This was the Apollo 13 of outbreaks—where just about everything that could go wrong did. And in that vein, those who tried valiantly to save all the lives they could embodied that doomed mission’s heroism. In this case, metaphorically speaking, everyone didn’t make it back.
Imagine being called into this situation: More than 40 frail, elderly patients with dementia are confined to two locked units for their own protection as two respiratory viruses—for which there is no vaccine and little treatment—spread among them.
The 2015 outbreak of respiratory syncytial virus (RSV) and human metapneumovirus (HMPV) lasted 16 days, with 30 of 41 patients infected with at least one of the viruses. One patient had the flu. Fifteen patients were hospitalized, and five of them died, authors of a recent study1 of the outbreak reported.
The outbreak presented a host of problems, including difficulty isolating and even cohorting the patients, says Steven Spires, MD, lead author of the study and assistant professor of infectious diseases at Vanderbilt University School of Medicine. The outbreak occurred in an unidentified VA long-term-care facility for which Vanderbilt provided infection control support.
The patients were in two locked units, and an initial attempt to cohort the infected into one of them failed. Infections were spreading within both units after apparently being introduced by infected staff members. Staff had delays getting test results, and patients did not reliably report symptoms. All of the alcohol hand-rub dispensers had been removed because one of the patients—who was no longer at the facility—had been drinking their contents.
“It was a perfect storm,” Spires says. “A locked unit—so everybody is stuck there together 24-7.” The patients who still had the physical ability to be mobile were still able to move around the unit. Most of them would not call the nurse if they had a runny nose and sore throat, Spires notes, adding, “It really hinged on an astute bedside nurse or provider to recognize that they may have a viral infection that may be contagious.”
He described the scenario further: The residents in this environment would not be seen every day by a midlevel clinician or a physician. The patients were not so sick that they would be confined to their beds, as they would have been in a hospital environment. So they were still walking around and touching surfaces, patients, and staff. In this environment, Spires says, “isolation the way that we typically think of isolation in the hospital is just not feasible.”
Spires and colleagues identified three keys to preventing future outbreaks of a respiratory virus within a long-term care facility that may be applicable for similar settings. These measures are critical:
- Conducting effective surveillance for cases among residents and healthcare workers during the respiratory viral season, and having an efficient method for identifying potential contagious pathogens rapidly.
- Employing effective data-driven methods in real time for isolating patients and staff in cohort groups in resource-limited settings.
- Ensuring strict adherence to hand hygiene and using appropriate isolation precautions.
Spires recently shared insights into this devastating outbreak in an interview with Hospital Infection Control & Prevention.
HIC: We often hear about flu in these kinds of outbreaks with this population, is it unusual to have outbreaks of RSV and HPMV of this severity?
Spires: One of the reasons that we published this is that we wanted people to understand that RSV and HPMV are just as important at causing severe illness in older adults as the flu. This has probably been the case for a long time, but we just did not recognize it until recently. In the past several years the technology to identify these viruses just wasn’t there yet. Now we have a lot of facilities that are using these multiplex PCR panels to diagnose viral infections in patients. We are realizing that these two viruses in particular tend to be almost as prevalent in certain seasons as influenza.
HIC: There are no vaccines or proven antiviral treatments for RSV and HMPV in this patient population?
Spires: That’s exactly right. Dr. William Schaffner, [well-known Vanderbilt epidemiologist], reviewed this article for us and he was most outspoken about this. He is a huge proponent of vaccinations, and getting more information out there about the morbidity and mortality of these viruses will help get more funding toward [developing] vaccines and antivirals for these pathogens. There is a monoclonal antibody that has been FDA-approved, I believe, for preventing RSV infections in pediatric patients. It has not been trialed in adults, so we really couldn’t justify using it in this outbreak. Some people will suggest that intravenous immunoglobulin—which basically is the general administration of immunoglobulins to older patients—might work. But again, there is absolutely no data that would support that.
HIC: Given that these were confined patients, a common supposition would be that the viruses were introduced by healthcare workers.
Spires: That was basically the presumptive evidence. Largely because of the fact that they don’t get a lot of visitors and the patients were not really having many contacts [other than healthcare workers]. There is a policy at VA [that stipulates] we were not allowed to question the healthcare workers without them coming forward voluntarily. From day one they were likely spreading [the viruses]. Wearing masks and hand hygiene was huge. The problem too was they were already [understaffed]. It was the middle of respiratory season, and it was a bad year for flu. They were already a third down from their normal labor pool, so people were just having to work because they needed them. The first step was saying don’t come to work if [you are sick]. We tried to set up some screenings for them to come forth. The manager did say if somebody called in sick they didn’t question them. We gave everyone bottles of alcohol-based hand rubs to keep in their pockets. They seemed to use them, but it was very difficult because in a hospital right where people walk in and out of doors there are [wall-mounted] hand rub dispensers. That was not the case here.
HIC: There was a delay in getting test results, but were you trying to enforce use of masks and hand hygiene compliance?
Spires: I think the healthcare workers were not as familiar with the fact that RSV is more likely to be spread by direct and indirect contact. So while they were very familiar with using masks on themselves when they go into a patient’s room with droplet precautions, they were not as familiar with using contact precautions for respiratory viral illnesses. I think for this reason they may not have been as compliant with the contact precautions.
HIC: Isolating symptomatic patients had to be extremely difficult in these conditions.
Spires: All of the rooms were semiprivate, and they were pretty much full. We had a few patients we were able to isolate on their own. So that’s probably the biggest knowledge that I have gained from this outbreak. When this situation does happen I feel better equipped to instruct on how to isolate and cohort these patients. At the time, we were just trying our best to isolate them as they showed up. Then things would happen in the middle of the night—a new case would develop or be found, and that patient may be moved to a new room. But the patient’s roommate who was already exposed would [possibly] give it to a new roommate that was unexposed potentially. Our cohorting efforts may have actually helped spread. I don’t know that for sure and I don’t know if doing it differently would have slowed the outbreak.
HIC: Has enough changed at the facility to prevent a recurrence?
Spires: I hope so. The biggest thing for any infection prevention measure is whether or not a culture of safety is there, whether people care about preventive measures enough to actually do them. This was such a bad outbreak and such severe outcomes of 5 deaths and 15 people left the unit [for hospitalization]. There was an emotional stir associated with this outbreak. I think the healthcare workers are more thoughtful about it, and they understand the significance of a viral infection in their patient population. I do think there is a difference there. They renovated and made sure sinks are where they should be and replaced the alcohol hand rubs.
REFERENCE
- Spires SS, Pope C, Talbot TR, et al. “Paramyxovirus outbreak in a long-term care facility: The challenges of implementing infection control practices in a congregate setting. Infect Control Hosp Epidemiol 2017;38:399–404
This was the Apollo 13 of outbreaks—where just about everything that could go wrong did. And in that vein, those who tried valiantly to save all the lives they could embodied that doomed mission’s heroism. In this case, metaphorically speaking, everyone didn’t make it back.
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