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Friday, November 29, 2013

RSV - Is it more common that the cold?

Unexplained rashes, sniffles, snot and all the other lovely body fluids that children can produce are an unfortunate consequence of being a parent.  For some parents, September signifies the return to school and getting life back in order for at least the next 10 months.  For those of us in the know, it really just signifies the start of cold and flu season (and by cold and flu I mean ALL of the viruses out there that cause respiratory or gastrointestinal infections).

Respiratory Syncytial Virus (RSV) is a virus that infects the lungs and airways and is considered the most common cause of lower respiratory tract infections in young children worldwide, with almost all children having their first RSV infection by two years of age. Similar to the Flu and Norovirus, RSV follows a seasonal pattern where annual outbreaks occur during fall, winter, and early spring among urban centres.  In the Northern hemisphere, epidemics generally peak in February and March. Within USA, 100,000 hospitalizations and 4,500 deaths annually are attributed to RSV infections. RSV is also a major cause of nosocomial infections.

RSV is usually a mild disease that goes away on its own. In very young children RSV can sometimes lead to serious infections like pneumonia or bronchiolitis (a swelling of the bronchioles — the smallest air passages of the lungs).   In most children, RSV usually causes symptoms similar to the common cold: stuffy or runny nose, cough, ear infections (sometimes), low-grade fever and sore throat.  RSV is most likely transmitted through direct contact with infectious secretions (via fomites) and/or large-particle aerosols; however, close contact with infected individuals, or significant exposure of nasal or conjunctival mucosa with contaminated hands is required for transmission.

A 2004 study published in Pharmacoeconomics reviewed data from 2000 and found that nearly 98% of RSV infection-related hospitalisations occurred in children <5 years old. There were approximately 86,000 hospitalisations, 1.7 million office visits, 402 000 emergency room visits and 236,000 hospital outpatient visits with associated annual direct medical $US394 million!

A more recent study published in the Spring of this year by Jacobs et al, in the Canadian Journal of Infectious Diseases and Medical Microbiology developed a model to determine costs of community (CRSV) and nosocomial RSV infections (NRSV).  Similar to stats in the US, 10% of hospitalized patients will acquire a nosocomial infection of which 71% are due to respiratory viruses!  Annual costs of NRSV in Canada for patients <1yr of age was determined to be about $7.9 Million.  The study determined that NRSV added $993 to each CRSV case and also found if improved infection control procedures were in place a reduction of transmitted treatment costs of $469/patient could be attained.  What a novel idea - Infection Prevention programs can help save money!

It's very hard to keep from catching RSV, just like it's hard to keep from catching a cold.  You can lower the chances by practicing good health habits such as washing your hands often, and teach your child to do the same.   If you're in the Northern Hemisphere and your child has to be admitted to hospital I hope you'll remember that respiratory viruses this time of year are just as rampant in hospitals as in the community.  Ask the nurse and doctor to wash their hands and don't be scared to find a disinfectant wipe to clean the area you're in!

Bugging Off!


Friday, November 22, 2013

#FF - Micro Blog's Viral Misfortunes

There are times when the best laid plans go to awry. In keeping on my viral theme for the month I had planned to talk about a Norovirus outbreak in a pediatric unit that was caused by healthcare workers.  I know I read the study, but my recall abilities seem to have gone into early hibernation.  Was it late spring, summer or early fall?  I know I was on a plane.....  Regardless, it was a great example of "inconvenience and irritation" from last week's blog "The Burden of You and the Flu". 

It was also the first time that Google let me down...at least in finding the study I was looking for.  My Google search however, did pop up the Micro Blog which is written by Jon Otter (@jonotter) and Saber Yezli from the UK.  If you're a Infection Prevention nut like me, follow it.  Touted as "Your window to the world of healthcare microbiology and epidemiology" -  Otter and Yezli post some great blogs. 

It was the "Domestic Outbreak of Gastroenteritis" that had me chuckling, not at Otter's misfortunes mind you, but because almost a year ago last night, I lived through the same thing.  Here's the summary of Otter's outbreak:

"Last Wednesday (let’s call it outbreak day 1), our 18-month old toddler “sprayed” projective vomit around our porch. My wife cleaned up the mess. On outbreak day 3, 36 hours later, my wife presented (grumpily) with acute gastroenteritis. We made every effort to limit domestic horizontal transmission (including regular bleach disinfection of contact surfaces in the bathroom and cohorting of personal effects) but to no avail; a little over 24 hours later on outbreak day 4, I endured acute gastroenteritis."

In the 2012 Kenny Outbreak, our then 3.5yr old projectile vomited over his bed, the carpet in his room and ME in the wee hours of a Friday.  By Sunday, both my husband and I were inflicted with the same thing (thankfully we have 3 bathrooms).  Our cohorting consisted of taking turns in parental duty by lying on the couch in the family room to ensure Sawyer was somewhat safe or sprawling on our bed.  I have never been so happy for the invention of TV, DVDs and pre-packaged food!

The truth is, Norovirus happens.  It is irritating.  It is an impediment and it is certainly an inconvenience!  It happens everywhere and especially when you least expect it!   As Otter detailed in an earlier blog about a Norovirus outbreak that was associated with a Car Dealership where the generous mother left the mess for the staff to clean up using nothing more than dry paper towels, you just never know when or how you may pick up your next gastro bug!  I need to get my car in for servicing...I can assure you I will never use a car dealership's washroom again!

Bugging Off!                                                        


PS - after using a "Life Line" and emailing a friend I now have the  title of the study I was looking for in the first place, An Outbreak of Norovirus Infection in a Bone Transplant Unit.  Better late than never I suppose - I hope you take the time to read it!


Monday, November 18, 2013

The Burden of You and the Flu

Depending on your situation in life we look at illness in many different ways.  As an irritant - your spouse or significant other or your children ALWAYS get sick when you have the least time to deal with their whining shenanigans.  As an impediment -  you do not have the time nor the patience to feel under the weather due to work or family commitments. As an inconvenience - your colleagues insist upon coming to work or your friends or family insist on coming for a visit without the forethought that they may spread their illness to you or your family.

In my blog from two weeks ago "Cleaning, Hand Hygiene & Vaccination a few of my Interventions for Flu Season" I have already captured the key tips (Interventions) for limiting the spread of the flu, but after reading an article recently published in AJIC by Mitchell et al titled "Understanding the burden of influenza infection among adults in Canadian hospitals: A comparison of the 2009-2010 pandemic season with the prepandemic and postpandemic seasons", I realized that the impact to me, my family, my colleagues or the burden of influenza on our healthcare system was not touched upon and is something of great importance and worthy of consideration.

The truth of the matter is that Influenza infections are costly. They cause substantial morbidity and mortality and are strain on every country's healthcare resources.  However, the impact or burden to our healthcare system varies greatly year to year depending on the Influenza strains in circulation.  The study reviewed lab-confirmed inpatient characteristics, treatment and outcomes of the pandemic season (2009-2010) with the prepandemic (2006-2007 & 2008-2009) and postpandemic (2010-2011) seasons. Of the 2868 cases identified, 629 cases were from the prepandemic season, 1132 cases from the pandemic season and 1107 cases from the postpandemic season. Of interest was the fact that the healthcare-associated influenza cases was lower during the pandemic than the pre and post pandemic seasons.  Also of interest was the fact that the Healthcare-associated Influenza cases was higher in acute care facilities than long term care facilities during the pandemic season as compared with pre and post pandemic seasons.

With respect to patient characteristics, during the pandemic season the median age of those inflicted during the pandemic season was significantly lower than the pre and post pandemic season (hence the lower infection rates seen in LTC's!).  Similarly, during the pandemic season inpatients were more apt to have pulmonary disease whereas in the postpandemic season they were more likely to have chronic heart and kidney disease.  Possibly as expected, more severe outcomes were reported during the pandemic season as vaccination rates were lower.

Of particular interest was the impact of infection prevention and control practices during the pandemic season.  With knowledge that vaccines were not readily available, ensuring effective interventions were in place (hand hygiene, cleaning and disinfection, isolation etc) likely helps limit healthcare-associated transmission.  If this is true, then the ugly truth is that the increase of healthcare-associated infections in the postpandemic season could be directly related to a lapse and complacency around in infection prevention practices.

We cannot underestimate the flu and its significant impact on the resources needed to effectively limit its spread.  Being prepared to combat Influenza should not be relegated as a response to an outbreak or a pandemic.  The threat of infection and the threat of transmission is an ongoing annual concern and should be an automatic response on a daily basis during Flu Season.  Influenza is an enveloped, easy to kill virus.  Ensuring that environmental surfaces and patient care equipment are cleaned and disinfected daily (and of course after each patient use!) will go a long way to minimizing transmission from environmental surfaces.   Of course, getting vaccinated and washing your hands helps too!

Bugging Off!



Wednesday, November 6, 2013

Viruses - they cause more infections than you think!

I'm not one for themes - well unless it comes to planning birthday parties: CARS, Angry Birds or surprise parties for "big" milestones.  In writing our weekly blogs, Lee and I have tried to weave a story about the use of disinfectants for infection prevention.  However unintentional, this month, as I plan out topics for the blog, I'm seeing a theme develop - viruses. 

In part the reason for developing theme is an article I read that was published in the October edition of AJIC by Tzialla et al titled "Viral Outbreaks in neonatal intensive care units: What we do not know".   Not unexpectedly, infants admitted to NICUs are at risk for contracting HAIs and certainly over the past decade, the HAIs rates have steadily increased.  However, the vast majority of outbreaks published in scientific studies focus on bacterial or fungal infections and certainly they do account for a significant portion of the outbreaks, the impact of viruses as nosocomial agents are not well documented.

Tzialla et al queried an outbreak database and found a total of 75 neonatal outbreaks of which 64 were directly related to neonatal patients and 44 (>68%) associated with NICUs.  The top 5 causative agents were: Rotavirus (>23%), RSV (>17%), Enterovirus (>15%), Hepatitis A (>10%) and Adenovirus (>9%) with gastrointestinal system infections accounting for >54% of outbreaks and respiratory tract infections accounting for >34%  of the infections.

From an infection prevention perspective, is there a common theme? 

• From a microbiological perspective, Rotavirus, Hepatitis A, Enteroviruses and Adenoviruses are non-enveloped viruses.  They tend to be hardier viruses that are more resistant to traditional disinfectant chemistries such as quaternary ammonium compounds.

• From a transmission perspective, Rotavirus, Enterovirus, Hepatitis A and Adenovirus can be transmitted via fecal-oral route - meaning the poor little neonate is eating poop!

• From a transmission perspective RSV, Adenovirus and Enterovirus are transmitted by contact with respiratory droplets.

• Transmission from contact with environmental surfaces and/or fomites has been documented.

• Many of these viruses increase circulation during the fall, winter and early spring.

We are well into Fall and what we typically call Flu Season, in fact there are only 46 more days until the first day of winter!  While we often plan well in advance for Halloween, the Canadian and US Thanksgiving and Christmas holidays (there are only 49 more days to shop!), do we consider planning for "Virus Season"?  Are there preventative measures we can and should consider putting into place?  When was the last time you reviewed the efficacy claims of the daily disinfectant your facility uses?  Does your product carry claims against Influenza, Norovirus, Rotavirus, RSV, Enterovirus, and Adenovirus?  Do you have an infection prevention plan that considers making a change to a more efficacious product to help in the prevention of viral outbreaks?  Do you increase the frequency with which high-touch hand contact surfaces are cleaned and disinfected in order to reduce the risk of transmission from contact with these surfaces?  Do you have a readily accessible Fact Sheets that can be reviewed with staff to help them identify when they may be ill to help minimize the risk that staff are the source of the outbreak?

A fulsome program that considers (and hopefully implements) infection PREVENTION measures such as changing of disinfectant solutions or increased cleaning and disinfection can certainly be implemented with relative ease and likely contribute to fewer infections.  The alternative of course is having to implement INTERVENTION measures to help combat a viral outbreak! 

Bugging Off!