An outbreak of respiratory syncytial virus and human metapneumovirus infections that affected 73% of patients in a dementia care ward underscores the complexities in mitigating the transmission of these viruses in long-term care facilities, according to recent study findings.
“Long-term care facilities [(LTCFs)] have unique challenges. Infection control policies from acute care hospitals cannot simply be mirrored in this setting and expected to work,” Steven Schaeffer Spires, MD, study author and assistant professor of infectious diseases at Vanderbilt University School of Medicine, said in a press release. “RSV and HMPV are viruses that need to be taken as seriously as we take [influenza], especially in older adults.”
The first illness related to the outbreak was identified in January 2015. The patient was transferred from the dementia care ward, located in Tennessee, to the ED for coughing, vomiting and other general symptoms. Days later, additional patients with symptoms including fever, cough and nasal congestion were also identified. The facility subsequently employed infection prevention protocols, which included grouping patients and staff, using contact precautions for patients with suspected illness and ceasing all group activities, to prevent further illnesses.
During the 16-day outbreak, 30 of 41 patients were infected with RVS, HMPV or both. Fifteen patients were hospitalized, and five died.
Thomas R. Talbot
Spires, Thomas R. Talbot, MD, MPH, associate professor of medicine and preventive medicine at Vanderbilt University School of Medicine and chief hospital epidemiologist at Vanderbilt University Medical Center, and colleagues highlighted several issues in infection control within the facility. Since it did not have on-site PCR testing, samples obtained from patients with suspected illness were assessed offsite, delaying results for nearly 2 weeks after collection. By the second week of the outbreak, there was limited availability of personal protective equipment because the number of areas that needed an isolation cart exceeded the number of carts available. Further, one-third of nursing staff called in sick or were sent home after developing symptoms that were consistent with illnesses involved in the outbreak. With a reduced workforce, health care personnel were shared among patients in an affected and unaffected unit of the facility. By day 12, infections had spread to both units.
A paper-based method of bed tracking made it difficult to monitor patient movement. New cases were placed in rooms with other cases to isolate those with suspected illnesses; however, asymptomatic patients were sometimes transferred to recently voided beds due to a lack of extra rooms.
Patients’ underlying conditions of dementia further challenged the implementation of preventive measures. They were unable to report their symptoms, which likely delayed case identification, and many patients did not comply with recommended restrictions. Because one patient had ingested an alcohol-based hand rub in the past, dispensers could not be placed at convenient locations for hand hygiene use.
After identifying these issues, the facility updated its practices to improve infection prevention procedures.
“Identification of infected residents and [health care personal] as well as implementation of essential infection prevention strategies were challenges that are likely not unique to our specific LTCF,” Spires and colleagues wrote. “Since this outbreak, several additions and changes to the facility’s infection prevention procedures that are aimed to prevent spread of all respiratory pathogens in a congregate setting instead of just focused on influenza have been implemented.”
According to the researchers, staff now conduct daily active screening during the respiratory viral season. Through a partnership with a private laboratory, test results can be attained within 24 to 48 hours. In addition, the facility was renovated to include hand rub dispensers at each doorway entrance, which are monitored by staff for oral ingestion among residents. The researchers recommend that during future outbreaks, health care professionals treat rooms with a case and exposed roommate as a single unit.
“Early detection of a contagious pathogen and identification of infected patients is important when trying to prevent an outbreak,” Spires said in the release. “However, once a certain number of residents were infected, we had almost no chance at preventing further cases from developing. Now that better technology is available to detect viruses other than influenza on a more routine basis, we are recognizing the importance of RSV, HMPV and other viruses in causing such morbidity in the older adult population. There is a clear need for vaccines and new antivirals to aid our efforts in prevention of these viral infections.” – by Stephanie Viguers
Disclosure: The researchers report no relevant financial disclosures.