“The Challenges of Viral Respiratory Healthcare-Associated Infections in Pediatrics”
Quach C, Shah R, Rubin LG. Burden of healthcare-associated viral respiratory infections in children’s hospitals. JPIDS. 2018; 7(1): 18-24.

It is well known that viral respiratory infections are a common healthcare associated infection (HAI) in children. For those of us who practice in states that have mandatory National Healthcare Safety Network (NHSN) reporting requirements for all HAIs, performing the necessary house-wide surveillance for respiratory viral HAIs (HA-VRI) becomes challenging in terms of time and IP resources especially during respiratory viral season when these viruses are circulating at high rates in the community. The prevalence of HA-VRI in children varies in the literature. There have been many reports of increased morbidity and mortality from HA-VRI especially in neonates and immunocompromised patients 1-4. Hospital laboratories that perform more sensitive testing, such as nucleic acid amplification, will diagnose more respiratory viruses. Detection of respiratory viral nucleic acid may also represent asymptomatic shedding. This is especially a concern for rhinovirus where prolonged shedding can make it unclear if a positive test represents shedding or infection. It is unclear how well the NHSN definitions perform for HA-VRI in children and how best to utilize IP resources to perform surveillance. We lack best practices for HA-VRI prevention and we lack antivirals against the most commonly identified viruses that cause HA-VRI. More information is acutely needed.

The study performed by Quach et al begins to help address some of these issues. They compared and assessed determinants of unit-specific HA-VRI incidence rates in two children’s hospitals during three respiratory viral seasons (2010-2013). This was a retrospective study of prospective cohorts at Montreal Children’s Hospital (MCH) and Cohen Children’s Medical Center (CCMC) in New York. Both hospitals have similar demographics (number of beds, level 4 NICU, PICU, bone marrow transplant unit, hematology oncology ward and general medical/surgical wards). Both hospitals had some wards with multiple beds per rooms. Prospective surveillance for HA-VRI used standard NHSN definitions that require compatible respiratory symptoms and viral detection. Both hospitals used the minimum number of days since admission and viral incubation periods to determine HA-VRI (shortest number of one day for influenza A/B at MCH and longest of 4 days for human metapneumovirus at CCMC). Only MCH conducted syndromic surveillance for HA-VRI. Both hospitals use a multiplex nucleic acid amplification test for viral detection on nasopharyngeal swabs or aspirates; MCH used an in-house assay that detects adenovirus, human metapneumovirus, influenza A and B, parainfluenza types 1,2,3 (PIV), respiratory syncytial virus (RSV), enterovirus, rhinovirus and coronaviruses 229E and OC43. CCMC used the Luminex TM multiplex nucleic acid amplification test which can detect the same viruses, however it cannot detect coronaviruses nor can it differentiate between enterovirus and rhinovirus requiring a supplemental test to differentiate between these two.

HA-VRI rates per 1000 patient days were determined including virus (excluding coronavirus and patients who tested negative but were found by syndromic surveillance) and unit specific rates. Multivariable regression analysis was used to assess determinants for HA-VRI. The HA-VRI rate for the 6 virus groups studied was significantly higher at MCH than at CCMC (1.91 vs 0.80 per 1000 patient-days, respectively, P <.0001). Overall the rate was lowest in the NICU, however units with the lowest HA-VRI rate differed between MCH and CCMC (Heme/Onc ward vs NICU respectively). The rank order of viruses identified was similar between the two hospitals with rhinovirus most commonly identified followed by PIV and RSV. When viral etiology was compared by unit type, the highest rates were in the PICU with rhinovirus followed by adenovirus and Heme/Onc wards with rhinovirus followed by PIV in both hospitals. When adjusted for unit type and HA-VRI they found less than 50% single rooms in a given unit to be statistically associated with a higher rate (1.33 times higher rate (95% CI 1.29-1.37) regardless of unit type, however neither hospital had a NICU with single rooms. The authors speculate that single rooms might not be sufficient to prevent nosocomial acquisition in the absence of meticulous hand hygiene and housekeeping, but since most of these viruses are spread by contact and droplets decreased crowding in single rooms would likely prevent some transmission. Both hospitals had visitor restriction policies due to illness or young age, however both hospitals admitted that their policies were rarely enforced. Staff who were ill were instructed to stay home, but it is not known how well this policy was enforced at either hospital. It is likely that more IP resources would have been required to perform syndromic surveillance at MCH. The authors acknowledged that potential misclassification of some community acquired infections as HAIs might have occurred and systematic HA-VRI surveillance was not performed after discharge so some patients with HA-VRI may not have been identified.

Prevention of HA-VRIs is difficult. Asymptomatic shedding can occur in both healthcare workers (HCW), patients, parents/caregiver and visitors. Ill HCW presenteeism is common and lean staffing results in HCWs coming to work ill because they do not want to burden their colleagues 5,6,7,8. The same lean staffing may affect oversight of ill parents/caregivers and visitors allowing for importation of viruses from the community. The hospital environment quickly becomes contaminated and these viruses are then spread on HCWs hands to patients. Respiratory viruses can persist on dry surfaces from 2 hours-3 months depending on the virus9. There is a need for studies that evaluate best practices for HA-VRI prevention, along with visitor policies that align with family centered care, but which are still safe for other patients and HCWs. We need to ensure healthcare worker non-punitive policies for staying home if ill. In order achieve this we need to have adequate staffing in hospitals so an ill HCW can stay home and daily work can still be completed safely.

Written by: Jane M. Gould, MD


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