This transcript has been edited for clarity. For more episodes, download the Medscape app or subscribe to the podcast on Apple Podcasts, Spotify, or your preferred podcast provider.
Forest W. Arnold, DO, MSc: Hello. I am Dr Forest Arnold. Welcome to Season 2 of the Medscape InDiscussion podcast series "RSV in Adults." Today we'll discuss preventing respiratory syncytial virus (RSV) outbreaks within healthcare facilities, and strategies to minimize transmission of RSV among healthcare workers and patients during an outbreak. First, let me introduce my guest: Dr Hannah Nam, assistant professor of medicine at UC Irvine, and director of transplant and immunocompromised hosts infectious diseases. Welcome to the Medscape InDiscussion podcast.
Hannah H. Nam, MD, MS: Thank you so much for inviting me here to talk about my favorite topic.
Arnold: The aim of today's podcast will be to go over two themes: providing strategies for healthcare professionals to prevent RSV outbreaks, and managing active RSV outbreaks. On a scale of 1 to 10, how big of an issue is RSV in healthcare facilities?
Nam: I think it's very underappreciated in terms of its impact. I would say 10, since RSV is my research area and my favorite topic to talk about.
Arnold: Excellent. What is the impact of RSV on healthcare facilities, their patients, and healthcare workers?
Nam: RSV is an interesting infection in that it really tends to affect the most vulnerable in our population. The risk factors for developing really bad disease when you get RSV tend to be older age, compounded by comorbidities such as chronic heart disease, lung disease, weakened immune system, frailty, and mobility issues. Of course, these are the patients that we're talking about today — those patients that are in healthcare facilities. For example, if you look at 2022 and 2023, when we had a huge RSV outbreak, the CDC-based RSV-NET put out data showing that out of all of those who were over 60 and hospitalized with RSV, about 17% were in long-term care facilities. RSV tends to be a pretty big issue in those residing in long-term care facilities, but I don't think it gets the proportional attention that it deserves.
Arnold: You mentioned that it's underappreciated, because we have such a high hospitalization rate. There's frequency and severity. It's communicative. Could you discuss the key infection-control measures for healthcare professionals to implement?
Nam: Some of the things to understand regarding measures to implement for RSV go back to how it gets transmitted. We've heard a lot about different isolation methods as well as different methods we can implement with COVID. We're also very familiar with these methods for influenza. RSV is a little different from these two viruses in how it transmits. RSV is a larger virus than both of these — about double the size of flu and COVID, and how it transmits is not primarily through aerosolization or coughing. Of course, some of those methods contribute to the transmission, but because it's such a large droplet, it tends to fall and sit on surfaces, and it can live on hard surfaces such as doorknobs for many hours. The primary mode of transmission for RSV tends to be contact, which is why you'll see isolation guidelines that incorporate contact as well as standard precautions, plus or minus the droplet component. This means that for healthcare workers to prevent transmitting RSV, one of the more important methods is to ensure that they're performing good hand hygiene, as well as making sure that all surfaces that the patient is touching are sterilized very well. For example, the patient just touching doorknobs or table surfaces after touching their face can transmit the virus pretty effectively. Healthcare workers then touch these surfaces, and environmental workers as well, who help clean the areas. Handwashing and contact precautions are much more important for RSV than for the other respiratory viruses.
Arnold: This is an area that is not underappreciated; it's just not known. I don't think that, because it's a larger molecule, we have a different mode of communication, and that's contact vs aerosolization. In your opinion, what are the most effective infection-control measures to prevent RSV outbreaks? I can only imagine that it's going to be based on what you just said, that contact plays heavily into this.
Nam: With any effective management strategy for infections in general, there usually have to be several components implemented at the same time. The key concepts for any outbreak, including RSV, are to identify the virus, isolate, and then inform all parties that are involved. Identifying includes facilities being aware of any viruses that are circulating in the community at the moment. Especially with RSV, it tends to go hand in hand with influenza, and for the past couple of years, with COVID as well. Facilities need to be aware of community circulation, and then educate all staff, including housekeeping and dietary, and any staff that interact with residents. After identifying the virus flow in the community, all facilities should be aware of increasing surveillance for that virus in general; and because increasing surveillance helps monitor for any increase in cases in residents and staff, it's really important that facilities do this. Another thing that's not done, but is really important, is identifying the pathogen. We have a lot of rapid tests being done for influenza as well as COVID. A lot of facilities have switched to using triplicate multiplexes — influenza, RSV, and COVID all together — but identifying RSV is really important here because the personal protection that you're going to use is completely different from that for COVID and influenza, in the sense that you're going to have a much higher focus on the contact precaution.
Arnold: You mentioned a contrast to influenza and COVID with RSV. With those other two viruses, healthcare workers usually get vaccinated and so do patients. With RSV, only patients get vaccinated. Will that have an impact on RSV outbreaks in facilities?
Nam: That's a really interesting question in that I don't think we necessarily know how well the RSV vaccine works in preventing transmission because all of the studies that were done with RSV have been done in patients who are going to be impacted by the RSV, and all of the studies have basically been empowered to show the decrease in symptoms with RSV. I do think that's going to be an area that's important for research. What we do know, extrapolated from the other viruses, is that vaccination has been an important strategy for healthcare workers to prevent transmission, so I do imagine that it will be similar for RSV. We just don't have great data to say that RSV vaccination is essential for healthcare workers in preventing transmission. On the flip side, you mentioned that RSV vaccination for patients prevents infection in patients, which is very true. What we still have to work on a lot is vaccinating the patients to begin with, because if you look at recent data for vaccine uptake for RSV, I think it shows that only about 20% of eligible adults have received the vaccine to begin with.
Arnold: We give influenza vaccine and then we've seen in studies that those patients that end up getting influenza will have less severe disease because they've been vaccinated. Do we expect that with RSV as well?
Nam: Yes. The RSV vaccine was looked at in terms of how well it decreases symptoms in patients over 60 years old. There are two separate vaccines that were approved last year that we're talking about. One of them is an adjuvanted vaccine; that has been effective at decreasing lower respiratory tract symptoms for patients over 60, in about 80% within the first RSV season. Then if you look at two seasons total, 2 years total aggregate, it's about 75% effective. The contrasting vaccine, which also was looked at in patients over 60 years old, showed that it was pretty effective in decreasing symptomatic infection with lower respiratory tract disease, at about 89%. Then if you look at two seasons, it was still about 85% effective. So the vaccine is pretty effective in decreasing symptoms over at least 2 years, which is how much data we have.
Arnold: Great. It sounds like the RSV vaccine is mainly to prevent RSV in whoever's immunized and it only indirectly prevents transmission of the virus, because it's obviously hard to spread it if you don't have it in the first place. Both are very good reasons to get the vaccine in the first place, to prevent our vulnerable populations from getting it. Two other things that we've discussed so far that are important is that RSV affects the most vulnerable populations — older adults, those with comorbidities, those who are frail and have mobility issues — and that we appreciate that RSV is different from influenza or COVID, especially in molecular size, making it not airborne as much as it is transmitted through contact. Let's move on to talking about outbreaks. Could you provide an overview of effective management strategies during RSV outbreaks for minimizing RSV transmission among healthcare workers and patients?
Nam: A lot of the strategies that work for outbreak management tend to be multicomponent and multifactorial. The first is, again, identifying that the pathogen you're dealing with is RSV. Testing early and then knowing that you have RSV is really important. This is especially important because RSV tends to co-circulate with influenza and COVID, as we've seen in the past couple of years, and if you just look at symptoms, they're completely indistinguishable; you can't tell whether you have RSV or flu or COVID just by symptoms. Knowing that you're dealing with RSV to begin with is most important. Also really important is understanding what resources you have and how to allocate those resources appropriately — understanding what kind of personal protective equipment you have, how much hand hygiene supplies you have, like gloves, etc. The other component is making sure that everyone is educated regarding RSV. This includes the patients themselves, but also visitors as well as healthcare workers, on what RSV is, how it transmits — especially through contact — and making sure that hand hygiene is really emphasized. Then, monitoring patients is important, because even one patient with RSV in a large facility, especially in grouped or long-term care facilities, can potentially mean that you're going to have other patients with RSV, especially if they were using common areas or sharing a room with other patients. Monitoring other patients as well as the healthcare workers, and taking care of the patients, are really important. Unfortunately there's no good treatment for RSV, what we call chemoprophylaxis — basically, giving patients medications to prevent RSV spread — but there's a lot of supportive care that we can offer to patients. So, it's about making sure that they have those appropriate treatments and then watching for symptoms to make sure they don't get worse. All of those are very important strategies to use together.
Arnold: You mentioned healthcare workers and patients being educated. You also mentioned visitors, which is a group of people I think are sometimes neglected. I'll see nurses and doctors washing their hands and wearing the proper isolation, and, of course, patients doing our protocols when they take the patient to, say, radiology. But visitors — sometimes I'll walk in and it's like they've ignored every sign on the door. Are they an exception or not?
Nam: No, of course not! Educating visitors is really, really important, especially because it's really easy for visitors to bring in RSV unknowingly to their loved ones while they're seeing them. But it's also very easy for them to carry it out. If the visitors are also using common areas where patients or others congregate, then it's potentially a source of transmission. I think it's very important that visitors also know what infection their loved one has, as well as how to prevent it from spreading.
Arnold: Exactly. We tend to selfishly want to protect ourselves, but we can bring our patients, and visitors can bring their loved ones, RSV unknowingly. Then they've got whatever ailment they came to the hospital with, whether it's a heart attack or pneumonia, and now they've got RSV on top of it. It's a catastrophe when that happens, especially because they're already sick and will probably respond worse than if they had been in their usual state of health prior to getting RSV.
Nam: I completely agree. We know with RSV that the more comorbidities you have, the more underlying issues you have, the worse the illness and the outcomes tend to be.
Arnold: What about isolation protocols? Do you have a comment about those?
Nam: For isolation protocols, it's twofold. One is in the setting of an outbreak. If you know that the patient potentially has RSV, the best isolation protocol, if resources provide, is to move that patient into a single-person room and hopefully minimize the risk for transmission to other roommates. The isolation protocols that are recommended by the CDC are standard and contact, and then plus or minus droplet, depending on the facility that you're at. But if you are at a facility that really doesn't have the resources to place the patient in a single room, the recommendation is to not move them and not place them in a new room with a new resident, unless you know that the other resident also has confirmed RSV. The other things that you can do, if you're not able to isolate the patient into a single room, is consider placing the beds further apart — at least 3 feet of separation between the two beds — and also make sure that the patients are not sharing any resources. So, not sharing any table surfaces or any common resources, if possible, until you know that the roommate is safe as well.
Arnold: Right. So if you have a large population with RSV, cohorting should be something that facilities consider doing.
Nam: I do think that based on their illnesses, cohorting is something that you should definitely consider doing, especially if you know that everyone has RSV for sure. That's where the testing and then knowing that they have RSV — the diagnosis — is really important. When you do a test for RSV, it's really important to know that they're negative for influenza or COVID, because we have seen co-infections with these viruses too.
Arnold: With COVID, we had a lot of talk about asymptomatic carriers. Is that an issue with RSV?
Nam: Absolutely, yes. With RSV, the symptoms start to show up about day 4-6 after you get infected. It's several days after you've been exposed that you start to show symptoms, and patients can be contagious for a day or two even before they start to show signs of illness. Unfortunately, asymptomatic transmission is a problem with RSV. The other group of patients that can be transmitting the infection asymptomatically are those with severe immunocompromise; we know that they can shed the virus for up to 4 weeks, and it can be transmitted with that shedding and after they've recovered from their symptoms as well.
Arnold: To summarize our discussion on the treatment of outbreaks, you mentioned that we have to identify the pathogen. That's very important. We have to understand our own resources when we're in a facility, and then we're going to end up applying multifactorial strategies all at the same time. It's also important to have healthcare workers, patients, and visitors educated about RSV before they come to the patient's bedside. This will help diminish transmission and help prevent RSV from entering facilities as well.
Today we talked to Dr Nam about RSV in adults, preventing RSV outbreaks within healthcare facilities, and strategies to minimize transmission of RSV among healthcare workers and patients during an outbreak. Thank you for tuning in. Please take a moment to download the Medscape app to listen and subscribe to this podcast series on RSV in adults. This is Dr Arnold for the Medscape InDiscussion podcast.
Listen to additional seasons of this podcast.
Resources
Respiratory Syncytial Virus Infection
Respiratory Syncytial Virus Hospitalization Surveillance Network (RSV-NET)
CDC - Healthcare Providers: RSV Vaccination for Adults 60 Years of Age and Over
Respiratory Syncytial Virus (RSV) Vaccine, Adjuvanted (Rx) – Arexvy
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Cite this: RSV and Healthcare Facilities: Preventing Outbreaks and Minimizing Transmission With Education, Testing, and Cohorting - Medscape - Apr 03, 2024.
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