|Credit CDC PHIL|
For the past 3 days newshounds Shiloh and Pathfinder at FluTrackers have been following, and archiving, local media reports of a large – and thus far unidentified – respiratory outbreak at a long-term care facility in Fairfax County, Virginia.
Respiratory illness outbreaks in nursing homes and long-term care facilities (LTCFs) are not uncommon as the residents are usually either elderly, suffer from chronic illnesses, or are otherwise immunocompromised.
But we usually see them during the fall and winter months, not mid-summer.
A 2017 study, published in Influenza Other Respir Viruses, discusses this all-too-familiar phenomenon.
Published online 2017 Jul 26. doi: 10.1111/irv.12464
Long‐term care facility environments and the vulnerability of their residents provide a setting conducive to the rapid spread of influenza virus and other respiratory pathogens. Infections may be introduced by staff, visitors or new or transferred residents, and outbreaks of influenza in such settings can have devastating consequences for individuals, as well as placing extra strain on health services.
As the population ages over the coming decades, increased provision of such facilities seems likely. The need for robust infection prevention and control practices will therefore remain of paramount importance if the impact of outbreaks is to be minimised. In this review, we discuss the nature of the problem of influenza in long‐term care facilities, and approaches to preventive and control measures, including vaccination of residents and staff, and the use of antiviral drugs for treatment and prophylaxis, based on currently available evidence.
What makes the current outbreak in Virginia a bit unusual is the timing, and the lack (thus far) of an identified etiological agent. The following Health Advisory comes from from the Fairfax County Health Department, after which I’ll return with more:
July 12, 2019
• Fairfax County Health Department is conducting an outbreak investigation at Greenspring, a long-term care facility with assisted living and skilled nursing care, in Springfield, VA.
• Since June 30, 2019, 55 out of the 263 residents assisted living and skilled nursing care have become ill with respiratory symptoms ranging from upper respiratory illness (cough) to pneumonia. Of the ill individuals, 20 have been hospitalized and two have died.
• A specific etiology has not been identified and additional tests are being conducted.
• Respiratory outbreaks at facilities for vulnerable, older adult populations are not uncommon, with 5-10 reported to the Health Department each year. However, outbreaks in the summer are infrequent. Given this outbreak and as staff may work at more than one long-term care facility across the County, we ask all facilities to maintain a heightened index of suspicion for an increase in the number of respiratory illnesses, including pneumonia, throughout your facility.
• Respiratory disease clusters should be immediately reported to Public Health. Contact the Health Department’s Communicable Disease Section immediately at 703-246-2433 (normal business hours) or 703-409-8449 (evenings and weekends) to report a suspect cluster and for additional guidance on testing and infection control measures. Do not wait for laboratory confirmation before making a report.
• Long-term care facilities should ensure that proper infection control precautions are put in place for all ill residents. Guidance on precautions and duration can be found on the following CDC webpage: https://www.cdc.gov/infectioncontrol/guidelines/isolation/appendix/type-duration-precautions.html. The Fairfax County Health Department is also available to provide guidance on appropriate precautions related to communicable diseases.
• Appropriate handwashing and respiratory etiquette amongst staff and residents are essential to limit disease spread. Please review handwashing and respiratory etiquette policies, trainings, and educational materials to ensure residents and staff are aware of the most recent guidance and no barriers occur to limit handwashing.
• All long-term care facility staff should be encouraged to report any respiratory illness to facility management. Any staff member with documented fever (>100.1°F) should be excluded from work until they are afebrile for 24 hours. Asymptomatic employees who work at multiple facilities, including Greenspring, do not need to be excluded from work.
While some local media headlines are touting the `Mystery Virus’ angle, in truth it can take a week or longer to run a full gamut of tests, and so I prefer to use the term as-yet-unidentified.
The CDC has a name for it: URDO (Unidentified Respiratory Disease Outbreak). They also have a work group, and a process, designed to address these types of outbreaks.
While influenza is relatively rare this time of year, and usually fairly easy to identify with rapid tests, there are hundreds of other viruses that must be considered – including RSV, any one of 4 dozen known adenoviruses, and a myriad of Picornavirus infections (which include Rhinoviruses & Enterovirues).
Even with the full firepower of the CDC’s labs, it is possible that a definitive diagnosis may not achieved. A 2015 study published in the NEJM (see The CDC’s EPIC CA-Pneumonia Study) followed 2500 cases over 5 years and found that in the majority (62%) of cases no definitive pathogenic agent was identified.
Specifically, they found:
- one or more viruses in 530 (23%) cases
- bacteria in 247 (11%) cases
- bacterial and viral pathogens in 59 (3%) cases
- and a fungal or mycobacterial pathogen in 17 (1%) of cases
The most commonly detected pathogens were:
- Human rhinovirus (in 9% of patients)
- Influenza virus (in 6%)
- and Streptococcus pneumoniae (in 5%).
With luck, this outbreak in Virginia will become less mysterious this coming week, and when we learn more, I’ll update this story.
This is a good reminder, however, of the importance of good hand hygiene – not only by the staff, but by the visitors to these facilities. And staying away if you suspect you might have an illness.
For more on the plethora of respiratory viruses that afflict humans, you may wish to revisit ILI’s Aren’t Always The Flu, and some other blogs on respiratory outbreaks in LTCFs include: