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• W2007617720 abstract "Respiratory syncytial virus (RSV) is a common community-acquired virus that causes upper and lower respiratory tract infections in children, hematologic malignancy patients, and hematopoietic stem cell transplant (HSCT) recipients. Nosocomial transmission of RSV in immunocompromised patients can significantly affect morbidity, mortality, and duration of hospitalization. Stringent infection control measurements are needed to control further hospital transmission. Prophylactic palivizumab was found to result in a significant reduction in hospitalization rates in high-risk children. In this article, we report a nosocomial outbreak of RSV in an adult HSCT unit (4 pods) from January 16 to February 4, 2004, including the infection control interventions used and the prophylactic administration of palivizumab in high-risk patients. Active surveillance identified 5 cases, a substantial increase from previous seasons (2 or 3 cases per season). All infected patients were isolated to 1 nursing pod and placed on contact isolation. All patients on the HSCT unit underwent rapid RSV antigen screening using nasal washes; this was repeated 1 week later, and 1 additional RSV case was identified. Patients identified to be at increased risk for RSV infection received prophylactic palivizumab. Routine screenings of the staff and visitors were undertaken. All patient and visitor areas were thoroughly cleaned with bleach. We educated health care workers about RSV transmission, highlighting proper hand hygiene and contact precautions. Four of 6 patients with RSV infection developed RSV pneumonia, and 2 of these patients died. Staff and visitors with upper respiratory symptoms were screened, and all were negative for RSV. Prophylactic palivizumab was administered in 16 patients who tested negative for RSV, but were considered to be at increased risk for RSV infection. None of these patients developed RSV infections. An RSV outbreak was controlled using prompt preventive measures, including cohorting patients, with a dedicated health care staff; contact isolation of patients; strict adherence to hand hygiene; and screening of visitors, family members, and health care staff for upper respiratory infection symptoms. Immunoprophylaxis with palivizumab, administered to high-risk patients, complemented strict infection control intervention. Thus, the role of palivizumab in the control of RSV hospital outbreaks merits further investigation. Respiratory syncytial virus (RSV) is a common community-acquired virus that causes upper and lower respiratory tract infections in children, hematologic malignancy patients, and hematopoietic stem cell transplant (HSCT) recipients. Nosocomial transmission of RSV in immunocompromised patients can significantly affect morbidity, mortality, and duration of hospitalization. Stringent infection control measurements are needed to control further hospital transmission. Prophylactic palivizumab was found to result in a significant reduction in hospitalization rates in high-risk children. In this article, we report a nosocomial outbreak of RSV in an adult HSCT unit (4 pods) from January 16 to February 4, 2004, including the infection control interventions used and the prophylactic administration of palivizumab in high-risk patients. Active surveillance identified 5 cases, a substantial increase from previous seasons (2 or 3 cases per season). All infected patients were isolated to 1 nursing pod and placed on contact isolation. All patients on the HSCT unit underwent rapid RSV antigen screening using nasal washes; this was repeated 1 week later, and 1 additional RSV case was identified. Patients identified to be at increased risk for RSV infection received prophylactic palivizumab. Routine screenings of the staff and visitors were undertaken. All patient and visitor areas were thoroughly cleaned with bleach. We educated health care workers about RSV transmission, highlighting proper hand hygiene and contact precautions. Four of 6 patients with RSV infection developed RSV pneumonia, and 2 of these patients died. Staff and visitors with upper respiratory symptoms were screened, and all were negative for RSV. Prophylactic palivizumab was administered in 16 patients who tested negative for RSV, but were considered to be at increased risk for RSV infection. None of these patients developed RSV infections. An RSV outbreak was controlled using prompt preventive measures, including cohorting patients, with a dedicated health care staff; contact isolation of patients; strict adherence to hand hygiene; and screening of visitors, family members, and health care staff for upper respiratory infection symptoms. Immunoprophylaxis with palivizumab, administered to high-risk patients, complemented strict infection control intervention. Thus, the role of palivizumab in the control of RSV hospital outbreaks merits further investigation. IntroductionRespiratory syncytial virus (RSV) is a well-known cause of lower respiratory tract infections in young children [1Izurieta H.S. Thompson W.W. Kramarz P. et al.Influenza and the rates of hospitalization for respiratory disease among infants and young children.N Engl J Med. 2000; 342: 232-239Crossref PubMed Scopus (897) Google Scholar], and is now increasingly recognized as an important cause of respiratory infections in adults, especially in the elderly and immunocompromised patients [2Falsey A.R. Treanor J.J. Betts R.F. et al.Viral respiratory infections in the institutionalized elderly: clinical and epidemiologic findings.J Am Geriatr Soc. 1992; 40: 115-119Crossref PubMed Scopus (176) Google Scholar]. By the age of 2 years, almost all children have been infected with RSV [3Shay D.K. Holman R.C. Newman R.D. et al.Bronchiolitis-associated hospitalizations among US children, 1980-1996.JAMA. 1999; 282: 1440-1446Crossref PubMed Scopus (1147) Google Scholar], but naturally acquired immunity is incomplete, and reinfection is common [4Fenton C. Scott L.J. Plosker G.L. Palivizumab: a review of its use as prophylaxis for serious respiratory syncytial virus infection.Paediatr Drugs. 2004; 6: 177-197Crossref PubMed Scopus (54) Google Scholar].The clinical features of reinfections are generally mild in immunocompetent patients, and the duration of viral shedding is relatively short. However, RSV infections have been associated with high morbidity and mortality rates (70%-100%) and prolonged viral shedding in both autologous and allogeneic adult stem cell transplant (HSCT) recipients [5Sable C.A. Hayden F.G. Orthomyxoviral and paramyxoviral infections in transplant patients.Infect Dis Clin N Am. 1995; 9: 987-1003PubMed Google Scholar, 6Whimbey E. Champlin R. Englund J. et al.Combination therapy with aerosolized ribavirin and intravenous immunoglobulin for respiratory syncytial virus disease in adult bone marrow transplant recipients.Bone Marrow Transplant. 1995; 16: 393PubMed Google Scholar]. The disease incidence varies seasonally, with a peak from November to April in the northern hemisphere. Outbreaks of RSV infections have been reported among nursing home patients and institutionalized young adults [7Falsey A.R. Hennessey P.A. Formica M.A. et al.Respiratory syncytial virus infection in elderly and high-risk adults.N Engl J Med. 2005; 352: 1749-1759Crossref PubMed Scopus (1334) Google Scholar, 8Osterweil D. Norman D. An outbreak of an influenza-like illness in a nursing home.J Am Geriatr Soc. 1990; 38: 659-662Crossref PubMed Scopus (43) Google Scholar, 9Falsey A.R. Noninfluenza respiratory virus infection in long-term care facilities.Infect Control Hosp Epidemiol. 1991; 12: 602-608Crossref PubMed Scopus (42) Google Scholar], but few reports have documented nosocomial RSV outbreaks among HSCT patients [10Abdallah A. Rowland K.E. Schepetiuk S.K. To L.B. Bardy P. An outbreak of respiratory syncytial virus infection in a bone marrow transplant unit: effect on engraftment and outcome of pneumonia without specific antiviral treatment.Bone Marrow Transplant. 2003; 32: 195-203Crossref PubMed Scopus (60) Google Scholar, 11Harrington R.D. Hooton T.M. Hackman R.C. et al.An outbreak of respiratory syncytial virus in a bone marrow transplant center.J Infect Dis. 1992; 165: 987-993Crossref PubMed Scopus (309) Google Scholar, 12Jalal H. Bibby D.F. Bennett J. et al.Molecular investigations of an outbreak of parainfluenza virus type 3 and respiratory syncytial virus infections in a hematology unit.J Clin Microbiol. 2007; : 1690-1696Crossref PubMed Scopus (62) Google Scholar].Active infection control surveillance strategies of RSV and other community-acquired respiratory viruses play crucial roles in identifying nosocomial transmission and controlling outbreaks. Studies have suggested that hand washing after patient contact, the use of gowns and gloves, and cohorting of staff and patients are effective preventive strategies [13Isaacs D. Dickson H. O'Callaghan C. Sheaves R. Winter A. Moxon E.R. Handwashing and cohorting in prevention of hospital acquired infections with respiratory syncytial virus.Arch Dis Child. 1991; 66: 227-231Crossref PubMed Scopus (100) Google Scholar, 14Madge P. Paton J.Y. McColl J.H. Mackie P.L. Prospective controlled study of four infection control procedures to prevent nosocomial infection with respiratory syncytial virus.Lancet. 1992; 340: 1079-1083Abstract PubMed Scopus (166) Google Scholar].Palivizumab (Synagis. MedImmune, Inc., Gaithersburg, MD, USA) is a humanized monoclonal antibody directed against the F glycoprotein of RSV; it was approved for the prophylaxis of RSV disease in high-risk infants [15American Academy of Pediatrics Committee on Infectious Diseases, Committee on Foetus and NewbornPrevention of respiratory syncytial virus infections: indications for the use of palivizumab and update on the use of RSV-IG IV.Pediatrics. 1998; 102: 1211-1216Crossref PubMed Scopus (379) Google Scholar, 16Carbonell X. Giuffre L. Kimpen J. et al.Guidelines for the use of Synagis palivizumab—a humanized monoclonal antibody, for the prevention of RSV disease in high-risk infants: a consensus opinion.Infect Med. 1999; 16: 1-5Google Scholar, 17Meissner H.C. Welliver R.C. Chartrand S.A. et al.Immunoprophylaxis with palivizumab, a humanized respiratory syncytial virus monoclonal antibody, for prevention of respiratory syncytial virus infection in high risk infants: a consensus opinion.Pediatr Infect Dis J. 1999; 18: 223-231Crossref PubMed Scopus (109) Google Scholar]. However, its effectiveness in high-risk adults has never been evaluated.In this article, we describe an outbreak of nosocomial RSV among HSCT unit patients at our institution, which was managed using strict infection control interventions and palivizumab immunoprophylaxis in high-risk adult HSCT patients.MethodsEpidemiologic InvestigationThe HSCT unit at The University of Texas M.D. Anderson Cancer Center (Houston, Texas) is a 52-bed unit divided into 4 pods (NE, NW, SW, and SE). From October through March each year, we monitor community- or hospital-acquired respiratory viral infections in hematologic malignancy patients. Patients with symptoms of upper respiratory infection undergo RSV and influenza screening, performed using rapid antigen tests and cultures of nasal washes.At our institution, the incidence of hospital-acquired RSV infection peaks in January and February, with a steady rate of 0.2 and 0.3/1000 patients' days in 2002 and 2003, respectively (Figure 1). However, in January and February 2004, active surveillance of symptomatic patients identified 5 HSCT patients with nosocomial RSV infections. This number represented a substantial increase in incidence of hospital-acquired RSV (0.74/1000 patients' days) when compared to that of previous seasons. We initiated strict infection control measures and investigated the outbreak on February 4th.Identification of Additional CasesNasal washes from all HSCT patients on all 4 pods were collected and sent for rapid RSV antigen screening tests on February 4th; the same day strict infection control measures were implemented. All health care workers who reported upper respiratory symptoms were restricted from patient contact and underwent rapid RSV antigen testing. A sign was placed at the entrance of each pod that stated that all visitors and family members were required to checkin at the nurses' station prior to entering patient rooms.A questionnaire, “Visitor Questionnaire for Upper Respiratory Symptoms,” was distributed to all visitors at the nurses' station. The questionnaire included 2 questions: “Do you currently have symptoms of a cold, that is, are you sneezing, coughing, have a runny nose, sore throat or fever?” and “Have you had close contact with someone that has a cold within the past 7 days?” All individuals who responded yes to either question were not granted visitation. All visitors who responded no were required to wear a sticker that read, “I have been screened today (date) and I am safe.” The nursing staff kept a record of all visitors who had been screened for upper respiratory signs. This system ensured that everyone entering patient rooms had undergone screening.One week later after the screening process had been established, all patients underwent follow-up rapid RSV antigen screening of nasal washes.DefinitionsUpper respiratory RSV infection was defined as rhinorrhea, nasal or sinus congestion, otitis media, pharyngitis, or cough with a clear chest radiograph, with or without fever. RSV pneumonia was defined as an acute respiratory illness in association with signs or symptoms of lower respiratory tract disease and new radiographic infiltrates. Infection was considered nosocomial if respiratory symptoms developed >5 days after hospital admission.Laboratory MethodsNasal washes were collected for rapid antigen detection using the Light Diagnostics Simufluor RSV/FluA immunofluorescence assay kit (Millipore Corporation, Bedford, MA,USA; catalog no. 3129). All specimens were placed in a viral transport medium on ice or refrigerated immediately and transported to the laboratory on ice. Specimens were treated and centrifuged into pellets; any specimens that did not contain sufficient respiratory epithelial cells were recollected. Upon treatment with the Simufluor RSV/Flu A reagent, the RSV antigen-antibody complex exhibits an apple-green fluorescence, whereas uninfected cells will stain a dull red [18Landry M.L. Ferguson D. SimuFluor respiratory screen for rapid detection of multiple respiratory viruses in clinical specimens by immunofluorescence staining.J Clin Microbiol. 2000; 38: 708-711PubMed Google Scholar]. Results were obtained within 2 hours and immediately reported to the clinician. The sensitivity and specificity of this test is between 85% and 100% [18Landry M.L. Ferguson D. SimuFluor respiratory screen for rapid detection of multiple respiratory viruses in clinical specimens by immunofluorescence staining.J Clin Microbiol. 2000; 38: 708-711PubMed Google Scholar].ResultsEpidemiologic InvestigationsOn January 16, 22, and 27, 2004, 3 patients admitted to the SW pod were diagnosed with nosocomial RSV infections. Patients 1 and 3 had evidence of pneumonia, whereas patient 2 had an upper respiratory infection with a negative chest X-ray. On January 28, patient 4, admitted to the SE pod, was diagnosed with pneumonia secondary to RSV. Five days later, on February 2nd, patient 5, admitted to the SW pod was diagnosed with RSV pneumonia (Figure 2). This increase in incidence of nosocomial RSV infection was higher than that in previous years, although not statistically significant. We initiated an outbreak investigation as part of our infection control plan when 2 or more nosocomial RSV or other respiratory virus infections are occurring in patients in the same vicinity and around the same period of time (Figure 1). All HSCT patients and health care workers on all 4 pods were screened using a rapid RSV antigen test of nasal washes. Six health care workers were found to have upper respiratory symptoms, but none were positive for RSV antigen. On February 4th, a sixth patient was diagnosed with a RSV upper respiratory tract infection (Figure 2). Table 1 shows the demographic and clinical characteristics of all 6 patients. All patients were treated with aerosolized ribavirin and palivizumab for at least 7 days. Of the 4 patients with RSV pneumonia, 2 died.Figure 2Timeline of RSV infections among the 6 identified patientsView Large Image Figure ViewerDownload Hi-res image Download (PPT)Table 1Demographics and Characteristics of Patients with Nosocomial RSV InfectionsPatients CharacteristicsAge/GenderUnderlying MalignancyType and Date of TransplantTime from Admission to onset of RSVInfection TypeTreatment Received and OutcomeCause of DeathPatient 141/ maleCutaneous T cell LymphmaAllogeneic matched related HSCT/07/21/200379 daysPneumoniaAerosolized Ribavirin 2 gram q8 h for 10 days and Palivizumab 15 mg/kg X1 and infection resolvedPatient 226/ femaleNodular Sclerosing Hodgkin DiseaseAutologous peripheral HSCT/01/22/20048 daysUpper respiratory tract infectionAerosolized Ribavirin 2 gram q8 h for 14 days and Palivizumab 15 mg/kg X1 and infection resolvedPatient 361/ maleMultiple MyelomaAutologous peripheral HSCT/01/09/200425 daysPneumoniaAerosolized Ribavirin 2 gram q8 h for 14 days and IVIG 500 mg/kg q48 h for 3 doses and infection resolvedPatient 461/ maleMantle cell LymphomaAllogeneic matched unrelated HSCT/05/22/200329 daysPneumoniaAerosolized Ribavirin 2 gram q8 h for 10 days and Palivizumab 15 mg/kg IV X1, treatment failed and patient diedSepsis complicated by multi-organ failurePatient 562/ femaleCMLAllogeneic matched unrelated HSCT/01/07/200427 daysPneumoniaAerosolized Ribavirin 2 gram q8 h for 14 days and IVIG 500 mg/kg q48 h for 3 doses, relapsed 6 days later, treatment was restated but patient died from respiratory failurePatient 667/ maleCMLAllogeneic matched unrelated HSCT/01/30/200412 daysUpper respiratory tract infectionAerosolized Ribavirin 2 gram q8 h for 7 days and Palivizumab 15 mg/kg IV X1 and infection resolvedAll patients had an absolute lymphocyte count of <1000 cells/mL at time of diagnosis of RSV infection at a mean of 277 (range: 40-790).RSV indicates respiratory syncytial virus; CML, chronic myelogenous leukemia; HSCT, stem cell transplantation. Open table in a new tab InterventionsAll RSV-infected patients, along with designated nurses, a respiratory care therapist, and a phlebotomist were moved to the RSV pod (SW). All patients on this pod with or without RSV infection were placed on contact isolation, with masks. No additional patients were admitted to the pod.All visitors with upper respiratory symptoms or a fever or who had been exposed to individuals with colds within the past 7 days were prohibited from entering patient rooms. The infection control practitioners conducted an intensive educational program for employees on all 4 pods that emphasized proper hand hygiene, and strict adherence to contact isolation with mask. Housekeeping performed environmental decontamination with bleach, and established more frequent, rigorous cleaning schedules for patient rooms, nursing areas, restrooms, break rooms, and waiting areas.We then identified HSCT patients who may be at high risk for complications if RSV infection is acquired using the following criteria: allogeneic transplantation, preengraftment, graft-versus-host disease (GVHD), high-dose steroids, or neutropenia with absolute neutrophil count <500 cells/mL. Sixteen patients met these criteria. All 16 were negative for RSV antigen and were given a single dose of 15 mg/kg of intravenous palivizumab. One week later, we performed follow-up screening of all HSCT patients; no new cases of RSV infection were identified. None of the 16 high-risk HSCT patients who had received palivizumab developed RSV infections (Tables 2 and 3 summarize all published RSV outbreaks in the pediatric and adult populations).Table 2Summary of RSV Outbreaks in the Pediatric PopulationReferences (No.)Unit Level of Care (No. of Beds)Date of the OutbreakNo. of Infants on the Ward at Time of OutbreakNo. of Infants Infected with RSVNo. of Deaths Secondary to RSV InfectionNo. of Infants Who Received Prophylactic PalivizumabNo. of RSV Infections after Administration of PalivizumabSalcedo et al. 45Salcedo S. Vinzo J. Calico I. et al.Administration of palivizumab during a nosocomial outbreak in a neonatal unit Abstract P241, presented at the XVII European Congress of Perinatal Medicine, Porto Portugal.Prenatal Neonatal Med. 2000; 5: 180Google ScholarNICU (17)/Intermediate care (15)Jan-005640All infants0Cox et al. 46Cox R.A. Rao P. Brandon-Cox C. The use of palivizumab monoclonal antibody to control an outbreak of respiratory syncytial virus infection in a special care baby unit.J Hosp Infect. 2001; 48: 186-192Abstract Full Text PDF PubMed Scopus (59) Google ScholarNICU (18)Nov/Dec 199917718 (high risk)0Kilani 47Kilani R.A. Respiratory syncytial virus (RSV) outbreak in the NICU: description of eight cases.J Trop Pediatr. 2002; 48: 118-122Crossref PubMed Scopus (34) Google ScholarNICU (20)20012081All infants0Heerens et al. 48Heerens A.T. Marshall D.D. Bose C.L. Nosocomial respiratory syncytial virus: a threat in the modern neonatal intensive care unit.J Perinatol. 2002; 22: 306-307Crossref PubMed Scopus (25) Google ScholarNeonatal critical care center (NA)Feb-98NA31noneN/AHeerens et al. 48Heerens A.T. Marshall D.D. Bose C.L. Nosocomial respiratory syncytial virus: a threat in the modern neonatal intensive care unit.J Perinatol. 2002; 22: 306-307Crossref PubMed Scopus (25) Google ScholarNeonatal critical care center (NA)Apr-98NA61noneN/AAbadesso et al. 30Abadesso C. Almeida H.I. Virella D. Carreiro M.H. Machado M.C. Use of palivizumab to control an outbreak of syncytial respiratory virus in a neonatal intensive care unit.J Hospital Infect. 2004; 58: 38-41Abstract Full Text Full Text PDF PubMed Scopus (43) Google ScholarNICU (26)Nov-98NA30noneN/AAbadesso et al. 30Abadesso C. Almeida H.I. Virella D. Carreiro M.H. Machado M.C. Use of palivizumab to control an outbreak of syncytial respiratory virus in a neonatal intensive care unit.J Hospital Infect. 2004; 58: 38-41Abstract Full Text Full Text PDF PubMed Scopus (43) Google ScholarNICU (26)Apr-981981All infants0Halasa et al. 49Halasa N.B. Williams J.V. Wilson G.J. et al.Medical and economic impact of a respiratory syncytial virus outbreak in a neonatal intensive care unit.Pediatr Infect Dis J. 2005; 24: 1040-1044Crossref PubMed Scopus (77) Google ScholarNICU (37)/Intermediate care (19)NANA90All not infected infants0Kurz et al. 50Kurz H. Herbich K. Janata O. et al.Experience with the use of palivizumab together with infection control measures to prevent respiratory syncytial virus outbreaks in neonatal intensive care units.J Hosp Infect. 2008; 70: 246-252Abstract Full Text Full Text PDF PubMed Scopus (32) Google ScholarNICU (12)Jan-071110All infants0NICU indicates neonatal intensive care unit; NA, not available; N/A, not applicable; RSV, respiratory syncytial virus. Open table in a new tab Table 3Summary of RSV Outbreaks in AdultsRSV Outbreaks in Immunocompromised AdultsReferencesUnit Level of Care (No. of Beds)Date of the OutbreakNo. of Patients on the Ward at Time of OutbreakNo. of Patients Infected with RSVNo. of Deaths Secondary to RSV InfectionNo. of Patients Who Received Prophylactic PalivizumabNo. of RSV Infections after Administration of PalivizumabHarrington et al. 11Harrington R.D. Hooton T.M. Hackman R.C. et al.An outbreak of respiratory syncytial virus in a bone marrow transplant center.J Infect Dis. 1992; 165: 987-993Crossref PubMed Scopus (309) Google ScholarBMT unitJan/Apr 1990NA3114 (all had pneumonia)NoneN/AJones et al. 51Jones B.L. Clark S. Curran E.T. et al.Control of an outbreak of respiratory syncytial virus infection in immunocompromised adults.J Hosp Infect. 2000; 44: 53-57Abstract Full Text PDF PubMed Scopus (27) Google ScholarHematology/Oncology ward (14)Feb/Apr 1997NA8 (including 5 posttransplantation)0NoneN/AAbdallah et al. 10Abdallah A. Rowland K.E. Schepetiuk S.K. To L.B. Bardy P. An outbreak of respiratory syncytial virus infection in a bone marrow transplant unit: effect on engraftment and outcome of pneumonia without specific antiviral treatment.Bone Marrow Transplant. 2003; 32: 195-203Crossref PubMed Scopus (60) Google ScholarBMT unitMay/Sep 2001NA162 (Both had pneumonia)NoneN/ACurrent studyBMT unitJan/Feb 2004526216 (high-risk)0RSV Outbreaks in Immunocompetent AdultsSorvillo et al. 52Sorvillo F.J. Huie S.F. Strassburg M.A. et al.An outbreak of respiratory syncytial virus pneumonia in a nursing home for the elderly.J Infect. 1984; 9: 252-256Abstract Full Text PDF PubMed Scopus (93) Google ScholarNursing homeMar/MayNA408NoneN/AHuang et al. 53Huang F.-L. Chen P.-Y. Shi Z.Y. et al.An unusual respiratory syncytial virus nosocomial outbreak in an adult psychiatry ward.Jpn J Infect Dis. 2009; 62: 61-62PubMed Google ScholarPsychiatry wardAug 2005258 patients and 4 HCW0NoneN/ACaram et al. 54Caram L.B. Chen J. Taggart E.W. et al.Respiratory syncytial virus outbreak in a long-term care facility detected using reverse transcriptase polymerase chain reaction: an argument for real-time detection methods.J Am Geriatr Soc. 2009; 57: 482-485Crossref PubMed Scopus (41) Google ScholarLong-term care facilityJan/Feb 200852220NoneN/ABMT indicates bone marrow transplant; NA, not available; N/A, not applicable; HCW, health care worker; RSV, respiratory syncytial virus. Open table in a new tab Twenty days later, control measures were discussed and reviewed. Contact isolation was discontinued for all non-RSV-infected patients. Screening of symptomatic health care staff and visitors was continued. The use of masks and gloves during patient contact was reinforced.DiscussionRSV is a frequent cause of both acute upper and lower respiratory tract infections, and the severity of clinical manifestation depends on patient age and health status. In immunocompromised patients, such as hematopoietic HSCT recipients, RSV upper respiratory disease may progress to fatal viral pneumonia [19Couch R.B. Englund J.A. Whimbey E. Respiratory viral infections in immunocompetent and immunocompromised persons.Am J Med. 1997; 102: 2-9Abstract Full Text Full Text PDF PubMed Scopus (186) Google Scholar]. In a previous study conducted at our institution, RSV was isolated in 31% of 343 cases of respiratory illness from July 1, 2000, to July 30, 2002, in leukemia and HSCT patients [20Chemaly R.F. Ghosh S. Bodey G.P. et al.Respiratory viral infections in adults with hematologic malignancies and human stem cell transplantation recipients: a retrospective study at a major cancer center.Medicine (Baltimore). 2006; 85: 278-287Crossref PubMed Scopus (266) Google Scholar]. Pneumonia developed in 36% (39 of 107) of RSV cases, and 6 of 36 (17%) patients treated for RSV pneumonia died. These high rates of pneumonia and death have been confirmed at other centers [21Raboni S.M. Nogueira M.B. Tsuchiya L.R. et al.Respiratory tract viral infections in bone marrow transplant patients.Transplantation. 2003; 76: 142-146Crossref PubMed Scopus (115) Google Scholar].Early treatment (before respiratory failure occurs) with aerosolized ribavirin, alone or in combination with immunotherapy, is key to reducing mortality in patients with established pneumonia [22Whimbey E. Englund J.A. Couch R.B. Community respiratory virus infections in immunocompromised patients with cancer.Am J Med. 1997; 102: 10-18Abstract Full Text Full Text PDF PubMed Scopus (145) Google Scholar, 23Ghosh S. Champlin R.E. Englund J. et al.Respiratory syncytial virus upper respiratory tract illnesses in adult blood and marrow transplant recipients: combination therapy with aerosolized ribavirin and intravenous immunoglobulin.Bone Marrow Transplant. 2000; 25: 751-755Crossref PubMed Scopus (157) Google Scholar]. Furthermore, the early use of aerosolized ribavirin-based therapy in immunocompromised patients with isolated upper respiratory symptoms can decrease the rate of progression to pneumonia [20Chemaly R.F. Ghosh S. Bodey G.P. et al.Respiratory viral infections in adults with hematologic malignancies and human stem cell transplantation recipients: a retrospective study at a major cancer center.Medicine (Baltimore). 2006; 85: 278-287Crossref PubMed Scopus (266) Google Scholar]. Thus, routine screening of HSCT patients with upper respiratory symptoms is important, especially during high seasonal peaks.In this article, we described an outbreak of nosocomial RSV in which 6 HSCT patients developed RSV infections. Two patients had isolated upper respiratory involvement, and 4 developed pneumonia. All 6 patients were promptly started on aerosolized ribavirin treatment, but 2 developed severe respiratory failure and died.Stringent infection control measures, including cohorting RSV-infected patients and healthy staff members to 1 pod, placing all patients on contact isolation, and screening visitors and staff, were implemented to control the outbreak. RSV is highly contagious, and rapid spread among hospitalized patients has been documented. The virus survives up to 7 hours on countertops, gloves, paper tissues, and clothes and 30 minutes on skin [24Hall C.B. Douglas Jr., R.G. Modes of transmission of RSV.J Pediatr. 1981; 99: 100Abstract Full Text PDF PubMed Scopus (298) Google Scholar]. Transmission occurs primarily through inoculation of nasopharyngeal or ocular mucous membranes after contact with virus containing secretions or fomites [25Hall C.B. Douglas Jr., R.G." @default.
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• W2007617720 title "Detection and Control of a Nosocomial Respiratory Syncytial Virus Outbreak in a Stem Cell Transplantation Unit: The Role of Palivizumab" @default.
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