Respiratory Syncytial Virus Outbreak at an Institution for the Mentally Retarded -- Washington

In March and April 1985, two distinct outbreaks of febrile respiratory illness caused by respiratory syncytial virus (RSV) were reported in a residential institution for the mentally retarded in northern Seattle-King County, Washington. Investigation of these outbreaks began when four of 25 ill residents required hospitalization and one died. The 496 residents, aged 4-85 years, were housed in large dormitory living units or smaller apartment units. The two dormitories involved in this outbreak, Hall A (32 residents with a mean age of 20 years) and Hall B (16 residents with a mean age of 19 years), served the most severely handicapped, who were often nonambulatory and had severe physical handicaps. The south wing of Hall B contained the infirmary, which served the entire institution.

The investigation of the outbreak in Hall A was undertaken March 22-25. Demographic and illness data, nasopharyngeal swabs, and convalescent sera were obtained from all of 32 residents, seven of 22 staff, and four classroom contacts of residents of the hall. Acute sera were also obtained from 11 residents.

The first resident became ill March 7 and was hospitalized the next day for wheezing and respiratory distress. She had traveled to athletic games on March 2 with a staff member, not from Hall A, who had rhinorrhea. During the outbreak, 16 of 32 residents became ill with fever of 38.0 C (100.4 F) or higher and either wheezing or upper respiratory symptoms (rhinorrhea, cough, or both). Of these 16, 13 had upper respiratory symptoms; eight, wheezing; five, otitis media; two, gastrointestinal symptoms; two, respiratory distress; and one, bronchopneumonia. Duration of illness was 2-17 days (mean 9 days). Four patients were hospitalized: one for 6 days and two for 5 days each, and one died with respiratory distress on her fourth hospital day. Two of these four had histories of asthma, and the patient who died had a history of multiple aspiration pneumonias. Three of the 16 ill residents, including the index patient, were both culture- and immunofluorescence (FA)-positive for RSV. The patient who died was FA-positive only. Three of seven staff members also had respiratory symptoms, and one was culture- and FA-positive for RSV. Age, sex, reason for handicap, preexisting respiratory illness, wing of dormitory residence, and age when institutionalized were comparable between ill and well residents. The mean age of ill residents was 17 years, and of well residents, 22 years. The mean duration of institutionalization (5.6 years for ill and 12.7 years for well residents) and mean length of residence at this institution (3.9 years for ill and 11.1 years for well residents) were increased in well residents.

Control measures included good hand-washing practices by staff, confining ill residents to their residences for the duration of their symptoms, and cohorting ill or exposed staff with ill or exposed residents. When possible, ill residents were placed in one wing of Hall A and well residents in the other, and separate staff members were assigned to each wing. Gloves, masks, and gowns were used by staff while caring for ill residents.

A similar investigation was performed in Hall B on April 18. Beginning April 6, 11 days after onset of the last case in Hall A, eight of 16 residents became ill with fever of 38.0 C (100.4 F) or higher and either wheezing or upper respiratory symptoms. The index patient in Hall B had no contacts in Hall A, but had been hospitalized for tracheostomy repair March 31- April 3 in a facility where RSV was known to be present. Of the eight ill patients, one was culture- and FA-positive for RSV, and another was culture-positive and FA-negative. All had upper respiratory symptoms; four, chest congestion; two, wheezing; and two, otitis media. None were hospitalized.

Sex, presence of preexisting respiratory disease, and reason for handicap were not associated with illness. Ill residents were younger than well residents (11.3, compared with 28.4 years) and had been institutionalized for a shorter time (6.2, compared with 19.3 years). Control measures similar to those used for Hall A were observed. Serologic results are pending from both halls. Reported by L Corey, MD, A Cent, B Harrison, Children's Orthopedic Hospital, A Downing, MD, R Doan, MD, R Finger, MD, J Kobayashi, MD, State Epidemiologist, Washington State Dept of Social and Health Svcs; Div of Field Svcs, Epidemiology Program Office, Div of Viral Diseases, Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: RSV can be responsible for outbreaks of serious respiratory illness in all age groups. Although it infects nearly all persons by age 2, reinfection occurs throughout life (1). Serious illness most often occurs among children under 2 years of age, for whom RSV is the leading cause of lower respiratory tract illness. In this age group, RSV can be a serious nosocomial pathogen (2). In one study, hospitalized infants and young children who become infected with RSV had nearly a twofold increase in length of hospitalization (3). Children with compromised cardiac, pulmonary, or immune systems are at greatest risk from RSV infection. A mortality rate as high as 37% has been reported among hospitalized patients with cardiac abnormalities who became infected with RSV (4). Outbreaks among the elderly in nursing homes have also been associated with serious illness and some deaths (5). In older children and adults, RSV most often causes an upper respiratory tract illness, often with fever; but otitis media, exacerbation of wheezing in asthmatic patients, altered airway reactivity in otherwise normal individuals, and lower respiratory tract illness also occur (6).

The basis for an association of illness with shorter duration of residence at the institution is not clear. One possible explanation is that those residing at the institution longer had experienced more RSV infections (because they were older and possibly because they had more frequent exposures to RSV infections) and, therefore, were less susceptible to infection or illness with additional exposures (1,7).

Institutional outbreaks accompany the yearly epidemics of RSV in the community. In the United States, these yearly community epidemics occur sometime between late fall and early spring and last 2-5 months. After introduction into an institution, RSV can spread by close contact or fomites, and staff members may be involved in this spread either by inadvertently carrying infectious material from one patient to another or by becoming infected themselves. Recommendations to control spread of RSV in hospitals include strict attention to good hand-washing practices and the use of gowns when contact with respiratory secretions of RSV-infected patient is likely (8). Infected patients should have private rooms when possible or be cohorted with other infected patients (9).

References

1. Henderson FW, Collier AM, Clyde WA Jr, Denny FW. Respiratory-syncytial-virus infections, reinfections and immunity: a prospective, longitudinal study in young children. N Engl J Med 1979;300:530-4.

2. Hall CB. The nosocomial spread of respiratory syncytial viral infections. Ann Rev Med 1983;34:311-9.

3. Hall CB, Douglas RG Jr, Geiman JM, et al. Nosocomial respiratory syncytial virus infections. N Engl J Med 1975;293:1343-6.

4. MacDonald NE, Hall CB, Suffin SC, Alexson C, Harris PJ, Manning JA. Respiratory syncytial viral infection in infants with congenital heart disease. N Engl J Med 1982;307:397-400.

5. Sorvillo FJ, Huie SF, Strassburg MA, Butsumyo A, Shandera WX, Fannin SL. An outbreak of respiratory syncytial virus pneumonia in a nursing home for the elderly. J Infect 1984;9:252-6.

6. Hall CB. Respiratory syncytial virus. In: Feigin RD, Cherry JD, eds. Textbook of pediatric infectious diseases. Philadelphia: WB Saunders Company, 1981:1247-67.

7. Parrott RH, Kim HW, Arrobio JO, et al. Epidemiology of respiratory syncytial virus infection in Washington, D.C.: II. Infection and disease with respect to age, immunologic status, race and sex. Am J Epidemiol 1973;98:289-300.

8. Garner JS, Simmons BP. Guideline for isolation precautions in hospitals. Infect Control 1983;4:245-325.

9. Williams WW. Guideline for infection control in hospital personnel. Infect Control 1983;4:326-49.

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