Influenza A virus outbreak in a neonatal intensive care unit

Laboratory medicine: The exemplar for value-based healthcare

Value-Based Healthcare (VBHC) aims to improve the overall quality, safety, and sustainability of healthcare while reducing delivery costs of more effective care. Despite advantages associated with VBHC transformation, the road to its adoption has been lengthy. Laboratory Medicine (LM) is in a prime position to lead the transition to VBHC because of its key role in diagnosis and treatment of patients. Laboratory medicine results inform/influence 50% to 70% of all clinical decisions. This article summarizes some issues associated with adoption of VBHC and related healthcare innovations and suggests potential approaches using LM-specific examples to help accelerate adoption. Laboratory medicine is both a useful model for VBHC implementation and facilitator for related innovation adoption by helping to target patient populations that would benefit most from specific interventions. The critical value of rapidly adopted diagnostic technologies used during the COVID-19 pandemic and economic recovery provide important insights about the need to embrace and accelerate VBHC implementation.

Infection Control and the Need for Family-/Child-Centered Care

Patient- and family-centered care (FCC) has become central to the delivery of medical care over the last 20 years and has been shown to improve patient outcomes. Infection control practices have the potential to greatly influence family centeredness and care providers, and hospital personnel must consider the potential impacts of isolation and the use of personal protective equipment (PPE). Approaching infection control with the perspective of FCC requires balancing patient safety and overall patient well-being. In this chapter, authors consider infection control and the benefits of FCC, family and sibling visitation, the use of playrooms, animals in healthcare settings including animal-assisted interventions, the potential adverse effects of infection control practices, and strategies to mitigate these impacts.

Isolation Precautions for Visitors to Healthcare Settings

Visitors may be involved in infection transmission within healthcare settings; however, there is currently limited published data on this subject. This chapter describes situations in which visitor-associated infection transmission occurred and highlights the potential role of visitors in the transmission of pathogenic organisms that can lead to outbreaks in healthcare settings. Infection prevention measures, including isolation precautions and visitor restriction, may be utilized and potentially adapted in order to protect patients and their visitors as well as healthcare personnel. The practical and ethical challenges regarding the use of isolation precautions among visitors to healthcare facilities are discussed.

Influenza Vaccination of Healthcare Workers in the United States, 1989-2002

Objectives.

We sought to estimate influenza vaccination coverage among healthcare workers (HCWs) in the United States during 1989-2002 and to identify factors associated with vaccination in this group. The Advisory Committee on Immunization Practices (ACIP) recommends annual influenza vaccination for HCWs to reduce transmission of influenza to patients at high risk for serious complications of influenza.

Design.

Analysis of cross-sectional data from 1989-2002 surveys conducted by the National Health Interview Survey (NHIS). The outcome measure was self-reported influenza vaccination in the past 12 months. Bivariate and multivariate analysis of 2002 NHIS data.

Setting.

Household interviews conducted during 1989-2002, weighted to reflect the noninstitutionalized, civilian US population.

Participants.

Adults aged 18 years or older participated in the study. A total of 2,089 were employed in healthcare occupations or settings in 2002, and 17,160 were employed in nonhealthcare occupations or settings.

Results.

The influenza vaccination rate among US HCWs increased from 10.0% in 1989 to 38.4% in 2002, with no significant change since 1997. In a multivariate model that included data from the 2002 NHIS, factors associated with a higher rate of influenza vaccination among HCWs aged 18-64 years included age of 50 years or older (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.1-2.1), hospital employee status (OR, 1.5; 95% CI, 1.2-1.9), 1 or more visits to the office of a healthcare professional in the past 12 months (OR, 1.5; 95% CI, 1.1-2.2), receipt of employer-provided health insurance (OR, 1.5; 95% CI, 1.1-2.1), a history of pneumococcal vaccination (OR, 3.9; 95% CI, 2.5-6.1), and history of hepatitis B vaccination (OR, 1.9; 95% CI, 1.4-2.4). Non-Hispanic black persons were less likely to be vaccinated (OR, 0.6; 95% CI, 0.5-0.9) than non-Hispanic white persons. There were no significant differences in vaccination levels according to HCW occupation category.

Conclusions.

Influenza immunization among HCWs reached a plateau during 1997-2002. New strategies are needed to encourage US HCWs to receive influenza vaccination to prevent influenza illness in themselves and transmission of influenza to vulnerable patients.

Influenza Vaccination of Healthcare Workers and Vaccine Allocation for Healthcare Workers During Vaccine Shortages

Influenza causes substantial morbidity and mortality annually, particularly in high-risk groups such as the elderly, young children, immunosuppressed individuals, and individuals with chronic illnesses. Healthcare-associated transmission of influenza contributes to this burden but is often under-recognized except in the setting of large outbreaks. The Centers for Disease Control and Prevention has recommended annual influenza vaccination for healthcare workers (HCWs) with direct patient contact since 1984 and for all HCWs since 1993. The rationale for these recommendations is to reduce the chance that HCWs serve as vectors for healthcare-associated influenza due to their close contact with high-risk patients and to enhance both HCW and patient safety. Despite these recommendations as well as the effectiveness of interventions designed to increase HCW vaccination rates, the percentage of HCWs vaccinated annually remains unacceptably low. Ironically, at the same time that campaigns have sought to increase HCW vaccination rates, vaccine shortages, such as the shortage during the 2004-2005 influenza season, present challenges regarding allocation of available vaccine supplies to both patients and HCWs. This two-part document outlines the position of the Society for Healthcare Epidemiology of America on influenza vaccination for HCWs and provides guidance for the allocation of influenza vaccine to HCWs during a vaccine shortage based on influenza transmission routes and the essential need for a practical and adaptive strategy for allocation. These recommendations apply to all types of healthcare facilities, including acute care hospitals, long-term-care facilities, and ambulatory care settings.

Prematurity and the burden of influenza and respiratory syncytial virus disease

BACKGROUND

Respiratory morbidity of former preterm infants and especially those with bronchopulmonary dysplasia (BPD) is high during infancy and early childhood.

DATA SOURCES

We performed a review based on a literature search including EMBASE, MEDLINE, and CINAHL databases to identify all relevant papers published in the English and German literature on influenza and respiratory syncytial virus infection associated with preterm infant, prematurity, and BPD between 1980 and 2014.

RESULTS

Recurrent respiratory symptoms remain common at preschool age, school age and even into young adulthood. Acute viral respiratory tract infections due to different pathogens cause significant morbidity and necessitate rehospitalizations during the first years of life. Influenza virus infection plays a minor role compared to respiratory syncytial virus (RSV) associated respiratory tract infection during infancy and early childhood. Nevertheless, particular morbidity to both viruses is high.

CONCLUSIONS

The particular burden of both viral diseases in preterm infants is dominated by RSV and its associated rehospitalizations during the first two years of life. Prophylactic measures include vaccination against influenza virus of family members and caregivers and active immunization starting at the age of 6 months, and monthly injections of palivizumab during the cold season to avoid severe RSV disease and its sequelae.

Preventing Nosocomial Influenza by Improving the Vaccine Acceptance Rate of Clinicians

Objectives:

To assess the effects of interventions to prevent transmission of influenza and to increase employee compliance with influenza vaccination.

Design:

The change in the proportion of hospitalized patients with laboratory-confirmed nosocomial influenza was observed over time and assessed using chi-square for trend analysis. The association between nosocomial influenza in patients and healthcare worker (HCW) compliance with vaccine was assessed by logistic regression.

Setting:

A 600-bed, tertiary-care academic hospital.

Methods:

After an outbreak of influenza A at this hospital in 1988, a mobile cart program was instituted with increased efforts to motivate employees to be vaccinated and furloughed when ill as well as new measures to prevent nosocomial spread.

Results:

HCW vaccination rates increased from 4% in 1987–1988 to 67% in 1999–2000 (P < .0001). Proportions of nosocomially acquired influenza cases among employees or patients both declined significantly (P < .0001). Logistic regression analysis revealed a significant inverse association between HCW compliance with vaccination and the rate of nosocomial influenza among patients (P < .001).

Conclusion:

A mobile cart vaccination program and an increased emphasis on HCWs to receive the vaccine were associated with a significant increase in vaccine acceptance and a significant decrease in the rate of nosocomial influenza among patients.

Healthcare providers as sources of vaccine-preventable diseases

Vaccine-preventable infectious diseases may be introduced into the healthcare setting and pose a serious risk to vulnerable populations including immunocompromised patients. Healthcare providers (HCPs) are exposed to these pathogens through their daily tasks and may serve as a reservoir for ongoing disease transmission in the healthcare setting. The primary method of protection from work-related infection risk is vaccination that protects not only an individual HCP from disease, but also subsequent patients in contact with that HCP. Individual HCPs and healthcare institutions must balance the ethical and professional responsibility to protect their patients from nosocomial transmission of preventable infections with HCP autonomy. This article reviews known cases of HCP-to-patient transmission of the most common vaccine-preventable infections encountered in the healthcare setting including hepatitis B virus, influenza virus, Bordetella pertussis, varicella-zoster virus, measles, mumps and rubella virus. The impact of HCP vaccination on patient care and current recommendations for HCP vaccination against vaccine-preventable infectious diseases are also reviewed.

Pandemic influenza A/H1N1 2009 antibodies in the metropolitan area of Buenos Aires in Argentina

OBJECTIVE

To estimate the infection prevalence in Buenos Aires during the outbreak of pandemic influenza A/H1N1 2009 virus (A(H1N1)pdm09).

METHODS

A(H1N1)pdm09-specific antibodies were measured by hemagglutination inhibition assay in human serum samples collected 6 months after the outbreak and before the introduction of the A(H1N1)pdm09 vaccine in Argentina. Baseline levels of cross-reactive antibodies to A(H1N1)pdm09 were determined by testing 162 serum samples collected before 2009.

RESULTS

The overall seroprevalence of A(H1N1)pdm09 in 150 children and 427 adults was 28.9% (95% confidence interval (CI) 25-33%), with a 58.0% prevalence in children <19 years of age and an 18.7% prevalence in adults ≥19 years of age (p<0.001). The prevalence was 43.5% in children <5 years old and 60.6% among children aged 5-18 years. The prevalence in adults declined with increasing age: 24.9% in 19-39-year-olds, 9.7% in 40-59-year-olds, and 8.1% in those ≥60 years old. The prevalence of specific A(H1N1)pdm09 antibodies was higher compared with the baseline in children (p=0.014), adolescents (p<0.001), and adults <40 years old (p=0.017). Seroprevalence in health care workers was not different from the rest of the population (13.6% vs. 19.3%, respectively; p=0.421).

CONCLUSIONS

The prevalence of specific A(H1N1)pdm09 antibodies was high at 28.9%. The highest prevalence was observed in children, adolescents, and young adults.

Oseltamivir pharmacokinetics, dosing, and resistance among children aged <2 years with influenza

BACKGROUND

Children <2 years of age are at high risk of influenza-related mortality and morbidity. However, the appropriate dose of oseltamivir for children <2 years of age is unknown.

METHODS

The National Institute of Allergy and Infectious Diseases Collaborative Antiviral Study Group evaluated oseltamivir in infants aged <2 years in an age-de-escalation, adaptive design with a targeted systemic exposure.

RESULTS

From 2006 to 2010, 87 subjects enrolled. An oseltamivir dose of 3.0 mg/kg produced drug exposures within the target range in subjects 0-8 months of age, although there was a greater degree of variability in infants <3 months of age. In subjects 9-11 months of age, a dose of 3.5 mg/kg produced drug exposures within the target range. Six of 10 subjects aged 12-23 months receiving the Food and Drug Administration-approved unit dose for this age group (ie, 30 mg) had oseltamivir carboxylate exposures below the target range. Virus from 3 subjects developed oseltamivir resistance during antiviral treatment.

CONCLUSIONS

The appropriate twice-daily oral oseltamivir dose for infants ≤8 months of age is 3.0 mg/kg, while the dose for infants 9-11 months old is 3.5 mg/kg.

Can infants be protected by means of maternal vaccination?

The administration of vaccines is not usually recommended in pregnant women because of a fear of severe adverse events for the fetus. However, contraindication to vaccination applies only to vaccines based on live attenuated viruses for the theoretical possibility that they might infect the fetus. In contrast, the use of several inactivated vaccines is useful and recommended. As a result of the transplacental passage of antibodies, maternal immunization can reduce the risk of vaccine-preventable diseases that may occur in the first months of life before the start or completion of the suggested vaccination schedule. One of the best examples is vaccination against influenza that can protect pregnant women from a disease that can lead to hospitalization and death in a significantly higher number of cases than in the general population and can induce protective specific antibody levels as well as being effective in infants in the first months of life. Other examples are vaccinations against tetanus, pertussis, pneumococcal infections and Haemophilus influenzae type b infection. This review analyses the advantages and limitations of maternal immunization as revealed by experience and the main publications.

Biomedical Waste

Biomedical waste comprises of all liquid and solid wastes generated from medical establishments and activities involving biological materials. Besides health care, the relevant activities include clinical research, research involving animals, animal farms, dead animals, and others. The generation of biomedical waste is not restricted to specific activity or organisations. It can originate from homes during dialysis and using insulin injections, animal health activities in rural areas, butchering of sick animals in butcher houses, medical shops, use of sanitary napkins and ear buds, use of diapers, and air ports when passengers through away restricted medicines without prescription.

Prevention of novel influenza infection in newborns in hospital settings: considerations and strategies during the 2009 H1N1 pandemic

During the 2009 influenza A (H1N1) pandemic, many pregnant women experienced severe illness and some gave birth while ill with suspected or confirmed pandemic (H1N1) 2009 influenza. Because of concerns about possible transmission of this novel virus to immunologically naïve newborns, and the absence of definitive studies regarding this risk, the Centers for Disease Control and Prevention (CDC) reviewed relevant literature to understand the potential burden of disease and routes of transmission affecting newborns. This report describes the issues considered during the 2009 H1N1 pandemic as CDC developed guidance to protect newborns in hospital settings. Also presented is a framework of protection efforts to prevent novel influenza infection in fetuses/newborns before birth and in hospital settings. Although developed specifically for the pandemic, the framework may be useful during future novel influenza outbreaks.

Oseltamivir pharmacokinetics and clinical experience in neonates and infants during an outbreak of H1N1 influenza A virus infection in a neonatal intensive care unit

Detailed oseltamivir pharmacokinetics have yet to be reported in neonates and infants; this group is at high risk of serious influenza-associated complications. Extrapolation of doses from older patients is complicated by rapid organ and drug-metabolizing enzyme maturation. A pharmacokinetic study has been conducted during an influenza A(H1N1) outbreak in a neonatal intensive care unit. Each included patient provided 4 samples for oseltamivir and 4 samples for its active metabolite oseltamivir carboxylate. A population pharmacokinetic model was developed with NONMEM. Allometric weight scaling and maturation functions were added a priori to scale for size and age based on literature values. Nine neonates and infants were recruited. A physiologically parameterized pharmacokinetic model predicted typical day 1 area under the curve (AUC(0-12)) values of 1,966 and 2,484 μg · h/liter for neonates and infants of ≤ 37 weeks of postmenstrual age (PMA) and >37 weeks of PMA treated with 1 mg/kg of body weight and 2 mg/kg, respectively. The corresponding steady-state AUC(0-12) values were 3,670 and 4,559 μg · h/liter. Premature neonates treated with 1 mg/kg and term babies treated with 2 mg/kg should have average oseltamivir carboxylate concentrations in a range similar to that for adults treated with 75 mg, corresponding to >200-fold above the half-maximal inhibitory concentration (IC(50)) value for influenza A(H1N1) from the start of therapy.

Influenza A/H1N1/2009 outbreak in a neonatal intensive care unit

BACKGROUND

Outbreaks of influenza A/H1N1/2009 in neonatal intensive care units (NICUs) have been reported only rarely. Annual vaccination of all healthcare workers (HCWs) against seasonal influenza is recommended but compliance is low and exposure to infected staff as the source of nosocomial outbreaks has been described.

AIM

To report an outbreak of influenza A/H1N1/2009 in a tertiary level NICU that resulted in considerable morbidity.

METHODS

When the first influenza case was identified, a prospective study was conducted and control measures were implemented to reduce the spread of infection throughout the NICU. Neonates who developed influenza were treated with oseltamivir, and exposed neonates were given prophylaxis with oseltamivir.

FINDINGS

Two infected infants who were immature by gestational age and birth weight developed pneumonitis requiring respiratory support, and a third full-term neonate had a mild uncomplicated illness. No significant adverse effects were noted during antiviral treatment or prophylaxis. The investigation identified infected HCWs as the likely source of the outbreak. There was a very low influenza vaccination rate of 15% among nursing staff.

CONCLUSION

Nosocomial influenza can cause considerable morbidity, especially in high risk neonates, and is readily transmissible in the NICU setting by unvaccinated staff members who contract influenza. To prevent outbreaks, in addition to infection control measures, the implementation of HCW vaccination is very important. Oseltamivir treatment was well-tolerated even among premature infants and appeared to be effective, because neonates with influenza had complete recovery and only one of those who received prophylaxis developed the infection.

Infants hospitalized in intensive care units with 2009 H1N1 influenza infection, California, 2009-2010

BACKGROUND

The 2009 H1N1 influenza virus emerged in April 2009 and primarily affected children and young adults. Few reports describe 2009 H1N1 influenza infection in infants. This report describes the clinical and epidemiologic features of 2009 H1N1 influenza in critically ill infants younger than 1 year of age.

METHODS

Laboratory-confirmed cases were reported to the California Department of Public Health as part of public health surveillance for 2009 H1N1 influenza. Data were collected using standardized report forms and medical-chart abstractions.

RESULTS

From April 23, 2009 through May 1, 2010, 82 cases of infants hospitalized in the intensive care unit with 2009 H1N1 influenza were reported in California. Medical charts were available for 77 of the infants, whose median age was 109 days (range: 1-361 days). Twenty-seven (35%) infants had a gestational age of 36 weeks or less. More than half (46; 60%) of the infants had at least 1 reported chronic medical condition. Thirty-five (45%) infants required mechanical ventilation; 7 (9%) died. Five infants were hospitalized since birth and acquired influenza infection during their admission; 2 (40%) of these infants died.

CONCLUSIONS

Infants who are premature or with chronic conditions seem to be at increased risk for developing severe 2009 H1N1 influenza infection. We encourage clinicians to maintain high suspicion for influenza in infants when influenza viruses are circulating. Vaccination should be encouraged among contacts of infants <6 months of age, who are too young to be immunized or treated with licensed antivirals. Infection control measures should also be implemented in hospital settings to reduce nosocomial transmission.

Influenza A/H1N1/09-10 infections in a NICU during the 2009-2010 H1N1 pandemic

Few cases of the pandemic influenza A H1N1 have been reported in very low birth weight infants. We report here a small outbreak in our NICU of 3 cases of influenza A/H1N1/09-10 in very low birth weight infants during the 2009-2010 H1N1 pandemic and describe their clinical presentations and favorable outcomes despite the lack of treatment.

Vaccination during pregnancy to protect infants against influenza: why and why not?

Influenza is a significant cause of morbidity and mortality for pregnant women and infants worldwide. Influenza vaccination during pregnancy has been shown to be safe and highly effective and should be recommended for all pregnant women before the influenza season. Despite existing recommendations, the vaccine is underused in most countries. Obstacles to immunization include insufficient awareness of the disease burden and of the importance and safety of immunization, fear of liability and the wish to minimize interventions during pregnancy. Therefore, educational interventions for the public and health care workers are necessary to increase protection of pregnant women and young infants from influenza related complications.

Nosocomial pandemic (H1N1) 2009, United Kingdom, 2009-2010

To determine clinical characteristics of patients hospitalized in the United Kingdom with pandemic (H1N1) 2009, we studied 1,520 patients in 75 National Health Service hospitals. We characterized patients who acquired influenza nosocomially during the pandemic (H1N1) 2009 outbreak. Of 30 patients, 12 (80%) of 15 adults and 14 (93%) of 15 children had serious underlying illnesses. Only 12 (57%) of 21 patients who received antiviral therapy did so within 48 hours after symptom onset, but 53% needed escalated care or mechanical ventilation; 8 (27%) of 30 died. Despite national guidelines and standardized infection control procedures, nosocomial transmission remains a problem when influenza is prevalent. Health care workers should be routinely offered influenza vaccine, and vaccination should be prioritized for all patients at high risk. Staff should remain alert to the possibility of influenza in patients with complex clinical problems and be ready to institute antiviral therapy while awaiting diagnosis during influenza outbreaks.

Identifying the probable timing and setting of respiratory virus infections

OBJECTIVE

Show how detailed incubation period estimates can be used to identify and investigate potential healthcare-associated infections and dangerous diseases.

METHODS

We used the incubation period of 9 respiratory viruses to derive decision rules for distinguishing between community- and hospital-acquired infection. We developed a method, implemented in a simple spreadsheet, that can be used to investigate the exposure history of an individual patient and more specifically to identify the probable time and location of infection. Illustrative examples are used to explain and evaluate this technique.

RESULTS

If the risks of hospital and community infection are equal, 95% of patients who develop symptoms of adenovirus infection within 5 days of hospital admission will have been infected in the community, as will 95% of patients who develop symptoms within 3 days for human-coronavirus infection, 2.5 days for severe acute respiratory syndrome, 1 day for influenza A, 0.5 day for influenza B, 12 days for measles, 2 days for parainfluenza, 4 days for respiratory syncytial virus infection, and 1.5 days for rhinovirus infection. Sources of infection suggested by analysis of the symptom onset times of individual patients are consistent with those from detailed investigations.

CONCLUSIONS

This work shows how a detailed understanding of the incubation period can be an effective tool for identifying the source of infection, ultimately ensuring patient safety.

Prophylaxis of Healthcare Workers in an Influenza Pandemic

The threat of an imminent influenza pandemic has galvanized global efforts to identify effective preparedness strategies and consider securing health resources. As the nations prepare to meet this threat, public health interventions are being carefully gauged within the context of influenza epidemiology, populations, and healthcare systems. A pandemic will place enormous demands on healthcare systems that include at the center of planning efforts the protection of healthcare workers. During an influenza pandemic, healthcare workers will be on the front lines delivering care to patients and preventing further spread of the disease. Protecting these workers from acquiring or transmitting infection in the hospital ward and outside the workplace is critical to containing a pandemic and limiting morbidity and mortality of the population. Several approaches to protecting healthcare workers include vaccination, antiviral 10.1007/978-0-387-78665-0_6443, use of personal protective equipment, and adherence to other infection control practices. In the absence of vaccination, application of antiviral drugs has been rationalized as the first-line defense against the 10.1007/978-0-387-78665-0_6288. While the treatment of ill individuals is top priority in most national contingency plans, the use of drugs as prophylaxis has been debatable. This chapter attempts to highlight the importance of a competent healthcare system in response to an influenza pandemic, and presents the conflicting issues that are surrounding an antiviral prophylaxis strategy. An overview of potential benefits and limitations, logistical constraints, and clinical and epidemiological consequences of healthcare worker prophylaxis is also provided.

Transmission risk factors and treatment of pediatric shigellosis during a large daycare center-associated outbreak of multidrug resistant Shigella sonnei: implications for the management of shigellosis outbreaks among children

BACKGROUND

Shigellosis outbreaks in daycare centers result in substantial disease and economic burdens in the United States. The emergence of multidrug resistant Shigella strains raises questions regarding control of transmission within daycare centers and treatment for children. From May to October 2005, 639 Shigella sonnei cases were reported in northwest Missouri, mostly among persons exposed to daycare centers.

METHODS

We conducted a case-control investigation among licensed daycare centers (LDCs) in northwest Missouri to determine transmission risk factors, tested isolates for antimicrobial resistance, and described treatment practices. Case LDCs had secondary attack rates of shigellosis>or=2% (range, 2%-25%) and control LDCs<or=2% (range, 0%-1.3%). We interviewed LDC staff and performed on-site inspections. Thirty-one outbreak isolates were tested for antimicrobial resistance. We interviewed physicians and reviewed health department outbreak-related treatment data.

RESULTS

We enrolled 18 case and 21 control LDCs. LDCs with >or=1 sink in every room (odds ratio [OR]: 0.1; 95% confidence interval [CI]: 0.02-0.5) or a diapering station in every room (OR: 0.1; 95% CI: 0.01-0.6) were less likely to be case-LDCs. Resistance to ampicillin and trimethoprim-sulfamethoxazole was found in 90% of the outbreak strains. Among 210 children treated with antimicrobial agents, azithromycin was used in 92 (44%) while a fluoroquinolone was used in 11 (5%) children.

CONCLUSIONS

During a large daycare center-associated shigellosis outbreak, strains were highly resistant to ampicillin and trimethoprim-sulfamethoxazole. Children were frequently treated with azithromycin and occasionally fluoroquinolones. Appropriate handwashing and diapering infrastructure are necessary to minimize spread of shigellosis within daycare centers, and could reduce use of antimicrobial agents.

Hospital-acquired influenza: a synthesis using the Outbreak Reports and Intervention Studies of Nosocomial Infection (ORION) statement

Nosocomial influenza outbreaks occur in almost all types of hospital wards, and their consequences for patients and hospitals in terms of morbidity, mortality and costs are considerable. The source of infection is often unknown, since any patient, healthcare worker (HCW) or visitor is capable of transmitting it to susceptible persons within hospitals. Nosocomial influenza outbreak investigations should help to identify the source of infection, prevent additional cases, and increase our knowledge of disease control to face future outbreaks. However, such outbreaks are probably underdetected and underreported, making routes of transmission difficult to track and describe with precision. In addition, the absence of standardised information in the literature limits comparison between studies and better understanding of disease dynamics. In this study, reports of nosocomial influenza outbreaks are synthesised according to the ORION guidelines to highlight existing knowledge in relation to the detection of influenza cases, evidence of transmission between patients and HCWs and measures of disease incidence. Although a body of evidence has confirmed that influenza spreads within hospitals, we should improve clinical and virological confirmation and initiate active surveillance and quantitative studies to determine incidence rates in order to assess the risk to patients.

Transmission of influenza A in human beings

Planning for the next influenza pandemic is occurring at many levels throughout the world, spurred on by the recent spread of H5N1 avian influenza in Asia, Europe, and Africa. Central to these planning efforts in the health-care sector are strategies to minimise the transmission of influenza to health-care workers and patients. The infection control precautions necessary to prevent airborne, droplet, and contact transmission are quite different and will need to be decided on and planned before a pandemic occurs. Despite vast clinical experience in human beings, there continues to be much debate about how influenza is transmitted. We have done a systematic review of the English language experimental and epidemiological literature on this subject to better inform infection control planning efforts. We have found that the existing data are limited with respect to the identification of specific modes of transmission in the natural setting. However, we are able to conclude that transmission occurs at close range rather than over long distances, suggesting that airborne transmission, as traditionally defined, is unlikely to be of significance in most clinical settings. Further research is required to better define conditions under which the influenza virus may transmit via the airborne route.

Infection control and pandemic influenza

If an influenza pandemic occurs, the spread of the virus should be reduced for as long as possible while an effective vaccine is produced. Influenza spreads mainly by large respiratory droplets (> 5 microm) depositing onto the mucosal surfaces of the eye, mouth or respiratory tract. Hands are another major means for spread, and are frequently contaminated by droplets. The most effective way to reduce the spread of the virus is with good infection control practices and social distancing. Infection control practices include the use of personal protective equipment (PPE), hand hygiene, and respiratory hygiene and cough etiquette. Infected people should be isolated and spatial separation observed in common areas where infected people may be present. Any practices that create aerosols (eg, nebulisation) should be avoided, unless performed with appropriate precautions, especially with all people in the room wearing appropriate PPE. Now is the time to re-examine all our current practices so that we are better prepared, well practised and have good infection control practices in place for all transmissible respiratory infections.

Vaccination contre la grippe: résultats d'une enquête sur la couverture vaccinale du personnel hospitalier à l'hôpital de la Croix-Rousse (hôpitaux de Lyon)

INTRODUCTION

The aim of this study was to evaluate the vaccinal status among Croix-Rousse Hospital workers, attitude towards this vaccination, and the information delivered in order to promote this vaccination.

METHODS

Questionnaires were delivered by electronic mailing.

RESULTS

Six hundred (and) twenty-nine questionnaires were analyzed (26.7% of hospital workers); 30.7% of responders were vaccinated against influenza, 89.2% of responders were aware of influenza and vaccine. Vaccine coverage was lower in younger workers, non health-care workers, non physician health-care workers, and surgeons who responded. Motivation and reserve varied according to the status, position, and age, with some discrepancies.

CONCLUSION

These results suggest implementing a better targeted vaccination campaign, according to the various categories of personnel.

Influenza vaccination among healthcare workers in a university children's hospital

OBJECTIVES

To evaluate the attitudes of pediatric healthcare workers (HCWs) toward influenza vaccination and to increase their rate of immunization.

METHODS

A survey was conducted among pediatric HCWs using an anonymous questionnaire. Survey results were used to design an intervention to increase the immunization rate of staff. Immunization rates before (2003-2004) and after (2004-2005) intervention were assessed using immunization clinic records.

SETTING

A university children's hospital in Switzerland.

INTERVENTIONS

(1) An informational letter based on misconceptions noted in the survey, (2) educational conversations with head nurses, (3) more "walk-in" immunization clinics, and (4) a direct offer of influenza immunization on the wards.

RESULTS

Among vaccine nonrecipients, doubts about the efficacy and necessity of influenza immunization were prevalent and more often reported by nurses than physicians (75% vs 41%, P = .002; and 55% vs 23%, P = .001, respectively). Physicians more often than nurses reported lack of time as a reason for not receiving influenza vaccination (23% vs 5%, P = .01). After intervention, the immunization rate of HCWs increased from 19% to 24% (P = .03). The immunization rate of physicians increased from 43% to 64% (P = .004). No change was noted among nurses (13% vs 14%) and other HCWs (16% vs 16%).

CONCLUSIONS

Misconceptions about influenza vaccination were prevalent among pediatric staff, particularly nurses. Active promotion and educational efforts were successful in increasing the immunization rate of physicians but not nurses and other HCWs.

Influenza in the neonatal intensive care unit

Influenza has historically been an uncommon illness in the newborn period, although epidemic outbreaks in neonatal intensive care units have been described. There is currently significant concern about the possibility of a new pandemic of influenza in the near future. During a pandemic neonates are likely to be exposed, with significant illness more likely in pre-term newborns due to reduced levels of passively transferred protective maternal antibodies. While newer therapies have been shown to be effective in reducing the severity of illness in adults and children, such therapies are untried in neonates. Supportive care and measures to contain and prevent spread of infection may well be the most important measures in the event of a neonate acquiring influenza, including the avian variety.

Clinical and epidemiologic characteristics of viral infections in a neonatal intensive care unit during a 12-year period

BACKGROUND

The incidence of viral infections in patients treated in the neonatal intensive care unit (NICU) is not well-known. We summarized the data of all patients with laboratory-confirmed viral infections admitted at the NICU of our hospital during the period of 1992-2003.

OBJECTIVES

To determine the incidence of viral infections among infants hospitalized in a NICU, the associated clinical manifestations and their outcome.

METHODS

Retrospective analysis of epidemiologic, virologic and clinical data from infants with proven viral infection. The diagnosis viral infection was confirmed by positive viral culture and/or polymerase chain reaction from clinical samples.

RESULTS

Viral infection was confirmed in 51 of 5396 infants (1%) admitted to the NICU; 20 (39%) had an enterovirus and parechovirus (EV/PEV) infection, 15 (29%) a respiratory syncytial virus (RSV) infection, 5 (10%) a rotavirus infection, 3 (6%) a cytomegalovirus (CMV) infection, 2 (4%) an adenovirus infection, 2 (4%) a parainfluenza virus infection, 2 (4%) a herpes simplex virus infection, 1 (2%) a rhinovirus infection and 1 (2%) a rubella virus infection. Three of the infants presented at birth with symptomatic rubella virus, CMV or herpes simplex virus infection. RSV infection developed mostly in hospitalized infants (60%), and 93% of infections occurred during the winter (November-March). The clinical presentations of EV/PEV disease were sepsis-like illness, prolonged seizures in term infants and gastrointestinal disease in preterm infants. RSV, parainfluenza virus, rhinovirus and CMV caused respiratory disease, predominantly in preterm infants. Gastrointestinal disease was seen only in preterm infants with adenovirus, rotavirus or EV/PEV infection. Mortality and serious sequelae were high in patients infected with EV/PEV (10 and 15%, respectively).

CONCLUSIONS

The incidence of viral infection in the NICU was 1%. Enteroviral infections were the most frequently diagnosed infections, occurred often in term infants born at home and presented with sepsis-like illness or seizures. Preterm infants hospitalized from birth mainly developed gastrointestinal disease caused by rotavirus and adenovirus infection or respiratory disease caused by RSV, parainfluenza and CMV infection. Enteroviruses were responsible for the highest mortality and development of serious sequelae.

Use of a mobile cart influenza program for vaccination of hospital employees

OBJECTIVE

Rates of annual influenza vaccination of healthcare workers (HCWs) remained low in our university hospital. This study was conducted to evaluate the impact of a mobile cart influenza vaccination program on HCW vaccination.

METHODS

From 2000 to 2002, the employee health service continued its annual influenza vaccination program and the mobile cart program was implemented throughout the institution. This program offered influenza vaccination to all employees directly on the units. Each employee completed a questionnaire. Vaccination rates were analyzed using the Mantel-Haenszel test.

RESULTS

The program proposed vaccination to 50% to 56% of the employees. Among the nonvaccinated employees, 52% to 53% agreed to be vaccinated. The compliance with vaccination varied from 61% to 77% among physicians and medical students and from 38% to 55% among nurses and other employees. Vaccination of the chief or associate professor of the unit was associated with a higher vaccination rate of the medical staff (P < .01). Altogether, the vaccination program led to an increase in influenza vaccination among employees from 6% in 1998 and 7% in 1999 before the mobile cart program to 32% in 2000, 35% in 2001, and 32% in 2002 (P < .001).

CONCLUSIONS

The mobile cart program was associated with a significantly increased vaccination acceptance. Our study was able to identify HCW groups for which the mobile cart was effective and highlight the role of the unit head in its success.

Improving influenza immunization rates among healthcare workers caring for high-risk pediatric patients

OBJECTIVE

To assess influenza vaccination rates of healthcare workers (HCWs) in neonatal intensive care units (NICUs), pediatric intensive care units (PICUs), and oncology units in Pediatric Prevention Network (PPN) hospitals.

PARTICIPANTS

Infection control practitioners and HCWs in NICUs, PICUs, and oncology units.

METHODS

In November 2000, posters, electronic copies of a slide presentation, and an influenza fact sheet were distributed to 32 of 76 PPN hospitals. In January 2001, a survey was distributed to PPN hospital participants to obtain information about the immunization campaigns. On February 7, 2001, a survey of influenza immunization was conducted among HCWs in NICU, PICU, and oncology units at participating hospitals.

RESULTS

Infection control practitioners from 19 (25%) of the 76 PPN hospitals completed the surveys. The median influenza immunization rate was 43% (range, 12% to 63%), with 7 hospitals exceeding 50%. HCWs (n = 1123) at 15 PPN hospitals completed a survey; 53% of HCWs reported receiving influenza immunization. Immunization rates varied by work site: 52% in NICUs and PICUs compared with 60% in oncology units. Mobile carts and PPN educational fact cards were associated with higher rates among these subpopulations (P < .001) (361 [63%] of 575 vs 236 [44%] of 541 for mobile carts; 378 [60%] of 633 vs 219 [45%] of 483 for fact cards).

CONCLUSION

Despite delayed distribution of influenza vaccine during the 2000-2001 season, immunization rates at 7 hospitals and among HCWs in high-risk units exceeded the National Association of Children's Hospitals and Related Institutions goal of 50%.