Respiratory virus shedding in a cohort of on-duty healthcare workers undergoing prospective surveillance

Contraction of Respiratory Viral Infection During air Travel: An Under-Recognized Health Risk for Athletes

Air travel has an important role in the spread of viral acute respiratory infections (ARIs). Aircraft offer an ideal setting for the transmission of ARI because of a closed environment, crowded conditions, and close-contact setting. Numerous studies have shown that influenza and COVID-19 spread readily in an aircraft with one virus-positive symptomatic or asymptomatic index case. The numbers of secondary cases differ markedly in different studies most probably because of the wide variation of the infectiousness of the infector as well as the susceptibility of the infectees. The primary risk factor is sitting within two rows of an infectious passenger. Elite athletes travel frequently and are thus prone to contracting an ARI during travel. It is anecdotally known in the sport and exercise medicine community that athletes often contract ARI during air travel. The degree to which athletes are infected in an aircraft by respiratory viruses is unclear. Two recent studies suggest that 8% of Team Finland members traveling to major winter sports events contracted the common cold most probably during air travel. Further prospective clinical studies with viral diagnostics are needed to understand the transmission dynamics and to develop effective and socially acceptable preventive measures during air travel.

Preschool-Aged Household Contacts as a Risk Factor for Viral Respiratory Infections in Healthcare Personnel

Background

Viral respiratory infections (VRIs) are common and are occupational risks for healthcare personnel (HCP). VRIs can also be acquired at home and other settings among HCPs. We sought to determine if preschool-aged household contacts are a risk factor for VRIs among HCPs working in outpatient settings.

Methods

We conducted a secondary analysis of data from a cluster randomized trial at 7 medical centers in the United States over 4 influenza seasons from 2011-2012 to 2014-2015. Adult HCPs who routinely came within 6 feet of patients with respiratory infections were included. Participants were tested for respiratory viruses whenever symptomatic and at 2 random times each season when asymptomatic. The exposure of interest was the number of household contacts 0-5 years old (preschool-aged) at the beginning of each HCP-season. The primary outcome was the rate of polymerase chain reaction-detected VRIs, regardless of symptoms. The VRI incidence rate ratio (IRR) was calculated using a mixed-effects Poisson regression model that accounted for clustering at the clinic level.

Results

Among the 4476 HCP-seasons, most HCPs were female (85.4%) and between 30 and 49 years of age (54.6%). The overall VRI rate was 2.04 per 100 person-weeks. In the adjusted analysis, HCPs having 1 (IRR, 1.22 [95% confidence interval {CI}, 1.05-1.43]) and ≥2 (IRR, 1.35 [95% CI, 1.09-1.67]) preschool-aged household contacts had higher VRI rates than those with zero preschool-aged household contacts.

Conclusions

Preschool-aged household contacts are a risk factor for developing VRIs among HCPs working in outpatient settings.

Incidence of Influenza Virus Infection among Wroclaw's Healthcare Workers in Pre-COVID-19 2019-2020 Influenza Season Using Novel Flu SensDx Device

Background: Healthcare workers (HCWs) are more exposed to influenza infection, and the influenza vaccination is recommended each year, to reduce the risk of influenza infection and prevent influenza transmission. This study is a cross-sectional study and the objectives were to determine the rate of influenza virus infection among HCWs in the 2019−2020 influenza season. Methods: Between January and March 2020, a survey was carried out in 2 hospitals and 15 primary health-care settings (PHCS) in Wroclaw (Poland). The novel point-of-care testing Flu SensDx device was used, which detects the M1 protein of the influenza virus using electrochemical impedance spectroscopy from biological material (throat/nasal swabs). Results: A total of 150 samples were collected. The majority of participating HCWs by profession were 83 physicians (55.3%) and half (51.3%) of the participating HCWs worked in PHCS. Influenza vaccination coverage was 61.3% in 2019−2020 and 46.0% in the 2018−2019 season for all participants. Of the participating HCWs, 44.0% were positive tested by the Flu SensDx device. There were no statistically significant differences among the positive tested HCWs, their influenza immunization history, and the presence of symptoms of influenza-like illness (p > 0.05). Conclusion: Although the results of the present study suggest that influenza vaccination does not reduce the frequency of influenza virus detection by Flu SensDx testing in the HCWs participants, larger studies are needed to estimate the incidence of influenza virus infection among HCWs to understand the underlying mechanism and fine-tune policies aimed at reducing nosocomial infections.

Risk factors associated with respiratory infectious disease-related presenteeism: a rapid review

BACKGROUND

Workplace transmission is a significant contributor to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreaks. Previous studies have found that infectious illness presenteeism could contribute to outbreaks in occupational settings and identified multiple occupational and organisational risk factors. Amid the COVID-19 pandemic, it is imperative to investigate presenteeism particularly in relation to respiratory infectious disease (RID). Hence, this rapid review aims to determine the prevalence of RID-related presenteeism, including COVID-19, and examines the reported reasons and associated risk factors.

METHODS

The review followed a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) search approach and focused on studies published in English and Chinese. Database searches included MEDLINE, EMBASE, Web of Science, China Knowledge Resource Integrated Database (CNKI) and preprint databases MedRxiv and BioRxiv.

RESULTS

The search yielded 54 studies, of which four investigated COVID-19-related presenteeism. Prevalence of work presenteeism ranged from 14.1 to 55% for confirmed RID, and 6.6 to 100% for those working with suspected or subclinical RID. The included studies demonstrated that RID-related presenteeism is associated with occupation, sick pay policy, age, gender, health behaviour and perception, vaccination, peer pressure and organisational factors such as presenteeism culture.

CONCLUSIONS

This review demonstrates that presenteeism or non-adherence to isolation guidance is a real concern and can contribute to workplace transmissions and outbreaks. Policies which would support workers financially and improve productivity, should include a range of effective non-pharmaceutical inventions such as workplace testing, promoting occupational health services, reviewing pay and bonus schemes and clear messaging to encourage workers to stay at home when ill. Future research should focus on the more vulnerable and precarious occupational groups, and their inter-relationships, to develop comprehensive intervention programs to reduce RID-related presenteeism.

Physician Well-being 2.0: Where Are We and Where Are We Going?

Although awareness of the importance of physician well-being has increased in recent years, the research that defined this issue, identified the contributing factors, and provided evidence on effective individual and system-level solutions has been maturing for several decades. During this interval, the field has evolved through several phases, each influenced not only by an expanding research base but also by changes in the demographic characteristics of the physician workforce and the evolution of the health care delivery system. This perspective summarizes the historical phase of this journey (the "era of distress"), the current state (Well-being 1.0), and the early contours of the next phase based on recent research and the experience of vanguard institutions (Well-being 2.0). The key characteristics and mindset of each phase are summarized to provide context for the current state, to illustrate how the field has evolved, and to help organizations and leaders advance from Well-being 1.0 to Well-being 2.0 thinking. Now that many of the lessons of the Well-being 1.0 phase have been internalized, the profession, organizations, leaders, and individual physicians should act to accelerate the transition to Well-being 2.0.

Active surveillance for acute respiratory infections among pediatric long-term care facility staff

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Staff at pediatric long-term care facilities (pLTCF) were responsive to electronic messages asking about acute respiratory illness symptoms.

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Staff in pLTCFs had respiratory viruses detected during acute respiratory infections and while asymptomatic.

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Contagious presenteeism occurred as some participants with ARIs worked while symptomatic.

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Staff with ARI may pose a risk of transmitting respiratory viral infections to frail and medically complex pLTCF residents.

Background

Transmission of respiratory viruses between staff and residents of pediatric long-term care facilities (pLTCFs) can occur. We assessed the feasibility of using text or email messages to perform surveillance for acute respiratory infections (ARIs) among staff.

Methods

From December 7, 2016 to May 7, 2017, 50 staff participants from 2 pLTCFs received weekly text or email requests to report the presence or absence of ARI symptoms. Those who fulfilled the ARI case definition (≥2 symptoms) had respiratory specimens collected to detect viruses by reverse transcriptase polymerase chain reaction assays. Pre- and postsurveillance respiratory specimens were collected to assess subclinical viral shedding.

Results

The response rate to weekly electronic messages was 93%. Twenty-one ARIs reported from 20 (40%) participants fulfilled the case definition. Respiratory viruses were detected in 29% (5/17) of specimens collected at symptom onset (influenza B, respiratory syncytial virus, coronavirus [CoV] 229E, rhinovirus [RV], and dual detection of CoV OC43 and bocavirus). Four participants had positive presurveillance (4 RV), and 6 had positive postsurveillance specimens (3 RV, 2 CoV NL63, and 1 adenovirus).

Conclusions

Electronic messaging to conduct ARI surveillance among pLTCF staff was feasible.

Absenteeism and presenteeism in healthcare workers due to respiratory illness

OBJECTIVE

To assess influenza symptoms, adherence to mask use recommendations, absenteesm and presenteeism in acute care healthcare workers (HCWs) during influenza epidemics.

METHODS

The TransFLUas influenza transmission study in acute healthcare prospectively followed HCWs prospectively over 2 consecutive influenza seasons. Symptom diaries asking for respiratory symptoms and adherence with mask use recommendations were recorded on a daily basis, and study participants provided midturbinate nasal swabs for influenza testing.

RESULTS

In total, 152 HCWs (65.8% nurses and 13.2% physicians) were included: 89.1% of study participants reported at least 1 influenza symptom during their study season and 77.8% suffered from respiratory symptoms. Also, 28.3% of HCW missed at least 1 working day during the study period: 82.6% of these days were missed because of symptoms of influenza illness. Of all participating HCWs, 67.9% worked with symptoms of influenza infection on 8.8% of study days. On 0.3% of study days, symptomatic HCWs were shedding influenza virus while at work. Among HCWs with respiratory symptoms, 74.1% adhered to the policy to wear a mask at work on 59.1% of days with respiratory symptoms.

CONCLUSIONS

Respiratory disease is frequent among HCWs and imposes a significant economic burden on hospitals due to the number of working days lost. Presenteesm with respiratory illness, including influenza, is also frequent and poses a risk for patients and staff.

TRIAL REGISTRATION

NCT02478905 (clinicaltrials.gov).

Use of whole-genome sequencing in the molecular investigation of care-associated HCoV-OC43 infections in a hematopoietic stem cell transplant unit

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HCoV−OC43 is involved in healthcare–associated infections.

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HCoV−OC43 genotypes B, E, F and G are identified.

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Asian and European strains of HCoV−OC43 circulate among patients.

Background

While respiratory viral infections are recognized as a frequent cause of illness in hematopoietic stem cell transplantation (HSCT) recipients, HCoV−OC43 infections have rarely been investigated as healthcare-associated infections in this population.

Objectives

In this report, HCoV−OC43 isolates collected from HSCT patients were retrospectively characterized to identify potential clusters of infection that may stand for a hospital transmission.

Study design

Whole-genome and S gene sequences were obtained from nasal swabs using next-generation sequencing and phylogenetic trees were constructed. Similar identity matrix and determination of the most common ancestor were used to compare clusters of patient’s sequences. Amino acids substitutions were analysed.

Results

Genotypes B, E, F and G were identified. Two clusters of patients were defined from chronological data and phylogenetic trees. Analyses of amino acids substitutions of the S protein sequences identified substitutions specific for genotype F strains circulating among European people.

Conclusions

HCoV−OC43 may be implicated in healthcare-associated infections.

Attitudes about sickness presenteeism in medical training: is there a hidden curriculum?

Background

Sickness presenteeism among healthcare professionals can compromise patient safety. To better understand what motivates this phenomenon, especially among trainees, the authors investigated attitudes of medical students, resident physicians, and faculty physicians about working when sick with what might be an infectious condition.

Methods

In 2012–2013, the authors employed a mixed methods, two-stage, cross-sectional survey at the University of Iowa Hospitals and Clinics of medical students (third-year students in the first survey and fourth-year students in the second survey), resident physicians in Internal Medicine, Pediatrics, and Family Medicine (first-year residents in the first survey and second-year residents in the second survey), and faculty physicians in Internal Medicine, Pediatrics, and Family Medicine. The first survey included one open-ended question querying attitudes about sickness presenteeism, answers to which underwent content analysis that identified 17 codes used to develop 23 additional closed-ended questions for a second survey.

Results

127 participants completed the second survey (44% response rate). Sixty percent of these participants felt obligated to work when sick; and 33% felt obligated to work with influenza-like symptoms (fever, myalgias, cough), with residents and students being more likely to do so than faculty (67% vs. 35% vs. 14%, p = 0.001). Most participants (83%) were motivated to work when sick to avoid creating more work for colleagues, and residents and students were more likely than faculty physicians to want to avoid negative repercussions (84% vs 71% vs. 25%, p < 0.001) or appear lazy or weak (89% vs 75% vs. 40%, p < 0.001). Most participants also recognized the need to avoid spreading infections to patients (81%) or colleagues (75%).

Conclusions

When deciding whether to work when sick, students, residents, and faculty report a mixture of motivations that focus on the interests of patients, colleagues, and themselves. Awareness of these mixed motivations, particularly among trainees, can help inform interventions aimed at limiting instances of sickness presenteeism to support a culture of patient safety and counter any tendencies toward a hidden curriculum of efficiency and achievement.

Which healthcare workers work with acute respiratory illness? Evidence from Canadian acute-care hospitals during 4 influenza seasons: 2010-2011 to 2013-2014

BACKGROUND

Healthcare workers (HCWs) are at risk of acquiring and transmitting respiratory viruses while working in healthcare settings.

OBJECTIVES

To investigate the incidence of and factors associated with HCWs working during an acute respiratory illness (ARI).

METHODS

HCWs from 9 Canadian hospitals were prospectively enrolled in active surveillance for ARI during the 2010-2011 to 2013-2014 influenza seasons. Daily illness diaries during ARI episodes collected information on symptoms and work attendance.

RESULTS

At least 1 ARI episode was reported by 50.4% of participants each study season. Overall, 94.6% of ill individuals reported working at least 1 day while symptomatic, resulting in an estimated 1.9 days of working while symptomatic and 0.5 days of absence during an ARI per participant season. In multivariable analysis, the adjusted relative risk of working while symptomatic was higher for physicians and lower for nurses relative to other HCWs. Participants were more likely to work if symptoms were less severe and on the illness onset date compared to subsequent days. The most cited reason for working while symptomatic was that symptoms were mild and the HCW felt well enough to work (67%). Participants were more likely to state that they could not afford to stay home if they did not have paid sick leave and were younger.

CONCLUSIONS

HCWs worked during most episodes of ARI, most often because their symptoms were mild. Further data are needed to understand how best to balance the costs and risks of absenteeism versus those associated with working while ill.

Approche syndromique multiplexe en réanimation

Le développement récent des nouveaux tests de diagnostic rapide par PCR multiplexe à visée syndromique, capables de détecter plusieurs dizaines de pathogènes en quelques heures, a entraîné un changement de paradigme en microbiologie et en pratique clinique. Plusieurs d’entre eux, comme les panels pour détecter les germes en cause dans les bactériémies, les infections respiratoires hautes ou basses et les méningoencéphalites, sont déjà disponibles et peuvent apporter une aide dans le diagnostic des infections chez les patients de réanimation. Bien que ces nouvelles techniques présentent des avantages évidents pour le dénombrement de micro-organismes et parfois pour la détection simultanée de gènes de résistance, pour les délais d’exécution et de rendus de résultats, elles présentent cependant certains défis, comme l’évaluation de leurs performances réelles, leur coût très élevé, le choix des stratégies d’utilisation et l’interprétation clinicobiologique des résultats. Dans cet article, nous avons passé en revue les différents tests qui peuvent ou pourront aider les réanimateurs dans leur pratique quotidienne, relevé leurs limites et leur impact bénéfique potentiel sur le soin des patients.

Shift Work and Respiratory Infections in Health-Care Workers

Recently, there has been interest in whether shift work may enhance susceptibility to infection. Our aim was to determine whether shift workers in the health-care field have a higher incidence, duration, and/or severity of influenza-like illness (ILI) and acute respiratory infection (ARI) than non–shift workers. From September 2016 to June 2017, 501 rotating and/or night-shift workers and 88 non–shift workers from the Klokwerk+ Study (the Netherlands, 2016–2017) registered the occurrence of ILI/ARI symptoms daily using a smartphone application. The incidence rate of ILI/ARI (defined as ≥2 symptoms on the same day/≥1 symptom on 2 consecutive days), the mean duration of each episode, and the incidence rate of severe episodes were compared between shift workers and non–shift workers using negative binomial regression and linear mixed-model analysis. In total, participants completed 110,347 diaries. Shift workers’ incidence rate of ILI/ARI was 1.20 (95% confidence interval (CI): 1.01, 1.43) times higher than that of non–shift workers, and for severe ILI/ARI episodes, shift workers’ incidence rate was 1.22 (95% CI: 1.01, 1.49) times higher. The mean duration of an ILI/ARI episode did not differ (ratio between means = 1.02, 95% CI: 0.87, 1.19). In conclusion, shift workers in health care had more ILI/ARI episodes and more severe ILI/ARI episodes than non–shift workers, but with a similar duration. Insight into underlying mechanisms connecting shift work and infection susceptibility will contribute to the design of preventive initiatives.

Assessment of Anti-HIV-1 Antibodies in Oral and Nasal Compartments of Volunteers From 3 Different Populations

In this study, we assessed the feasibility of collecting standardized nasal and salivary samples at centers in Nairobi (Kenya), Kigali (Rwanda), and London (United Kingdom) using different collection devices and media (synthetic absorptive matrices versus flocked swabs, and Salimetrics oral swabs versus whole oral fluid collection). We detected anti-Gag (p24) and envelope (gp140) antibodies in both nasal fluid and salivary collections from all HIV-infected individuals, and cross-reactive anti-p24 antibodies were detected in 10% of HIV-uninfected individuals enrolled at one site. Collections from the nasal turbinates were comparable with samples collected deeper in the nasopharyngeal tract, and the yield of anti-p24 IgA in the whole oral fluid samples was higher than in samples collected from the parotid gland. We noted a trend toward reduced levels of anti-HIV antibody in the volunteers receiving anti-retroviral therapy. Levels of antibodies were stable over multiple collection visits. Overall, this study shows that nasal and salivary samples can be collected in a standardized manner over repeated visits in both low- and high-resource settings. These methods may be used in support for future HIV vaccine clinical trials.

Human metapneumovirus in the preterm neonate: current perspectives

Premature birth (<37 weeks gestation) occurs in ~11% of all births in the US. These infants are at risk of chronic lung disease and respiratory conditions, including bronchopulmonary dysplasia. Respiratory viruses are important causes of acute respiratory illness (ARI) in preterm infants, leading to rehospitalization, increased health care burden, and long-term morbidity. Human metapneumovirus (HMPV) is a paramyxovirus discovered in 2001 that is related to respiratory syncytial virus. Epidemiologic studies show that HMPV is a leading cause of ARI in children and adults worldwide. Prematurity is a major risk factor for severe HMPV disease, requiring hospitalization. Moreover, limited data suggest that HMPV infection during infancy is associated with asthma and recurrent wheezing, which are common long-term pulmonary complication of prematurity. HMPV causes nosocomial outbreaks of ARI in hospitals and long-term care facilities, although there are few studies of the prevalence of HMPV in neonatal intensive care unit populations. HMPV is a common and important virus in premature infants, and caregivers for preterm infants should consider this virus in patients with acute respiratory symptoms.

Burden and viral aetiology of influenza-like illness and acute respiratory infection in intensive care units

The purpose of this investigation was to study the viral aetiology of influenza-like illness (ILI) and acute respiratory tract infection (ARTI) among patients requiring intensive care unit admission. A cross-sectional retrospective study was carried out in Sicily over a 4-year period. A total of 233 respiratory samples of patients with ILI/ARTI admitted to intensive care units were molecularly analyzed for the detection of a comprehensive panel of aetiologic agents of viral respiratory infections. About 45% of patients was positive for at least one pathogen. Single aetiology occurred in 75.2% of infected patients, while polymicrobial infection was found in 24.8% of positive subjects. Influenza was the most common aetiologic agent (55.7%), especially among adults. Most of patients with multiple aetiology (76.9%) were adults and elderly. Mortality rates among patients with negative or positive aetiology did not significantly differ (52.4% and 47.6%, respectively). Highly transmissible respiratory pathogens are frequently detected among patients with ILI/ARTI admitted in intensive care units, showing the occurrence of concurrent infections by different viruses. The knowledge of the circulation of several types of microorganisms is of crucial importance in terms of appropriateness of therapies, but also for the implication in prevention strategies and hospital epidemiology.

Respiratory viruses and their impact in healthcare

PURPOSE OF REVIEW

As viral respiratory infections are responsible for significant morbidity and mortality, and are associated with numerous challenges for infection control, we provide an overview of the most recent publications on healthcare-associated respiratory infections.

RECENT FINDINGS

Populations most susceptible to respiratory viruses include neonates, immunocompromised and elderly populations. Newer polymerase chain reaction-based assays are more sensitive and are able to detect multiple respiratory viruses. The significance of virus detection among asymptomatic individuals, however, remains unclear. There is more evidence of airborne transmission of influenza, but currently N95 masks are recommended only for aerosol generating procedures. Transocular transmission of influenza has been demonstrated in the experimental setting, but further research is needed of transocular transmission of other respiratory viruses. Mandatory vaccination of healthcare workers against influenza has been shown to reduce influenza rates and patient mortality.

SUMMARY

Infection control measures can be supplemented with use of polymerase chain reaction testing to determine causes, but the cornerstone of prevention relies on enforcing appropriate isolation measures for patients: hand hygiene; appropriate use of personal protective equipment by healthcare workers; illness screening of visitors; and influenza vaccination of healthcare workers, patients and families.

Better tests, better care: improved diagnostics for infectious diseases

In this IDSA policy paper, we review the current diagnostic landscape, including unmet needs and emerging technologies, and assess the challenges to the development and clinical integration of improved tests. To fulfill the promise of emerging diagnostics, IDSA presents recommendations that address a host of identified barriers. Achieving these goals will require the engagement and coordination of a number of stakeholders, including Congress, funding and regulatory bodies, public health agencies, the diagnostics industry, healthcare systems, professional societies, and individual clinicians.

Healthcare workers as vectors of infectious diseases

Nosocomial infections cause considerable morbidity and mortality. Healthcare workers (HCWs) may serve as vectors of many infectious diseases, many of which are not often primarily considered as healthcare-associated. The probability of pathogen transmission to patients depends on several factors, such as the characteristics of a pathogen, HCW and patient. Pathogens with high transmission potential from HCWs to patients include norovirus, respiratory infections, measles and influenza. In contrast, human immunodeficiency virus (HIV) and viral hepatitis are unlikely to be transferred. The prevention of HCW-associated transmission of pathogens include systematic vaccinations towards preventable diseases, continuous education, hand hygiene surveillance, active feedback and adequate staff resources.