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RSV, HMPV outbreak in dementia care ward highlights challenges in infection control

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January 16, 2017

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.

Tom Talbot
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.

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Keith Kaye
Keith S. Kaye

This study was remarkable for several reasons. First, the attack rate was very high, as was the associated morbidity and mortality. Second, with the increasing availability of rapid diagnostics, more outbreaks will be recognized and attributed to specific pathogens. Third, the outbreak was propagated by infected LTCF workers. This is not particularly unusual, but is still notable. Fourth, and perhaps most interesting and unique, were the factors that made it particularly hard for this LTCF to contain the outbreak. These included the vulnerability of residents because poor functional status is a well-recognized risk factor for health care associated infections. The high incidence of dementia made adherence to infection control precautions very difficult in many instances. Due to space limitations, sharing of rooms between infected and uninfected residents was unavoidable. Due to the high attack rates and the high incidence of ill staff, cohorting staff to work exclusively with infected or uninfected patients was not possible. Infection control supplies were limited — or there was a threat of severe shortages.

LTCFs are not hospitals. Persons who live in these settings are not patients, but residents. Thus, the ability to contain and manage infectious outbreaks can be severely limited. As more and more care is shifted to nonhospital settings, and as our population ages, we are likely to see more outbreaks and infectious threats in LTCF settings in the foreseeable future.

Keith S. Kaye, MD, MPH

Infectious Disease News Editorial Board member; President-elect, Society for Healthcare Epidemiology of America; Professor of Internal Medicine, Director of Clinical Research, Division of Infectious Diseases, University of Michigan Medical School


Disclosure: Kaye reports no relevant financial disclosures.