what you do. You make a difference.

46

First off let me salute you for the work you do under the conditions you describe. So much for the stereotype of “nice” Canadians, eh? Wow.

I hope so. The alternative is worse. And I hope that the negative impacts of those procedures being delayed and the long waits are not too bad.

Oh we are out of both Amoxicillin and Amox clav here, along with little antipyretics on the shelves (much time is spent by pediatricians talking down parents’ fever phobia).

I had a baby with a positive screen for galactosemia last week. Baby was being breast fed, and for the non medical babies with that condition need to avoid lactose or risk serious harms. Switching to a soy formula is required to avoid damage pending definitive diagnosis. None to be found. We were out of samples. Oh they eventually found a container and had family out of state find more near them and ship it to them.

This in a world leading economy.

47

I wound up making my own - but admittedly not everyone has the skills to do that.

48

Although the above assessment is accurate, it should be emphasized that most Canadians are quite kind, if passive-aggressive by times. It would be unwise for tourists to assume everyone in Canada is nice, as we are essentially like any other people. Alcohol and stimulants (especially jimsonweed) can make people do crazy things, and a lot of medical things cause behavioural changes, some of which are easily fixed.

I do not know if the statistic about danger is true, but it is from the quoted article. Personally, in years of practice I can count on two hands the number of unpleasant encounters, have several fingers left over, and remember each one. For me, this works out to under 0.004% of encounters.

Patients are often miffed about long wait times, often with reason, and one apologizes for this and other things often even though it is outside of one’s control. Most patients understand and just want acknowledgement of their issue. You can often agree, or at least agree in principle, or agree in part. One develops a thick skin. I am fortunate in that I have remained a kind person. Some people get easily frustrated and this affects them more.

49

I think it is fair to say there has been a lot about bronchiolitis in Canadian news. There does seem to be some social concern although few want to actually mask again.

Here’s hoping things settle soon and Covid stays covert.

50

The piss-off for me is that the experts are just asking or recommending that we mask-up, as if that will ever work. If I go to the local grocery store I may be only one of two or three, if not the only one, wearing one.

51

It doesn’t annoy me, but I don’t think masking at this time will be effective since bronchiolitis is already out there, too few do it, and you are unlikely to get serious symptoms if over eight years old.^ Some of this is anxiety due to flu and Covid, since flu season may be more severe and for the same reasons - lack of the usual previous exposures. Flu also can affect older adults severely, of course. And a Covid variant combining severe lower lung symptoms with high contagion would be an unwelcome guest at the party.

^ However you should follow local advice, consider masking if symptomatic or in higher risk environs, and strongly consider getting your flu shot if over 65, are at higher risk or have any chronic condition.

52

I’m still wearing a mask for 12 hours a shift, so I have pretty much 0 sympathy for anti-maskers, and yes, we’re seeing a ton of RSV and flu.

53

Not sure how much difference a Public Health Emergency Declaration would make but mountains moved when adult capacity was at risk of being swamped. Now? Bupkis.

54

I started getting flu shots every year, when I developed asthma as an adult (had it as a kid, largely grew out of it, it came back in my mid-20s). My husband never bothered, until we had kids, and I pointed out that a dose of the flu would make it harder to take care of himself, let alone helping out with the youngsters.

I don’t even wait 15 minutes any more - since I’ve been getting the immunizations for nearly 40 years, I feel safe in saying I’m not likely to react badly.

I had the same question.

55

I am really worried that the healthcare system has entered a negative spiral that may be difficult or even impossible to pull out of. It’s worse in the pediatric side of things, but even the adult medicine side has too few providers for the anticipated demand, and with more people quitting every day. I honestly do not know how we get out of this.

As for the anti-vaxxers, I used to believe that things would change once we had a large enough pile of dead bodies. I now think we could have millions of children dead from vaccine-preventable diseases, and it would change nothing. We have far too many radically selfish people in our population now.

56

I’m not quite as fatalistic. For the adult side I’ll even take a mildly sanguine view.

The medical system handled the extreme prolonged and repetitive surges event that has been Covid, battered but without complete collapse. Whatever Covid as an annual recurring event looks like, and the influenza it will often be on top of, will still be major threats, and yes, we still need to get prepared to deal with the next pandemic better than we handled this one (and there is zero doubt that there will be a next one), but for non-surge times? It may be that hospitals are more threatened by trends developing pathways that keep people out of the hospital providing outcomes as good or better at less cost. Adult hospitals may have to deal with what the issue has been for pediatrics, that the gulf between capacity needed at baseline and for potential surges is hard to square.

Primary care needs? Projections are that there will be shortages of physicians in Family Medicine, Internal Medicine, and Geriatrics … but plenty of Nurse Practitioners and Physician Assistants. We need work developing the processes and flows to work together better as teams, but keeping each member more at the top of the their skill sets in a coordinated manner can pull it off. I suspect newer docs are more prepared to do that than us over 60 are.

Anti-vax is pernicious and endemic. The current bump is a direct consequence of political opportunism providing greater soapboxes for harmful misinformation, but we’ve had bumps before. And drops. And new bumps … The other side is that the long term trend has been huge decreases in disease because of vaccines, despite the anti-vaxxers and the just hesitant, with more diseases likely to become vaccine-preventable and more effective vaccines to come.

FWIW … way too early for me to breathe any sighs of relief … and it makes no sense to me whatsoever … but instead of things getting much worse after Thanksgiving office sick volume has eased up a small bit (even a small bit is a big deal when over capacity), and I’ve not had an ICU follow up visit in a few days. Just one office view and just a few days, but it gives me hope that maybe, just maybe, the surge won’t break pediatric capacity as completely as I’ve been panicked about. (I am curious to see if the next weeks’ FluTracker numbers see some flattening, although again, doing such is the exact opposite of what I would have predicted to happen.)

Fingers crossed. The Pit OP still still stands: the lack of concern about the obvious threat horrifies and disgusts me, even if we do miraculously dodge disaster despite it.

57

The flu season is looking bad. Obviously masking helped but rates are twenty times higher than this nadir.

58

And, of course, there is no plan to deal with Canada’s health care problems. I am not even aware of a major political candidate who has suggested any sort of serious plan beyond meaningless fiddling like “finding efficiencies.”

I am not precisely sure why we have become unable to deal with significant problems, but COVID sure proved we can’t.

59

Apologies first off… LOOOONG time lurker (think Tuba , Opal long ago) but I don’t remember everything , but feel free to treat me as a reg. I know the rules and ignorance is not allowed by me (for any mods willing to give me the benefit nope like two decades old lurker I should know better).

But I finally had to post , usually spend my time in GD but first post in the pit… yikes im an ass so it does fit. But RickJay? Um the NDP have been touting increasing healthcare for over 5 decades… please stop pretending they dont exist. I as what I call “an actual” canadian conservative, my concern has always been saving money long term. Which the NDP wants more than the PC’s anyday. Pay today so we don’t pay 30 years from now… with our lives or 6 times what we would have paid back then. Please stop claiming things like the “finding efficiences” nonsense that’s the two main parties libs and cons doing that nonsense. By all means mention them but keep the other parties that do have an added platform out of the claims of “nobody”…(paraphrasing of course)

So now you’re aware… I don’t know how you weren’t though they’re very vocal.

Also since its the pit , Both major party leaders need to stop knobbing on companies who provide nobody with anything (we provide demand…) so Fuck Trudeau and Fuck every PC member but especially anyone from Alberta (sorry I’m from there… its bad…).

Sincerely a “former” con , who left after the racist dogwhistling trump like reformers got in… ironically raging against the gays in their rainbow leotards (the raging was done in a rainbow wetsuit… oh stockwell day the irony…). Vote NDP only party who will increase healthcare… been that way for decades. I was just stupid and blind.

Also thank you sincerely to all dopers even the banned ones and trolls/socks/trocks(that were good) you have provided me with decades of facts and entertainment. Thank you all. Not sure if I’ll ever post again , but now that I’ve signed up I probably will. Special shout out to Qagdop (spelling sorry man) and gigobuster you two are legends too me :wink: , Thanks again.

(I know enough that this is where I would put my “regards” in :wink: ).

60

“Increasing healthcare” is not a plan. The governments we have DO increase healthcare; health care spending goes up more or less every year. The federal government has increased healthcare transfers every single year for the last 20-plus years. Provinces increase health care spending most years.

Sorry, but “we will spend more money” is not a plan. It isn’t actually working, and there’s a limit as to how it CAN work, and it should be plainly obvious “spending more money” doesn’t necessarily help something.

Perhaps we do need to spend more on health care, but you know who spends more than we do? The USA. Do you think they have a better health care system? I’m hoping you don’t. Do you know who spends less than we do? A surprising number of countries with better healthcare outcomes.