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By Kimberly E Clash, RN, BSN; Updated 10/04 by Karen Mackie, RN, MA, CIC
The Organism
- RSV, a paramyxovirus, is a large enveloped RNA virus that is
highly infectious with two major strains (A and B) circulating
concurrently (1,4).
- Although it is the most common cause of lower respiratory tract
illness in young children, it may also cause significant morbidity
in the older child and adult as well.
- It manifests as tracheobronchitis, bronchiolitis and pneumonia
in the very young child, and life threatening infections usually
occur during the first two years of life.
- In adults and older children, morbidity from RSV is secondary
to acute upper respiratory tract infection, exacerbation of wheezing
and bronchitis (4).
- Children with chronic cardiopulmonary disease or immunosuppression
are at greater risk of significant morbidity and mortality from
RSV.
Epidemiology
RSV is the major viral respiratory tract pathogen of early infancy and produces illness with the
greatest frequency during the first 2 years of life (2). The spread of RSV in the community can
be by the rise in the number of cases of bronchiolitis and pneumonia in the pediatric population as
well as a rise in the number of hospital admissions in young children with acute lower respiratory disease.
Transmission is by direct or close contact with contaminated secretions which may involve droplets or
fomites. RSV can persist on environmental surfaces for many hours and for 30 minutes or more on hands.
Health care related spread of RSV to organ transplant recipients or patients with cardiopulmonary
abnormalities or immunity compromised condition has been associated with severe and fatal
disease in children and adults (1).
Incubation period: ranges from 1 – 10 days (1, 2) 4-6 days is more common (2).
Period of Communicability: shortly prior to and for the duration of active disease (2). Viral
shedding is usually 3 – 8 days (1) but may last longer especially in young infants.
Risk of RSV and Associated Clinical Syndromes:
- Bronchiolitis makes up 43-90% of respiratory illnesses caused
by RSV in children.
- Pneumonia (5-40%), tracheobronchitis (10-30%) and croup (3-10%)
make up the remainder of illnesses caused by RSV (4).
Conditions that increase the risk of severe/fatal RSV infection:
- Cyanotic or complicated congenital heart disease
- Conditions causing pulmonary hypertension
- Underlying pulmonary disease
- Broncho-pulmonary dysplasia
- Prematurity
- Immuno-deficiency disease
- Therapy causing immuno-suppression
Distribution:
- Worldwide, seasonal in temperate zones
- Outbreaks occur reliably every year, most often during late
fall, winter and occasionally spring with a predictable and regular pattern.
- RSV activity begins in November, peaks in January and February
and continues until April to mid-May for an average of 22 weeks
(4). It is also seen in BMT patients throughout the year.
- Boys have a higher incidence of infection than girls (4).
- Of children hospitalized with RSV infection, large proportions
of them are from low socioeconomic status (4).
- In general, gender and socioeconomic status influence the severity
of infection, not the rate of infection (4).
- Peak incidence of RSV, bronchiolitis and pneumonia is observed
at 2 months of age.
- RSV infection rates decrease with increasing age.
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Clinical Manifestations
RSV in Infants and Young Children
- In young children, RSV infection is manifested primarily as
lower respiratory tract disease (i.e. pneumonia, bronchiolitis,
tracheobronchiolitis) and upper respiratory tract illness, often
with fever and otitis media.
- Pneumonia and bronchiolitis are the most frequent lower respiratory
tract illnesses in infants.
- Croup is the least common manifestation of RSV, making up less
than 5-10% of cases.
- Pneumonia and bronchiolitis may be difficult to differentiate
and both may present with wheezing, rhonchi, rales and infiltrates
on chest roentgenograms.
- Bronchiolitis is most commonly associated with wheezing and
hyperaeration of the lung.
- Lower respiratory tract disease is usually preceded by upper
respiratory tract infection (URI) with nasal congestion and pharyngitis.
- Symptoms of URI include fever (38-40 C) and cough which may
be paroxysmal and associated with vomiting.
- After several days of URI symptoms, lower respiratory tract
involvement becomes evident.
- Lower respiratory tract illness is characterized by dyspnea,
an increase in respiratory rate, retractions of the intercostal
muscles, crackles and wheezing on auscultation and multiple areas
of interstitial infiltration and hyperinflation of the lung on
chest roentgenogram.
- Cyanosis with lower respiratory tract involvement is rare and
is usually associated with prolonged hypoxemia.
- The duration of respiratory illness due to RSV infection ranges
from 7-21 days.
- Length of hospitalization, if needed, for RSV infection averages
3-7 days.
- Immunity is not complete and reinfection is common (4).
RSV in Older Children and Adults
- Secondary infection with RSV, after the first three years of
life, is usually manifested as upper respiratory tract illness
or tracheobronchitis, however, lower respiratory illness may also
occur.
- Common signs and symptoms of URI include nasal congestion and
cough.
- Upper respiratory infections with RSV may mimic the common cold
but tend to be more severe and prolonged than respiratory illnesses
caused by other viral agents such as rhinovirus.
- Symptoms of respiratory illness due to RSV infection in the
older child and adult most commonly include fever, runny nose,
wheezing and shortness of breath.
- Less commonly, older children and adults may present with sinus
pain, ear pain, sore throat and rhonchi and crackles on auscultation.
- Immunity is not complete and reinfection is common (4).
Diagnosis
- Diagnosis of RSV in infants with lower respiratory tract illness
may be made on the basis of both clinical and epidemiologic findings
(4).
- The three most commonly used techniques for viral identification
are fluorescent antibody stains of infected nasal epithelium cells,
enzyme-linked immunosorbent assay (ELISA) on nasopharyngeal secretions
(see NPA directions Link) and viral culture of respiratory secretions
(8).
- Viral isolation of nasal wash produces the highest viral recovery
and a higher percentage of positive results (4,8).
- All specimens should be inoculated into proper cell lines as
soon as possible because the virus is labile when subjected to
pH and temperature changes.
- Rapid techniques are also available for diagnosing RSV infection
and include immunofluorescent assays, enzyme immunoassay, radioimmunoassays,
DNA-RNA hybridization and RNA polymerase chain reaction.
- Ideally cell cultures should be used in addition to a rapid
technique in order to confirm diagnosis (4).
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Complications
Infants
- Young infants and those with underlying diseases are most likely
to experience complicated RSV infection.
- 25% - 60% of fatal RSV infections occur in children with cardiopulmonary
and congenital disorders.
- Conditions placing young infants at high risk for severe infection
with RSV include premature birth, bronchopulmonary dysplasia,
cystic fibrosis, congenital heart disease, immunocompromised conditions,
neurologic disease, nephrotic syndrome and low birth weight (4).
- Acute complications in infants include apnea and respiratory
failure.
- Apnea, as a result of RSV infection, most commonly presents
in the first 1-2 months of age, in premature infants and in infants
exhibiting moderate to severe hypoxemia.
- There is limited evidence that RSV may contribute to the occurrence
of sudden infant death syndrome (SIDS) in infants older than 3
months of age.
- Hypercarbia, respiratory failure and apnea are the major factors
leading to assisted ventilation in RSV infected cases (4).
- The role of RSV in the occurrence of wheezing and pulmonary
function abnormalities in infants infected and/or hospitalized
with RSV at a young age is unknown (4).
Immunocompromised Patients·
- Infants and young children with immunocompromised conditions
are at high risk for experiencing complications from RSV infection.
- Suppression of cell mediated immunity is a major factor contributing
to the severity of disease in these patients.
- Patients who are severely immunocompromised (i.e. HIV, transplant
recipients on immunosuppressive therapy) may exhibit extensive
pulmonary infection and prolonged shedding of the virus (4).
Treatment
- Primary treatment is supportive and should include hydration, careful assessment of respiratory status,
including measurements of O2 saturation, use of supplemental O2, and
ventilator support.
- Supplemental oxygen to the hypoxemic patient to maintain oxygen
saturation of at least 92%.
- Antibiotic treatment should be reserved for cases where bacterial
infection is proven to be complicating infection with RSV.
Ribavirin
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- aerosol treatment is generally not recommended (1) and should be
only be used on a case-by-case basis
- a broad spectrum antiviral agent.
- administered as small particle aerosol in a tent, oxyhood,-mask
or ventilator.
- administered for 8-20 hours per day for 2-5 days.
- should be considered for patients with underlying cardiac,
pulmonary or immunosuppressive conditions (high-risk cases)
(4).
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Infection Control
- Prevention, not treatment, is the goal for the control of RSV
infection.
- Prophylactic intervention is problematic due to the very young
age at which RSV first attacks.
- Breast-feeding offers some protection to the infant.
- RSV spreads through close contact, direct inoculation of droplets
of the secretions from an infected person and indirect transmission
from hands that touch infectious secretions that contaminate environmental
surfaces.
- Although prevention of infection through interruption of transmission
of the virus is difficult in the home and community, preventing
transmission in the hospital setting is essential (4).
- The Centers for Diseases Control and Prevention (CDC) recommend
the use of droplet precautions for patients with RSV. At JHH,
we have used a 2 stage control plan that includes a category of
isolation called Pediatric Droplet Precautions. These precautions
are similar to the CDC's Droplet Precautions. In addition these
precautions require that gloves must be worn to enter the room.
- The following link provides a synopsis of the 2 stage control
plan used at Johns Hopkins Hospital [RSV
2-Stage Control Plan] (7). Currently, the plan is in effect
throughout the Children's Center and a modified version is in
place in the oncology center.
RSV Prophylaxis
- RSV-IGIV (RespiGam®) and Palivizumab (Synagis®) are licensed for prophylaxis against RSV and
have been approved for use in selected children <24 months with chronic lung disease
or history of pre-term birth (gestational age <35 weeks) by the Academy of Pediatrics.
- There is no vaccine available for RSV (4).
References
- American Academy of Pediatrics. (2003). Respiratory syncytial
virus. In G. Peter (Ed.), In Red book: Report of the committee
on infectious diseases. (23rd ed. , pp. 523-528). Elk Grove Village,
IL:Author.
- American Public Health Association. (2000). Acute Febrile Respiratory Disease. In J. Chin (Ed.), Control
of Communicable Diseases Manual (17th ed., pp. 427-430). Washington, DC.
- Glezen, W. P., Taber, L. H., Frank, A. L. & Kasel, J. A. (1986).
Risk of primary infection and reinfection with respiratory syncytial
virus. American Journal of Diseases of Children, 140, 543-546.
- Hall, C. B. & McCathy, C. A. (2000). Respiratory syncytial
virus. In G. L. Mandell, J. E. Bennett, & R. Dolin. Principles
and Practice of Infectious Diseases. (5th ed., pp. 1782-1801).
Philadelphia, PA: Churchill Livingstone.
- Hall, C. B., Geiman, J. M., Biggar, R., Kotok, D. I., Hogan,
P.M. & Douglas, R. G. (1976). Respiratory syncytial virus infections
within families. New England Journal of Medicine, 294, 414-419.
- Henderson, F. W., Clyde, W. A., Collier, A.M. & Denny, F.
W. (1979). The etiologic and epidemiologic spectrum of bronchiolitis
in pediatric practice. Journal of Pediatrics, 95, 183-190.
- Karanfil, L. V., Conlon, M., Lykeens, K., Masters, C.F.,
Forman, M., Griffith, M. E., Townsend, T. R. & Perl, T.M. (1999).
Reducing the rate of nosocomially transmitted respiratory syncytial
virus. American Journal of Infection Control, 27 (2), 91-96.
- Murphy, M. D. (1988). Respiratory syncytial virus. In L. G.
Donowitz (Eds.). Hospital Acquired Infection in the Pediatric
Patient. Baltimore, MD:Williams and Wilkins.
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Respiratory
Syncytial Virus (RSV) Pediatric Control Plan
Stage 1: Stage
2:
Stage 1:
Effective when the first hospitalized patient from the local community with confirmed RSV
infection is identified each fall.
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| Nasopharyngeal aspirate (NPA) Specimens
for Viral Culture and Antigen Detection |
Any child < 6 years of age with bronchiolitis or pneumonia.
All children < 6 years of age with known HIV infection who
come into the hospital (does not apply to neonates with presumptive
HIV during their hospitalization after delivery).
|
| Pediatric Droplet Precautions |
Indicated for any child <
6 years of age with bronchiolitis or pneumonia |
| Duration of Precautions for
Suspected Cases |
If the child's RSV antigen
test is negative, Pediatric Droplet Precautions may be discontinued.
Droplet Precautions should be followed for symptomatic children who may have
a viral respiratory illness other than RSV. |
| Duration of Precautions for
Confirmed Cases |
Patients with no immune suppression:
After symptoms related to RSV have resolved and one week
after the first positive RSV antigen test, a second test may
be performed. Pediatric Droplet Precautions may be discontinued
if the second antigen test is negative.
Patients with immune suppression:
Precautions may be discontinued only after 2 consecutive
negative RSV antigen tests, obtained one week apart, after
consulting with Pediatric Infectious Diseases.
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| Placement of Patients |
Private room is preferable
if space is available. Roommates may not be patients with congenital
heart or chronic lung disease and patients with immune suppression.
Contact Hospital Epidemiology & Infection Control for assistance
with placement issues. |
| Pediatric Droplet
Precautions are as follows: |
- Gloves are required for contact with infective secretions.
- Masks (preferably with visors) are required when healthcare workers (HCW)
are at the patient's bedside (e.g. within 3 feet of the patient).
- Gowns are required to touch the patient.
- Pediatric Droplet Precautions
are not required when caring for a roommate of a RSV patient
unless the roommate is also on precautions.
- Parents of children on Pediatric
Droplet Precautions do not need to wear masks, gowns, or
gloves, but do need to wash hands upon leaving the room
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Stage 2:
Effective when five hospitalized patients from the local community
with confirmed RSV infection have been identified
|
| NPA Specimens
for Viral Culture and Antigen Detection |
Any child < 6 years of age with any respiratory symptoms.
All children < 6 years of age with known HIV infection who
come into the hospital (does not apply to neonates with presumptive
HIV during their hospitalization after delivery).
|
| "Pediatric Droplet Precautions" |
Indicated for any child <
6 years of age with any respiratory symptoms and any child <6 years of age with
known HIV infection. |
| Duration of Precautions for
Suspected Cases |
If the child's RSV antigen
test is negative and the RSV culture is negative at 5 days,
Pediatric Droplet Precautions may be discontinued. |
| Duration of Precautions for
Confirmed Cases |
Patients with no immune suppression:
After symptoms related to RSV have resolved and one week
after the first positive RSV antigen test, a second test may
be performed. Pediatric Droplet Precautions may be discontinued
if the second antigen test is negative.
Patients with immune suppression:
Precautions may be discontinued only after 2 consecutive
negative RSV antigen tests, obtained one week apart AND AFTER
CONSULATION WITH PEDICATRIC INFECTIOUS DISEASES.
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| Placement of Patients |
Private room is
preferable if space is available. Roommates may not be patients
with immune suppression, congenital heart disease, or chronic
lung disease. Contact Infection Control for assistance with
placement issues. |
| Sibling Visitation |
Sibling visitation
will be suspended for children < 2 years of age who are visiting
CMSC, Obstetrical Nursing Units and the Newborn Nursery.
Exceptions may be made after consultation with Hospital Epidemiology
and Infection Control or Pediatric Infectious Diseases. |
Stage 2 will be in effect until
10 days have passed without admission of a community-acquired RSV
case and without evidence of further nosocomial transmission.
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Respiratory
Syncytial Virus (RSV) Oncology Control Plan
Stage 1: Stage
2:
Stage 1:
Effective when the first hospitalized patient from the local community with confirmed RSV
infection is identified each fall.
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| Nasopharyngeal aspirate (NPA) Specimens
for Viral Culture and Antigen Detection |
The test is indicated for any adult oncology patient with bronchiolitis, pneumonia including increasing
oxygen requirement, sputum production or flu-like symptoms. Flu-like symptoms include fever,
runny nose, cough and body aches.
|
| Droplet Precautions |
Indicated for any adult oncology patient with bronchiolitis,
pneumonia including increasing oxygen requirement, sputum production or flu-like symptoms.
Flu-like symptoms include fever, runny nose, cough and body aches. |
| Duration of Precautions for
Suspected Cases |
Precautions can be discontinued after 7 days if the initial antigen was
negative, the initial culture is negative and the patient is symptom free. If symptoms persist,
precautions shall be continued. |
| Duration of Precautions for
Confirmed Cases |
Precautions may be discontinued after obtaining 2 consecutive negative
RSV antigen tests, taken one week apart.
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| Droplet Precautions are as follows: |
- Gloves & Gowns are required for contact with infective materials.
- Masks (preferably with eye protection) are required if
within 3 feet of the patient.
- All protective attire must be removed before leaving the room
and hands must be cleaned.
- Visitors must follow precautions.
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| Visitation |
- Visitors with flu-like symptoms may not visit.
- Children under 12 are not allowed to visit.
- Exceptions to the above will be granted only with permission from
the attending physician and nurse manager.
|
| Staff Guidelines |
Personnel responsible for the care of Weinberg patients must wear a
mask and gloves for all patient contacts while they have symptoms of a cold but are afebrile. When possible,
assignments of symptomatic personnel should be made so as to minimize their contact with patients who
have congenital heart disease, chronic lung disease, or immunue suppression.
- Oncology personnel who are febrile (>38°C) or have flu-like
symptoms must stay home or if they become sick while at work, must go home.
- Oncology personnel are strongly encouraged to recieve the Influenza
vaccine yearly.
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Stage 2:
Effective when five hospitalized patients from the local community
with confirmed RSV infection have been identified
|
| NPA Specimens
for Viral Culture and Antigen Detection |
The test is indicated for any adult oncology patient with increasing
oxygen requirement, sputum production or flu-like symptoms. Flu-like symptoms include fever,
runny nose, cough and body aches.
|
| "Pediatric Droplet Precautions" |
Are indicated for any adult oncology patient with increasing
oxygen requirement, sputum production or flu-like symptoms. Flu-like symptoms include fever,
runny nose, cough and body aches. |
| Duration of Precautions for
Suspected Cases |
If the patient's RSV antigen
test is negative and the RSV culture is negative at 5 days,
Droplet Precautions may be discontinued. |
| Duration of Precautions for
Confirmed Cases |
Precautions may be discontinued only after 2 consecutive
negative RSV antigen tests, obtained one week apart AND AFTER
CONSULATION WITH INFECTIOUS DISEASES.
|
| Placement of Patients |
Private room.
Contact Hospital Epidemiology & Infection Control for assistance with placement issues. |
| Visitation |
- Visitors with flu-like symptoms may not visit.
- Children under 12 are not allowed to visit.
- Exceptions to the above will be granted only with permission from
the attending physician and nurse manager.
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| Staff Guidelines |
In addition to the precautions in Stage One, when Stage Two goes into effect
ALL STAFF & VISITORS shall wear masks and practice meticulous hand hygiene regardless of symptoms
when entering ALL patient rooms.
When performing care for patients who are known/suspected to RSV, mask (preferably with visor) will be
worn to enter the room; gloves and gown will be worn if touching the patient's infectious secretions.
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Stage 2 will be in effect until
10 days have passed without admission of a community-acquired RSV
case and without evidence of further nosocomial transmission.
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