Fairfax Co. Va Health Advisory: Outbreak of Respiratory Illness at a Long-Term Care Facility

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Credit CDC PHIL

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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.

Influenza in long‐term care facilities

Louise E. Lansbury, 1 Caroline S. Brown, 2 and Jonathan S. Nguyen‐Van‐Tam 1

Published online 2017 Jul 26. doi: 10.1111/irv.12464

Abstract

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:

Outbreak of Respiratory Illness at a Long-Term Care Facility

July 12, 2019

Health Advisory

SUMMARY:

• 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.

SUGGESTED ACTIONS:

• 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.

https://www.cdc.gov/urdo/downloads/URDO-Factsheet.pdf

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:

DOH: 2nd NJ Facility Reporting Adenovirus Outbreak & 10th Fatality At Wanaque Center

Wisconsin DOH Elizabethkingia Update

Study: HRV In Long-Term Care Facilities

Serena Williams pays tribute to ‘little powerhouse’ Halep after final defeat

• ‘It was just her day,’ says disappointed Williams
• American admits her fitness has not been ideal

Serena Williams denied that nerves or the pressure of chasing down Margaret Court’s record of 24 grand slam titles had anything to do with her stunning 6-2, 6-2 Wimbledon defeat by Simona Halep.

Williams looked far from her best as she sprayed 26 unforced errors compared with only17 winners against Halep, and the American has now lost three grand slam finals since winning her 23rd major title at the Australian Open in 2017.

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More than committed anti-vaxxers, parents who are unsure about vaccination are one of the top 10 threats to global health this year. What’s behind this crisis of confidence?

My son had his first vaccination within hours of entering the world. In the London borough where he was born eight years ago, tuberculosis rates ran high. When a nurse appeared at my hospital bed bearing the BCG vaccine, I offered my red and roaring baby without a moment’s hesitation.

Since then, he and his sister have had every inoculation going. I proffer them up, willingly and gratefully, to each needle and nasal spray, unwavering in my belief in the scientific consensus that they are safe, effective and essential public health tools.

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States without Nations: Age Assessments for Unaccompanied Children: Alternative Facts, Policies, and Logic

U.S. officials are unlawfully moving asylum-seeking children from costly shelters into relatively cheaper Immigration and Customs Enforcement jails.  The Deportation Research Clinic has reviewed hundreds of age assessment cases since January 1, 2016.  Among the 205 formal Memorandums of Age Determination coded to date we found ORR officials blatantly misstating the results of medical assessments and official policies.  Along with keeping adults out of facilities meant for minors, officials from the Office of Refugee and Resettlement are placing unaccompanied children into ICE jails.  We found ORR coordinating with ICE, repeatedly violating the policies for placement, and also hurting children’s asylum claims.

Source: States without Nations: Age Assessments for Unaccompanied Children: Alternative Facts, Policies, and Logic

Border Patrol Official Circulates Article That Deems Our Reporting on Secret Facebook Group a Threat — ProPublica

One agent who received the piece was troubled that an official in charge of an intelligence unit would send it out under his Border Patrol email, and worried that it could undermine trust in the unit’s work. “We need effective intel units that have garnered the trust of agents, the community, and elected officials,” said the agent, who asked not to be identified for fear of retribution. “Distributing partisan opinion pieces under the guise of intelligence, undermines the credibility of our intelligence department and raises doubt about the intelligence we distribute.”

Source: Border Patrol Official Circulates Article That Deems Our Reporting on Secret Facebook Group a Threat — ProPublica

Immigrant Rights Groups: Congress Must Investigate Separation & Suffering Caused by Trump ‘Remain-in-Mexico’ Policy

July 12, 2019

Immigrant Rights Groups: Congress Must Investigate Separation & Suffering Caused by Trump ‘Remain-in-Mexico’ Policy

Recent Stories Demonstrate Great Harm to Children on Both Sides of Border

WASHINGTON, D.C. – Ahead of a congressional hearing today about family separation and the mistreatment of migrant children, a group of immigrant rights organizations working on behalf of asylum seekers released a statement and stories of families separated by the Trump administration’s “Remain-in-Mexico” policy:
 
The following statement is from Al Otro Lado, Center for Gender & Refugee Studies, Human Rights Watch, Kino Border Initiative, Latin America Working Group and the Southern Poverty Law Center.
 
“Today’s hearing of the House Oversight Committee regarding family separation and the mistreatment of migrants in detention facilities run by the U.S. government is incredibly important. As evidenced by the recent accounts summarized below, the Trump administration’s ‘Remain-in-Mexico’ policy has put migrant children in even greater danger and caused enormous harm on both sides of the U.S.-Mexico border.”
 
The groups cited the following examples:
  • A woman from El Salvador traveling with her 4-year-old daughter and two younger siblings entered the U.S. near Tijuana, Mexico, to seek asylum. The woman had been the primary caretaker for her siblings ever since their mother was murdered in El Salvador. Upon apprehension by Customs and Border Protection (CBP), the woman and her child were detained and returned to Mexico to await their immigration court hearings, while her siblings were transferred to the Office of Refugee Resettlement (ORR), which is responsible for the care and custody of unaccompanied children
  • A Guatemalan father and his 15-year-old son were detained separately in CBP holding cells known as hieleras (iceboxes) because of their frigid, cramped conditions. Before separating them, CBP officers tore up the son’s birth certificate and threw it in the trash. After four days in CBP custody, the father was returned to Mexicali under the ‘remain-in-Mexico’ policy. The son was transferred to ORR custody. Following the separation, the son was so traumatized that he had to be hospitalized.
  • After crossing the border in Texas, a Nicaraguan mother and her two sons, ages 7 and 18, were detained in a CBP hielera for four days. The mother and her younger son were then sent to California, where they spent four more days in CBP custody before being returned to Mexico. Initially, the mother had no idea where to find her older son but learned later that he was detained in Texas.
  • Fearing gang violence, a Salvadoran family of four fled to the United States to seek asylum. Following apprehension by CBP, the mother and two daughters were detained for seven days in a hielera. Although they became gravely ill, CBP did not allow them to see a doctor. The mother and older daughter have since been returned to Mexico, while the younger daughter and her father (who had been separately detained) were released to live with relatives.
“As this administration has continued to abandon its legal and ethical obligations to those seeking protection in our country, the crisis is as much across the border as it is here.
 
“Congress must drastically increase oversight regarding the human impact of the administration’s anti-immigrant policies. These policies have created a humanitarian crisis that demands an immediate response.”