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Challenges remain in pediatric hospital infection prevention, control
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The past decade has brought about remarkable successes in reducing health care-associated infections in hospitalized children, most notably in the reduction of central line-associated bloodstream infections. However, challenges remain, including the prevention and control of health care-associated respiratory viral infections.
Hospital outbreaks of respiratory syncytial virus and influenza and their associated morbidity and mortality have been described since the 1970s. Outbreaks with RSV can have secondary attack rates close to 50% and high rates of transmission to health care personnel. Historically, these “perennial weeds” in pediatric wards were attributed to community outbreaks of respiratory viruses in childhood causing severe disease in otherwise healthy children.
Lisa Saiman
Philip Zachariah
More recently, two factors have increased our understanding of these pathogens among hospitalized children. One is the increasing proportion of hospitalized children with comorbid conditions associated with severe disease from respiratory viral infections (about 10% in recent estimates). Another factor is the widespread adoption of molecular diagnostics for detecting respiratory viral pathogens. Commercially available real-time PCR-based techniques enable testing for a broad array of viruses in addition to RSV and influenza. Thus, outbreaks caused by hitherto difficult-to-detect respiratory viruses, such as human metapneumovirus and adenovirus, are increasingly reported.
Lack of data on disease burden
However, there are no current estimates of the total burden of health care-associated respiratory viral infections in the pediatric population. Previous reports estimated that approximately 20% of all patients with health care-associated pneumonia had viral respiratory infections, 70% of which were adenovirus, influenza virus, parainfluenza virus and RSV. Creation of accurate estimates is hampered by the lack of uniformly accepted case definitions, as well as varying testing practices for acute respiratory illness across institutions. In addition, there are no pediatric HAI reporting requirements or quality metrics for these infections.
Nonetheless, prevention and control of respiratory viruses is a priority for pediatric health care facilities but a complex undertaking for multiple reasons. First is epidemiologic characteristics common to several viruses; eg, transmission from asymptomatic or mildly ill children hospitalized with other diagnoses or transmission from adult and child visitors or from health care personnel. In particular, children may have a prolonged duration of viral shedding before symptom onset. Second, viruses can be transmitted from contact with contaminated fomites, a behavior potentially more common among children. Third, pediatric and adult patients remain susceptible because many respiratory infections recur throughout life. Fourth, hospitalizations due to respiratory viruses occur in parallel with seasonal community outbreaks and/or outbreaks in pediatric long-term care facilities, but the burden varies year-to-year. Finally, effective vaccines or antiviral agents are unavailable for most viral pathogens.
Coordination of care necessary
Despite these challenges, effective infection prevention and control of respiratory viruses is possible by coordinating the interdisciplinary care team across multiple care sites and within facilities. Health care provider education is essential to ensure appropriate isolation of patients and identification of viral pathogens. Ongoing surveillance for viral activity in the community and hospital can help early detection. Appropriate specimen collection, transport and processing allow rapid results from PCR-based testing; this requires costly laboratory infrastructure. Prevention requires prompt institution of transmission precautions for suspected and confirmed infection implemented before specimen acquisition. Current isolation guidelines for different viral pathogens are based on recommendations from the CDC’s Healthcare Infection Control Practices Advisory Committee (HICPAC) 2007 guidelines for infection prevention. Alerting health care personnel by integrating epidemiologic alerts into the electronic medical record can facilitate implementation of appropriate isolation procedures. However, questions still remain regarding appropriate isolation for some respiratory pathogens; eg, “opportunistic airborne agents,” such as influenza, and the appropriate duration of isolation during prolonged hospitalization.
Additional strategies for infection prevention
Other strategies have been proposed to limit outbreaks. Cohorting patients with influenza-like illness (ILI) can decrease transmission within facilities and may be useful in space-limited settings. However, different viral pathogens may present as ILI and can make this problematic.
Restricting visitors, either by ILI symptoms or by not allowing children to visit, is widely implemented during influenza season. However, this strategy depends on effective screening strategies and voluntary participation. Such restrictions may be perceived as onerous by families and can be a challenge to family-centered care.
Restriction of health care personnel with acute respiratory infections also relies on voluntary participation, cooperation of colleagues and supervisors, and adequate sick leave policies.
Vaccination of health care personnel remains the recommended strategy for preventing influenza outbreaks. To improve vaccination rates, some facilities have implemented mandatory vaccination policies or policies with consequences for declining vaccination; eg, mandatory mask use. Chemoprophylaxis with oseltamivir (Tamiflu, Genentech) and palivizumab (Synagis, MedImmune) has been used in high-risk settings to control influenza and RSV outbreaks. However, the utility of these interventions has not been tested in multicenter trials.
Prevention in acute care settings
Lastly, prevention and control of respiratory viral pathogens in acute care settings is an integral part of the public health response to control emerging pathogens. The past decade has witnessed outbreaks of severe acute respiratory syndrome (SARS), the 2009 influenza A(H1N1) pandemic, and the current Middle East respiratory syndrome coronavirus (MERS-CoV). These events highlight the need for rapid scaling up of infection prevention and control activities, substantive organizational investment and coordination with local health departments and the CDC.
In conclusion, health care-associated respiratory viral infections pose a growing challenge in pediatric populations and are less well studied compared with other HAIs. Early detection and isolation remains the cornerstone for effective strategies to prevent transmission. Well-designed prospective, multicenter, collaborative studies are needed to better define the epidemiology, disease burden and effectiveness of preventive strategies for health care-associated respiratory viral infections.
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Philip Zachariah, MD, is a fellow in Pediatric Infectious Diseases at Columbia University Medical Center. He can be reached at pz2177@cumc.columbia.edu.
Disclosure: The authors report no relevant financial disclosures.