Nosocomial outbreak of epidemic keratoconjunctivitis accompanying environmental contamination with adenoviruses

Efficacy of patient-sided breath shields for slit-lamp examination

OBJECTIVE

To evaluate the efficacy of patient-sided breath shields in preventing oronasal droplet transmission during slit-lamp examination.

DESIGN

Experimental study testing the efficacy of patient-sided breath shields on a slit lamp.

METHODS

Two commercially available patient-sided breath shields and a 3-dimensional (3D)-printed shield designed by the authors were attached to a slit-lamp chin rest for testing. Each shield was exposed to 3 standardized sprays of coloured dye from a spray gun with its nozzle adjusted to simulate the angular dispersion of a human sneeze. Any overspray not blocked by the shields was recorded and compared with spray with no shield (control). Image-processing software was used to ascertain the surface area of overspray not blocked by the tested shield compared with the control of no shield.

RESULTS

With typical use, both commercially available patient-sided shields and the 3D-printed shield blocked 100% of forward-travelling measurable droplets from a simulated sneeze spray. Even when set to the furthest distance setting to simulate the worst-case scenario, shield 1 and the 3D-printed shield blocked 99.96% and 99.65% of overspray, respectively. However, slow-motion footage did reveal that a considerable amount of spray rebounded off the shields and extended peripherally past its borders.

CONCLUSIONS

With typical use, all tested shields prevented 100% of oronasal transmission. To encourage accessibility, the authors offer a free 3D model and instructions for creating the tested patient-sided breath shield. Patient-sided shields should be combined with other infection-control measures to minimize transmission.

Is It an Outbreak of Health Care-Associated Infection? An Investigation of Binocular Conjunctival Congestion After Laparoscopic Cholecystectomy Was Traced to Chitosan Derivatives

Background

From May 6 to May 23, 2019, 24 (80.00%) patients who underwent laparoscopic cholecystectomy (LC) developed binocular conjunctival congestion within 4–8 h after their operation in the day ward of a teaching hospital.

Methods

Nosocomial infection prevention and control staff undertook procedural and environmental investigations, performed a case-control retrospective study (including 24 cases and 48 controls), and reviewed all lot numbers of biological material products to investigate the suspected outbreak of health care-associated infection.

Findings

Initially, an outbreak of health care-associated infection caused by bacteria was hypothesized. We first suspected the membranes that covered patients' eyes were cut using non-sterile scissors and thus contaminated, but they failed to yield bacteria. In addition, both corneal and conjunctival fluorescein staining results were negative in case-patients and isolated bacteria were ubiquitous in the environment or common skin commensals or normal flora of conjunctiva from 218 samples from day surgery and the day ward. Hence, we considered a non-infectious factor as the most likely cause of the binocular conjunctival congestion. Then, we found that case-patients were more likely than LC surgery patients without binocular conjunctival congestion to be exposed to biological materials in a retrospective case-control study. When we reviewed lot numbers, duration of use, and the number of patients who received four biological material products during LC in the day ward, we found that the BLK1821 lot of a modified chitosan medical membrance (the main ingredient is chitosan, a linear cationic polysaccharide) was used concurrently to when the case aggregation appeared. Finally, we surmised there was a correlation between this product and the outbreak of binocular conjunctival congestion. Relapse of the pseudo-outbreak has not been observed since stopping usage of the product for 6 months.

Conclusion

A cluster of binocular non-infectious conjunctival congestion diagnosed after LC proved to be a pseudo-outbreak. We should pay more attention to adverse events caused by biomaterials in hospitals.

Topical pharmacologic interventions versus placebo for epidemic keratoconjunctivitis

BACKGROUND

Viruses cause about 80% of all cases of acute conjunctivitis. Human adenoviruses are believed to account for 65% to 90% of cases of viral conjunctivitis, or 20% to 75% of all causes of infectious keratoconjunctivitis worldwide. Epidemic keratoconjunctivitis (EKC) is a highly contagious subset of adenoviral conjunctivitis that has been associated with large outbreaks at military installations and at medical facilities. It is accompanied by severe conjunctival inflammation, watery discharge, and light sensitivity, and can lead to chronic complications such as corneal and conjunctival scarring with discomfort and poor quality of vision. Due to a lack of consensus on the efficacy of any pharmacotherapy to alter the clinical course of EKC, no standard of care exists, therefore many clinicians offer only supportive care.

OBJECTIVES

To assess the efficacy and safety of topical pharmacological therapies versus placebo, an active control, or no treatment for adults with EKC.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, which contains the Cochrane Eyes and Vision Trials Register; 2021, Issue 4); Ovid MEDLINE; Ovid Embase; Latin American and Caribbean Health Sciences database (LILACS); ClinicalTrials.gov; and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), with no restrictions on language or year of publication. The date of the last search was 27 April 2021.

SELECTION CRITERIA

We included randomized controlled trials in which antiseptic agents, virustatic agents, or topical immune-modulating therapy was compared with placebo, an active control, or no treatment.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodology.

MAIN RESULTS

We identified 10 studies conducted in Asia, Europe, the Middle East, and North Africa with a total of 892 participants who were treated for 7 days to 6 months and followed for 7 days up to 1.5 years. Study characteristics and risk of bias In most studies participants were predominantly men (range: 44% to 90%), with an age range from 9 to 82 years. Three studies reported information on trial registration, but we found no published study protocol. The majority of trials had small sample sizes, ranging from 18 to 90 participants enrolled per study; the only exception was a trial that enrolled 350 participants. We judged most studies to be at high or unclear risk of bias across risk of bias domains. Findings We included 10 studies of 892 EKC participants and estimated combined intervention effects in analyses stratified by steroid-containing control treatment or artificial tears. Six trials contributed to the comparisons of topical interventions (povidone-iodine [PVP-I], trifluridine, ganciclovir, dexamethasone plus neomycin) with artificial tears (or saline). Very low certainty evidence from two trials comparing trifluridine or ganciclovir with artificial tears showed inconsistent effects on shortening the mean duration of cardinal symptoms or signs of EKC. Low certainty evidence based on two studies (409 participants) indicated that participants treated with PVP-I alone more often experienced resolution of symptoms (risk ratio (RR) 1.15, 95% confidence interval (CI) 1.07 to 1.24) and signs (RR 3.19, 95% CI 2.29 to 4.45) during the first week of treatment compared with those treated with artificial tears. Very low certainty evidence from two studies (77 participants) suggested that PVP-I or ganciclovir prevented the development of subepithelial infiltrates (SEI) when compared with artificial tears within 30 days of treatment (RR 0.24, 95% CI 0.10 to 0.56). Four studies compared topical interventions (tacrolimus, cyclosporin A [CsA], trifluridine, PVP-I + dexamethasone) with topical steroids, and one trial compared fluorometholone (FML) plus polyvinyl alcohol iodine (PVA-I) with FML plus levofloxacin. Evidence from one trial showed that more eyes receiving PVP-I 1.0% plus dexamethasone 0.1% had symptoms resolved by day seven compared with those receiving dexamethasone alone (RR 9.00, 95% CI 1.23 to 66.05; 52 eyes). In two trials, fewer eyes treated with PVP-I or PVA-I plus steroid developed SEI within 15 days of treatment compared with steroid alone or steroid plus levofloxacin (RR 0.08, 95% CI 0.01 to 0.55; 69 eyes). One study found that CsA was no more effective than steroid for resolving SEI within four weeks of treatment (RR 0.84, 95% CI 0.67 to 1.06; N = 88). The evidence from trials comparing topical interventions with steroids was overall of very low level certainty. Adverse effects Antiviral or antimicrobial agents plus steroid did not differ from artificial tears in terms of ocular discomfort upon instillation (RR 9.23, 95% CI 0.61 to 140.67; N = 19). CsA and tacrolimus eye drops were associated with more cases of severe ocular discomfort, and sometimes intolerance, when compared with steroids (RR 4.64, 95% CI 1.15 to 18.71; 2 studies; N = 141). Compared with steroids, tacrolimus did not increase the risk of elevated intraocular pressure (RR 0.07, 95% CI 0 to 1.13; 1 study; N = 80), while trifluridine conferred no additional risk compared to tear substitute (RR 5.50, 95% CI 0.31 to 96.49; 1 study; N = 97). Overall, bacterial superinfection was rare (one in 23 CsA users) and not associated with use of the intervention steroid (RR 3.63, 95% CI 0.15 to 84.98; N = 51). The evidence for all estimates was of low or very low certainty.

AUTHORS' CONCLUSIONS

The evidence for the seven specified outcomes was of low or very low certainty due to imprecision and high risk of bias. The evidence that antiviral agents shorten the duration of symptoms or signs when compared with artificial tears was inconclusive. Low certainty evidence suggests that PVP-I alone resolves signs and symptoms by seven days relative to artificial tears. PVP-I or PVA-I, alone or with steroid, is associated with lower risks of SEI development than artificial tears or steroid (very low certainty evidence). The currently available evidence is insufficient to determine whether any of the evaluated interventions confers an advantage over steroids or artificial tears with respect to virus eradication or its spread to initially uninvolved fellow eyes. Future updates of this review should provide evidence of high-level certainty from trials with larger sample sizes, enrollment of participants with similar durations of signs and symptoms, and validated methods to assess short- and long-term outcomes.

Adenovirus: Epidemiology, Global Spread of Novel Types, and Approach to Treatment

Adenoviruses (AdVs) are DNA viruses that typically cause mild infections involving the upper or lower respiratory tract, gastrointestinal tract, or conjunctiva. Rare manifestations of AdV infections include hemorrhagic cystitis, hepatitis, hemorrhagic colitis, pancreatitis, nephritis, or meningoencephalitis. AdV infections are more common in young children, due to lack of humoral immunity. Epidemics of AdV infection may occur in healthy children or adults in closed or crowded settings (particularly military recruits). The vast majority of cases are self-limited. However, the clinical spectrum is broad and fatalities may occur. Dissemination is more likely in patients with impaired immunity (e.g., organ transplant recipients, human immunodeficiency virus infection). Fatality rates for untreated severe AdV pneumonia or disseminated disease may exceed 50%. More than 100 genotypes and 52 serotypes of AdV have been identified and classified into seven species designated HAdV-A through -G. Different types display different tissue tropisms that correlate with clinical manifestations of infection. The predominant types circulating at a given time differ among countries or regions, and change over time. Transmission of novel strains between countries or across continents and replacement of dominant viruses by new strains may occur. Treatment of AdV infections is controversial, as prospective, randomized therapeutic trials have not been done. Cidofovir has been the drug of choice for severe AdV infections, but not all patients require treatment. Live oral vaccines are highly efficacious in reducing the risk of respiratory AdV infection and are in routine use in the military in the United States but currently are not available to civilians.

Blocking the prevalence of adenoviral conjunctivitis in premature infants by combined disinfection method

This study aimed to determine the cause behind the outbreak of nosocomial adenoviral conjunctivitis in the Neonatal Intensive Care Unit (NICU) and the impact of infection control measures. The objectives of the present study include investigation of the hospital-borne infection associated with adenoviral conjunctivitis, analysis of the possible risk factors, setting bundle infection control measures, which were adjusted according to the control effect. The present study also aims to observe the effect of different intervention measures on controlling adenoviral conjunctivitis. During the first and second intervention periods, overall 635 and 597 NICU patients were enrolled, respectively. Ophthalmoscopy was conducted among 188 (in the first intervention) and 184 (in the second intervention) patients (P>0.05). The times of ophthalmoscopy the patients received were 417 and 457 (P<0.001). During the first intervention, 13 patients suffered from adenoviral conjunctivitis, while no patients with adenoviral conjunctivitis were found during the second intervention (P<0.001). All adenoviral conjunctivitis cases were reported 6-27 days (mean 12 days) after ophthalmoscopy. The hydrogen peroxide disinfection bundle measures can effectively restrict the prevalence of adenoviral conjunctivitis associated with ophthalmoscopy in premature infants.

Cost Savings From a Policy to Diagnose and Prevent Transmission of Adenoviral Conjunctivitis in Employees of a Large Academic Medical Center

IMPORTANCE

Adenoviral conjunctivitis is highly contagious, can be associated with systemic infections, and can cause chronic visual impairment. It accounts for a large proportion of acute conjunctivitis. Outbreaks of epidemic keratoconjunctivitis (EKC) are costly in terms of productivity loss from work furloughs and spread to patients and have resulted in clinic and departmental closures.

OBJECTIVE

To examine the institutional cost savings of a policy to diagnose adenoviral conjunctivitis and triage and furlough medical center employees with this condition to prevent outbreaks.

DESIGN, SETTING, AND PARTICIPANTS

This quality improvement study assessed Johns Hopkins Medicine employees with red eye from November 1, 2011, through October 31, 2018, who were triaged at the occupational health clinic whose conditions were diagnosed using polymerase chain reaction (PCR) validated for adenoviral conjunctivitis.

INTERVENTIONS

Only employees with positive PCR test results were furloughed, with furlough length tailored to subtype (a minimum of 2 weeks for EKC and 1 week otherwise).

MAIN OUTCOMES AND MEASURES

Total number of furloughs avoided and cost savings associated with reducing unnecessary furloughs.

RESULTS

Of 2142 employees with red eye, 1520 (71.0%) underwent PCR testing; 130 (8.6%) had positive adenoviral PCR test results, of whom 41 (31.5%) had EKC. Furloughing 130 employees with positive PCR test results vs furloughing all 1520 employees clinically suspected of having adenoviral conjunctivitis represented an estimated annual savings of $442 073, or $3 094 511 during 7 years. The cost of performing PCR on employees suspected of having adenoviral conjunctivitis was 5.0% of the cost associated with furloughing all employees with red eye. No outbreaks occurred.

CONCLUSIONS AND RELEVANCE

In this quality improvement study, this policy, notable for development and use of PCR for adenoviral conjunctivitis on a large scale, resulted in substantial cost savings from fewer work furloughs compared with the number of employees who would have been furloughed based on clinical diagnosis. These results may provide impetus for policy adoption by other institutions and for development of a rapid, sensitive, and specific diagnostic test for adenoviral conjunctivitis.

Disinfectant potential in inactivation of epidemic keratoconjunctivitis-related adenoviruses by potassium peroxymonosulfate

PURPOSE

The aim of this study was to test the antiviral effectivity of potassium peroxymonosulfate (RUBYSTA^®, KYORIN) against five epidemic keratoconjunctivitis-related types of Human adenovirus D in vitro.

METHODS

Five types of Human adenovirus D (8, 37, 53, 54 and 56) were incubated with 1% potassium peroxymonosulfate, 0.1% sodium hypochlorite (NaClO) or alcohol-based disinfectant for 30 s or 1 min. These solutions were subjected to measurements of viral titres by infection assays in A549 cells. At day 6 post-infection, both, supernatants and cells, were collected and the viral genome was assessed by real-time polymerase chain reaction analysis.

RESULTS

Treatments with 1% potassium peroxymonosulfate led to significant reduction in all tested Human adenovirus D types comparable to disinfecting effects by 0.1% NaClO. Overall, potassium peroxymonosulfate demonstrated sufficient inactivation of the major epidemic keratoconjunctivitis-causing Human adenovirus D to be considered for disinfection and prevention purposes in ophthalmological clinics and hospitals.

CONCLUSION

This study demonstrated that potassium peroxymonosulfate is a promising disinfectant for the prevention of epidemic keratoconjunctivitis nosocomial infections in ophthalmological clinics.

Hand hygiene and instrument sanitization in ophthalmology clinics

PURPOSE OF REVIEW

This article reviews the various challenges in infection control in eye clinics and successful measures taken to prevent nosocomial infections.

RECENT FINDINGS

The Center for Disease Control recommends hand-washing when hands are visibly soiled, and after direct contact with patients, and inanimate objects such as medical equipment. Published studies have identified poor hygiene in clinical settings as a major cause of nosocomial outbreaks, particularly in cases of epidemic keratoconjunctivitis (EKC). Some studies of EKC outbreaks are able to support direct observation of hygiene lapses with molecular analysis that can match viral strains on particular instruments to those found in infected patients. Although most studies are about adenoviral infection and tonometer use, researchers have found viral and bacterial loads on other common surfaces, indicating a need for further research.

SUMMARY

Proper hygiene in eye clinics requires special attention because of the potential to examine many patients at a time and because multiple instruments are often used during a single exam. Studies reinforce the link between hygiene and outbreak prevention, and more research can be done to determine the specific links between certain instruments and nosocomial infections.

Outbreak of Adenovirus in a Neonatal Intensive Care Unit: Critical Importance of Equipment Cleaning During Inpatient Ophthalmologic Examinations

PURPOSE

Outbreaks of adenovirus in neonatal intensive care units (NICUs) can lead to widespread transmission and serious adverse outcomes. We describe the investigation, response, and successful containment of an adenovirus outbreak in a NICU associated with contaminated handheld ophthalmologic equipment used during retinopathy of prematurity (ROP) screening.

DESIGN

Epidemiologic outbreak investigation.

PARTICIPANTS

A total of 23 hospitalized neonates, as well as NICU staff and parents of affected infants.

MAIN OUTCOME MEASURES

Routine surveillance identified an adenovirus outbreak in a level IV NICU in August 2016. Epidemiologic investigation followed, including chart review, staff interviews, and observations. Cases were defined as hospital-acquired adenovirus identified from any clinical specimen (NICU patient or employee) or compatible illness in a family member. Real-time polymerase chain reaction (PCR) and partial- and whole-genome sequencing assays were used for testing of clinical and environmental specimens.

RESULTS

We identified 23 primary neonatal cases and 9 secondary cases (6 employees and 3 parents). All neonatal case-patients had respiratory symptoms. Of these, 5 developed pneumonia and 12 required increased respiratory support. Less than half (48%) had ocular symptoms. All neonatal case-patients (100%) had undergone a recent ophthalmologic examination, and 54% of neonates undergoing examinations developed adenovirus infection. All affected employees and parents had direct contact with infected neonates. Observations revealed inconsistent disinfection of bedside ophthalmologic equipment and limited glove use. Sampling of 2 handheld lenses and 2 indirect ophthalmoscopes revealed adenovirus serotype 3 DNA on each device. Sequence analysis of 16 neonatal cases, 2 employees, and 2 lenses showed that cases and equipment shared 100% identity across the entire adenovirus genome. Infection control interventions included strict hand hygiene, including glove use; isolation precautions; enhanced cleaning of lenses and ophthalmoscopes between all examinations; and staff furlough. We identified no cases of secondary transmission among neonates.

CONCLUSIONS

Adenovirus outbreaks can result from use of contaminated ophthalmologic equipment. Even equipment that does not directly contact patients can facilitate indirect transmission. Patient-to-patient transmission can be prevented with strict infection control measures and equipment cleaning. Ophthalmologists performing inpatient examinations should take measures to avoid adenoviral spread from contaminated handheld equipment.

Use of real-time semiquantitative PCR data in management of a neonatal intensive care unit adenovirus outbreak

OBJECTIVE

To describe an adenovirus outbreak in a neonatal intensive care unit (NICU), including the use of qualitative and semiquantitative real-time polymerase chain reaction (qPCR) data to inform the outbreak response.

DESIGN

Mixed prospective and retrospective observational study.

SETTING

A level IV NICU in the southeastern United States.PatientsTwo adenovirus cases were identified in a NICU. Screening of all inpatients with qPCR on nasopharyngeal specimens revealed 11 additional cases.InterventionsOutbreak response procedures, including enhanced infection control policies, were instituted. Serial qPCR studies were used to screen for new infections among exposed infants and to monitor viral clearance among cases. Changes to retinopathy of prematurity (ROP) exam procedures were made after an association was noted in those patients. At the end of the outbreak, a retrospective review allowed for comparison of clinical factors between the infected and uninfected groups.

RESULTS

There were no new cases among patients after outbreak identification. One adenovirus-infected patient died; the others recovered their clinical baselines. The ROP exams were associated with an increased risk of infection (odds ratio [OR], 84.6; 95% confidence interval [CI], 4.5-1,601). The duration of the outbreak response was 33 days, and the previously described second wave of cases after the end of the outbreak did not occur. Revisions to infection control policies remained in effect following the outbreak.

CONCLUSIONS

Retinopathy of prematurity exams are potential mechanisms of adenovirus transmission, and autoclaved or single-use instruments should be used to minimize this risk. Real-time molecular diagnostic and quantification data guided outbreak response procedures, which rapidly contained and fully terminated a NICU adenovirus outbreak.

Five-year trends in adenoviral conjunctivitis in employees of one medical center

Objective

To describe the 5-year findings after a policy to screen for, diagnose, and isolate medical center employees with adenoviral conjunctivitis was implemented.

Design

Observational report with a retrospective evaluation of a current quality improvement initiative.

Setting

Johns Hopkins Medicine, Baltimore, Maryland.

Participants

Johns Hopkins Medicine employees.

Methods

Data were retrieved from records maintained for this initiative, in which employees with suspected adenoviral conjunctivitis were evaluated in the Occupational Health Clinic and swabbed for polymerase chain reaction (PCR) testing for adenoviral conjunctivitis. Signs, symptoms, work area, diagnoses, and disposition of employees with eye complaints as well as PCR result and adenoviral type were recorded. Five-year data were reviewed.

Results

From 2011 to 2016, of 10,000 full-time equivalent employees, 1,059 employees visited the Occupational Health Clinic with suspicion of adenoviral conjunctivitis. Of these, 104 (10%) were PCR positive for adenovirus. Of these PCR-positive employees, 26 (25%) had the worst clinical presentation, epidemic keratoconjunctivitis (EKC). The Outpatient Pharmacy had the highest number of adenoviral conjunctivitis cases (n=9). The proportion of red-eye employees having PCR-positive adenoviral conjunctivitis increased over 5 years (P<.005, Cochrane-Armitage test for trend) as did the proportion of employees with EKC (P<.05). The proportion of employees with EKC caused by type 37 also increased (P<.05).

Conclusions

Adenoviral conjunctivitis represents 10% of employee cases clinically suspected of this infection. Employees in patient-care areas should be screened even if they have no direct patient contact. Despite increases in the proportions of adenoviral conjunctivitis and of EKC over 5 years, no outbreaks occurred. This policy helps identify incipient EKC outbreaks and guides infection control efforts.

Human viral pathogens are pervasive in wastewater treatment center aerosols

Wastewater treatment center (WTC) workers may be vulnerable to diseases caused by viruses, such as the common cold, influenza and gastro-intestinal infections. Although there is a substantial body of literature characterizing the microbial community found in wastewater, only a few studies have characterized the viral component of WTC aerosols, despite the fact that most diseases affecting WTC workers are of viral origin and that some of these viruses are transmitted through the air. In this study, we evaluated in four WTCs the presence of 11 viral pathogens of particular concern in this milieu and used a metagenomic approach to characterize the total viral community in the air of one of those WTCs. The presence of viruses in aerosols in different locations of individual WTCs was evaluated and the results obtained with four commonly used air samplers were compared. We detected four of the eleven viruses tested, including human adenovirus (hAdV), rotavirus, hepatitis A virus (HAV) and Herpes Simplex virus type 1 (HSV1). The results of the metagenomic assay uncovered very few viral RNA sequences in WTC aerosols, however sequences from human DNA viruses were in much greater relative abundance.

Adenovirus-related epidemic keratoconjunctivitis outbreak at a hospital-affiliated ophthalmology clinic

Adenovirus-associated epidemic keratoconjunctivitis (A-EKC) is a cause of large and prolonged outbreaks in ophthalmology clinics and can result in substantial morbidity. A-EKC outbreaks are often the result of contaminated ophthalmologic equipment, surfaces, or hands. Contaminated multidose eye drops are also a likely culprit, but few prior studies provide clear epidemiologic evidence that adenovirus transmission resulted from contamination of eye drops. We describe an A-EKC outbreak at a large, hospital-affiliated eye clinic that affected 44 patients. The unique epidemiology of the outbreak provides strong evidence that contaminated multidose dilating eye drops resulted in adenovirus transmission. Removal of multidose eye medication from the clinic, combined with case finding, enhanced infection control and enhanced environmental cleaning, led to rapid control of the outbreak.

Outbreaks of epidemic keratoconjunctivitis caused by human adenovirus type 8 in the Tibet Autonomous Region of China in 2016

From April to November 2016, two outbreaks of epidemic keratoconjunctivitis (EKC) occurred successively at primary and middle schools in the Tibet Autonomous Region of China, and a total of 197 clinically diagnosed cases were reported. Real-time PCR analyses confirmed that human adenovirus (HAdV) infection was related to these outbreaks. Further studies involving sequence determination and phylogenetic analysis based on the penton base, hexon, and fiber genes indicated that human adenovirus type 8 (HAdV-8), belonging to species D, was responsible for the outbreaks. This is the first report of a HAdV-8 associated EKC outbreak in mainland of China, and the results of this study are expected to provide support for future research into HAdV-8 in China.

Different Clinical Presentations of the Same Epidemic Keratoconjunctivitis Outbreak in Premature Babies and Their Parents

PURPOSE

This study aims to report the differences in the findings of epidemic keratoconjunctivitis (EKC) between premature babies and their families at an outbreak of viral conjunctivitis.

METHODS

In this prospective observational study, premature babies (25 patients) who were diagnosed with EKC and the family members (30 patients, mother, father, or grandmother/father) who had EKC after contacting them were monitored closely. Patients were divided into two groups as preterm babies (group 1) and adults (group 2).

RESULTS

The present study investigated particularly subepithelial corneal infiltrates (SEI) occurrence after EKC, which was searched for at each visit in the 2nd week, 1st month, and 3rd month after EKC. Distribution of SEI in two groups was statistically significant at each visit (<0.0001). There was more SEI in group 2.

CONCLUSIONS

None of the preterm cases were found to have SEI after EKC.

Adenovirus: Epidemiology, Global Spread of Novel Serotypes, and Advances in Treatment and Prevention

Adenoviruses (AdVs) are DNA viruses that typically cause mild infections involving the upper or lower respiratory tract, gastrointestinal tract, or conjunctiva. Rare manifestations of AdV infections include hemorrhagic cystitis, hepatitis, hemorrhagic colitis, pancreatitis, nephritis, or meningoencephalitis. AdV infections are more common in young children, due to lack of humoral immunity. Epidemics of AdV infection may occur in healthy children or adults in closed or crowded settings (particularly military recruits). The disease is more severe and dissemination is more likely in patients with impaired immunity (e.g., organ transplant recipients, human immunodeficiency virus infection). Fatality rates for untreated severe AdV pneumonia or disseminated disease may exceed 50%. More than 50 serotypes of AdV have been identified. Different serotypes display different tissue tropisms that correlate with clinical manifestations of infection. The predominant serotypes circulating at a given time differ among countries or regions, and change over time. Transmission of novel strains between countries or across continents and replacement of dominant viruses by new strains may occur. Treatment of AdV infections is controversial, as prospective, randomized therapeutic trials have not been conducted. Cidofovir is the drug of choice for severe AdV infections, but not all patients require treatment. Live oral vaccines are highly efficacious in reducing the risk of respiratory AdV infection and are in routine use in the military in the United States, but currently are not available to civilians.

Detection and Prevalence of Adenoviral Conjunctivitis among Hospital Employees Using Real-Time Polymerase Chain Reaction as an Infection Prevention Tool

Hospital employees with suspected adenoviral conjunctivitis underwent evaluation and testing with real-time polymerase chain reaction. Viral conjunctivitis was suspected in 307 (59%) of 518 employees with eye complaints; adenovirus was detected in 4% (22 of 518). Four employees had genotypes consistent with epidemic keratoconjunctivitis. This algorithm minimizes productivity loss compared with clinical diagnosis.

Infect Control Hosp Epidemiol 2014;35(6):728–731

A Polymerase Chain Reaction-Based Algorithm to Detect and Prevent Transmission of Adenoviral Conjunctivitis in Hospital Employees

PURPOSE

To devise and implement a practice algorithm that would enable rapid detection and appropriate furlough of hospital employees with adenoviral conjunctivitis in order to prevent healthcare-associated epidemic keratoconjunctivitis.

DESIGN

Evaluation of an ongoing quality assurance/improvement initiative.

METHODS

Employees of Johns Hopkins Hospital with signs and symptoms of adenoviral conjunctivitis underwent evaluation by nurse practitioners in Occupational Health and rapid diagnostic testing by real-time polymerase chain reaction (PCR). Sequencing was used to determine serotype when adenovirus was detected. Signs, symptoms, diagnosis, and disposition of employees with eye complaints as well as PCR and serotype results were recorded.

RESULTS

Over a 36-month period approximately 18% of initial employee visits were due to unique, eye-related complaints. Viral conjunctivitis was suspected in 542 of 858 employees with eye complaints (62%); adenovirus was detected by PCR in 44 of 542 suspected viral conjunctivitis cases (8%) or 44 of 858 employees with any eye concern (5%). Fourteen of the 44 employees had adenoviral serotypes and clinical presentation consistent with epidemic keratoconjunctivitis (type 37 [n = 6], 8 [n = 4], 4 [n = 3], 19 [n = 1]). Other serotypes found in individuals with less severe conjunctivitis were 3 (n = 5), 4 (n = 5), 56 (n = 4), 1 (n = 2), 42 (n = 1), and 7 (n = 1). No healthcare-associated adenoviral conjunctivitis outbreaks occurred after algorithm implementation, and fewer employees required furlough than had clinical diagnosis alone been used.

CONCLUSIONS

The algorithm is an effective infection prevention tool that minimizes productivity loss compared to clinical diagnosis and allows for determination of prevalence and serotype characterization of adenoviral conjunctivitis in hospital employees.

Virology and epidemiology analyses of global adenovirus-associated conjunctivitis outbreaks, 1953-2013

This study aimed to compare the virology and epidemiology of epidemic keratoconjunctivitis (EKC), pharyngoconjunctival fever (PCF) and acute haemorrhagic conjunctivitis (AHC) outbreaks worldwide caused by the human adenovirus (HAdV) from 1953 to 2013. Eighty-three hexon sequences from 76 conjunctivitis outbreaks were analysed and subtyped using Mega 5.05, Clustal X and SimPlot software. Epidemiology was performed for the area, age and seasonal distribution. A phylogenetic analysis indicated that all the isolates could be divided into three subgenetic lineages, without a common ancestor. The major causes of the outbreaks were Ad8, Ad7 and Ad2 co-infection with enterovirus 70 (EV70) in EKC, PCF and AHC, respectively. The epidemiological findings suggested that EKC and AHC were circulating predominantly in Asia during the early winter and spring, whereas PCF was circulating mainly in China, Australia and the United States during the summer. This study suggests that EKC, AHC and PCF outbreaks have different circulating patterns throughout the world and are caused by different adenovirus serotypes. A global surveillance system should be established to monitor conjunctivitis outbreaks in the future.

Use of ward closure to control outbreaks among hospitalized patients in acute care settings: a systematic review

BACKGROUND

Though often used to control outbreaks, the efficacy of ward closure is unclear. This systematic review sought to identify studies defining and describing ward closure in outbreak control and to determine impact of ward closure as an intervention on outbreak containment.

METHODS

We searched these databases with no language restrictions: MEDLINE, 1946 to 7 July 2014; EMBASE, 1974 to 7 July 2014; CINAHL, 1937 to 8 July 2014; and Cochrane Database of Systematic Reviews, 2005 to May 2014. We also searched the following: IndMED; LILACS; reference lists from retrieved articles; conference proceedings; and websites of the CDCP, the ICID, and the WHO. We included studies of patients hospitalized in acute care facilities; used ward closure as a control measure; used other control measures; and discussed control of the outbreak(s) under investigation. A component approach was used to assess study quality.

RESULTS

We included 97 English and non-English observational studies. None included a controlled comparison between ward closure and other interventions. We found that ward closure was often used as part of a bundle of interventions but could not determine its direct impact separate from all the other interventions whether used in parallel or in sequence with other interventions. We also found no universal definition of ward closure which was widely accepted.

CONCLUSIONS

With no published controlled studies identified, ward closure for control of outbreaks remains an intervention that is not evidence based and healthcare personnel will need to continue to balance the competing risks associated with its use, taking into consideration the nature of the outbreak, the type of pathogen and its virulence, mode of transmission, and the setting in which it occurs. Our review has identified a major research gap in this area.

Human adenovirus type 8: the major agent of epidemic keratoconjunctivitis (EKC)

Human adenovirus type 8 (HAdV-8) is the most common causative agent of a highly contagious eye disease known as epidemic keratoconjunctivitis (EKC). HAdV-8 strains have been classified into genome types HAdV-8A to 8K and HAdV/D1 to D12 according to restriction endonuclease analysis. This review focuses on the significance of HAdV-8 as an agent of EKC. Molecular analysis of HAdV-8 genome types HAdV-53 and HAdV-54 was performed to reveal potential genetic variation in the hexon and fiber, which might affect the antigenicity and tropism of the virus, respectively. On the basis of the published data, three patterns of HAdV-8 genome type distribution were observed worldwide: (1) genome types restricted to a microenvironment, (2) genome types distributed within a country, and (3) globally dispersed genome types. Simplot and zPicture showed that the HAdV-8 genome types were nearly identical to each other. HAdV-54 is very close to the HAdV-8P, B and E genomes, except in the hexon. In a restriction map, HAdV-8P, B, and E share a very high percentage of restriction sites with each other. Hypervariable regions (HVRs) of the hexon were conserved and were 100% identical among the genome types. The fiber knob of HAdV-8P, A, E, J and HAdV-53 were 100% identical. In phylogeny, HVRs of the hexon and fiber knob of the HAdV-8 genome types segregated into monophyletic clusters. Neutralizing antibodies against one genome type will provide protection against other genome types, and the selection of future vaccine strains would be simple due to the stable HVRs. Molecular analysis of whole genomes, particularly of the capsid proteins of the remaining genome types, would be useful to substantiate our observations.

Outbreak of epidemic keratoconjunctivitis caused by human adenovirus type 56, China, 2012

HAdV-56 is a new recombinant type isolated from epidemic keratoconjunctivitis (EKC) patients and has been sporadically isolated in Japan several times. Here, an outbreak of EKC in the city of Dalian, China involving a large number of workers in two factories was reported; this was the first outbreak of EKC associated with HAdV-56 worldwide.

Epidemic adenoviral keratoconjunctivitis possibly related to ophthalmological procedures in a neonatal intensive care unit: lessons from an outbreak

PURPOSE

Epidemic adenoviral keratoconjunctivitis can spread rapidly among preterm infants who frequently undergo ophthalmological examination. Here we present our experience on a nosocomial outbreak that affected 8 nursery staff members and 26 premature infants. We focus on the presentation and progress of the outbreak, the diagnosis of the disease and the measures taken for its control.

METHODS

Data were collected from patients' files and records of the infection control team. Conjunctival swabs were collected to perform direct fluorescent assay (DFA) and viral culture. Diagnosis was made according to clinical evidence and/or detection of the virus. Statistical analysis was performed using SPSS 15.0 statistical software.

RESULTS

Infection was introduced to our unit after a laser photocoagulation procedure of a 28-week gestational infant and circulated rapidly within the unit due to direct transmission through contaminated medical equipment, fomites and hands of nursery staff members. Neither the patients, nor the nursery staff members developed systemic symptoms. While DFA tests were positive in seven infants, culture positivity could be demonstrated in only three infants. Contact and droplet precautions were implemented with the recommendation of the infection control team. No recurrence occurred after definition of the last case on the 32nd day.

CONCLUSION

Ophthalmologic procedures continue to be a potential source of adenovirus outbreaks. However, negligence of contact measures during routine daily nursing care seems to be a more important contributing factor for rapid spread. Strict adherence to appropriate aseptic procedures is required to prevent this potentially hazardous infection in preterm infants.

Community acquired respiratory and gastrointestinal viral infections: challenges in the immunocompromised host

PURPOSE OF REVIEW

Newer molecular diagnostic techniques have advanced the field of clinical microbiology and infectious diseases, particularly with respect to characterizing the role that community acquired viruses play in the clinical course and outcomes of the immunocompromised host. This review will examine recent studies describing the impact of adenovirus, rhinovirus, hepatitis E and norovirus in the course of solid organ and stem cell transplant recipients, as well as their epidemiology and implications for infection prevention and control.

RECENT FINDINGS

Adenovirus transmission is poorly understood; recent studies increasingly point to reactivation of latent infection in the immunocompromised host. Rhinovirus shedding can persist for weeks after acute viral infection, complicating hospital infection control policies. Hepatitis E is increasingly recognized as a potential pathogen in the stem cell and solid organ transplant population, and should be considered in the work-up for unexplained liver function test abnormalities. Similar to rhinovirus, norovirus shedding from the gastrointestinal tract may persist for months in the immunocompromised host; infected patients are at a higher risk for transmitting norovirus compared with infected healthcare workers.

SUMMARY

Additional studies are needed, particularly with respect to transmission, for these community acquired viral infections, which often have devastating consequences in the immunocompromised patient population.

Outbreak of adenovirus serotype 8 conjunctivitis in preterm infants in a neonatal intensive care unit

BACKGROUND

Adenovirus keratoconjunctivitis outbreaks have rarely been reported in preterm infants. An outbreak of adenovirus conjunctivitis occurred between 15 January and 25 February at a neonatal intensive care unit of a university hospital in Turkey.

AIM

To describe the evolution, investigation and management of the outbreak.

METHODS

Adenovirus type 8 was identified in 14 samples by polymerase chain reaction analysis. A case-control study was performed to determine the risk factors.

FINDINGS

Fifteen preterm neonates, five healthcare workers (HCWs) and four parents suffered from conjunctivitis signs such as lacrimation, swelling and redness of the eye. A retinopathy of prematurity (ROP) examination was found to be the most important risk factor for adenovirus conjunctivitis (odds ratio: 17.5; 95% confidence interval: 1.9-163.0; P=0.012). The eyelid speculum (blepharostat) used during the ROP examination was not sterilized between each patient and was found to be the cause of contamination.

CONCLUSION

The outbreak was controlled by measures such as barrier precautions, hand hygiene, sterilization of the blepharostat, suspending patient transfer to other units, and excluding infected HCWs for at least 15 days.

Comparison of surface sampling methods for virus recovery from fomites

The role of fomites in infectious disease transmission relative to other exposure routes is difficult to discern due, in part, to the lack of information on the level and distribution of virus contamination on surfaces. Comparisons of studies intending to fill this gap are difficult because multiple different sampling methods are employed and authors rarely report their method's lower limit of detection. In the present study, we compare a subset of sampling methods identified from a literature review to demonstrate that sampling method significantly influences study outcomes. We then compare a subset of methods identified from the review to determine the most efficient methods for recovering virus from surfaces in a laboratory trial using MS2 bacteriophage as a model virus. Recoveries of infective MS2 and MS2 RNA are determined using both a plaque assay and quantitative reverse transcription-PCR, respectively. We conclude that the method that most effectively recovers virus from nonporous fomites uses polyester-tipped swabs prewetted in either one-quarter-strength Ringer's solution or saline solution. This method recovers a median fraction for infective MS2 of 0.40 and for MS2 RNA of 0.07. Use of the proposed method for virus recovery in future fomite sampling studies would provide opportunities to compare findings across multiple studies.

Treatment of viral conjunctivitis with antiviral drugs

Viral conjunctivitis is one of the most common disorders observed in ophthalmic emergency departments, yet no established treatment exists. Lately, antiviral medications have been introduced into clinical practice; however, a systematic review focusing on their use and effectiveness in the treatment of viral conjunctivitis has not been previously reported. We systemically reviewed the literature to identify studies where antiviral drugs were used to treat viral conjunctivitis. Currently, aciclovir, trifluridine and valaciclovir are commonly used as antiviral agents to treat herpesvirus infections. Cidofovir has been used successfully to treat some cases of adenoviral conjunctivitis, although toxicity has also been reported. The use of other medications, such as idoxuridine, has been minimized in clinical practice due to their high toxicity. Interestingly, most of the antiviral drugs developed are used to treat herpesvirus infections, while less progress has been made in the field of adenoviral infections. For other viral causes of conjunctivitis, no effective remedy is currently available, and treatment focuses on the relief of symptoms. Caution should be exercised when coadministering other pharmacological agents, such as corticosteroids, because of emerging adverse effects.