Purpose and Goal: CEARP #1093

  • Describe the risk factors for acquiring respiratory syncytial virus (RSV).
  • Identify strategies for the prevention of RSV.

None of the planners, faculty or content specialists has any conflict of interest or will be presenting any off-label product use. This presentation has no commercial support or sponsorship, nor is it co-sponsored. 

Requirements for Successful Completion

  • Successfully complete the post-test.
  • Complete the evaluation form.

Date

  • December 2013 - December 2015

Learning Objectives

  • Describe the risk factors for acquiring RSV infection.
  • Describe the detrimental effects of RSV infection.
  • Identify at least two strategies for the prevention of RSV infection.

Infection and Incidence

  • RSV is a contagious viral infection that causes respiratory illness.
  • There are two strains of RSV (RSV-A and RSV-B).
  • RSV can cause an upper respiratory infection.
    • Common cold
  • RSV can cause a lower respiratory tract infection.
    • Bronchiolitis
    • Pneumonia
  • RSV is the most common cause of bronchiolitis in infants <1 year of age.
  • RSV infection in infancy is a risk factor for long-term complications.
  • Wheezing
    • Bronchial hyperreactivity
    •  Obstructive sleep apnea
    • Asthma

Exposure

  • RSV infections generally occur during fall, winter and early spring.
    • In the United States, generally November-April
    • In western Washington state, generally December-March
  • The timing and severity of RSV can vary from year to year.
  • First time exposure
    • 25%-40% of infants will develop bronchiolitis or pneumonia.
    • 0.5%-2% will require hospitalization.
    • Most infants that are hospitalized are <6 months of age.
    • Most children have had an RSV infection by 2 years of age.

Transmission

  • Persons infected with RSV are contagious for 3-8 days.
  • Infants with weakened immune systems can be contagious for as long as 4 weeks.
  • RSV is generally spread by school-aged children.
  • RSV can be rapidly spread by coughing or sneezing.
    • RSV can be spread by direct contact with infected persons.
    • RSV can also be spread by indirect contact.
    • RSV can survive on hard surfaces for many hours.
    • RSV survives on soft surfaces for shorter amounts of time.
  • Most infants will recover within 1-2 weeks.
  • After recovery, infants continue to spread the virus for 1-4 weeks.
  • Infants that are reinfected generally have less severe illness.

Risk Factors

  • All infants are at risk of acquiring RSV infection.
  • Some infants are at higher risk.
  • Demographic factors
    • Premature birth
    • Male gender
    • Low birth weight for age
    • <12 weeks at start of RSV season
    • Twins or higher multiples
  • Clinical factors
    • Chronic lung disease
    • Congenital heart disease
    • Cystic fibrosis
    • Down syndrome 
    • Neuromuscular disease
    • Immunodeficiency
    • Congenital malformations
  • Environmental factors
    • Daycare attendance
    • School-age siblings
    • Crowded home environment
    • Sharing a bedroom
    • Lack of breastfeeding
    • Tobacco smoke exposure
    • Use of wood-burning stoves
    • Nosocomically acquired RSV 

Symptoms

  • Most infants will show symptoms 4-6 days after exposure.
  • Primary symptoms
    • Runny nose
    • Decreased appetite
  • Secondary symptoms
    • Coughing
    • Sneezing
    • Fever
    • Wheezing
  • Symptoms in very young infants
    • Irritability
    • Decreased activity
    • Breathing difficulties
      • Apnea
      • Cyanosis

Treatment

  • There is no specific treatment for RSV.
  • Supportive care is the most common approach.
  • For severe symptoms:
    • IV hydration
    • Supplemental oxygen
    • Frequent suctioning
    • Intubation and mechanical ventilation 

Prevention

  • There are currently no vaccines to prevent RSV infection.
  • Frequent hand washing is most important.
  • Frequent washing of hard surfaces
  • Frequent washing of toys and bedding
  • Minimize spread if family member is infected.
    • Infected persons should minimize contact with infant.
    • Visitors should be restricted during RSV season.
  • Limiting time spent in daycare can be beneficial.
  • Synagis prophylaxis can help prevent serious illness.

Synagis Prophylaxis

  • Synagis (palivizumab) is a monoclonal antibody.
    • Provides antibody protection against RSV
    • Decreases risk of serious RSV infection
    • Reduces hospitalizations due to severe RSV illness
    • Given monthly as an IM injection during RSV season
    • Missing or delaying a dose increases risk of infection.
  • American Academy of Pediatrics Guidelines
    • Infants born at or before 28 weeks' gestation and younger than 12 months of age at the start of RSV season (5 doses)
    • Infants born at 29-32 weeks' gestation and younger than 6 months of age at the start of RSV season (5 doses)
    • Infants born at 32-35 weeks' gestation and younger than 3 months of age at the start of RSV season (up to 3 doses) if they:
      • Will be attending daycare
      • Have a sibling younger than 5 years of age
    • Infants born at or before 35 weeks' gestation and younger than 12 months at the start of RSV season (5 doses) if they:
      • Have a congenital abnormality of the airways
      • Have a congenital neuromuscular disease that compromises handling of respiratory secretions
    • Infants and children younger than 24 months of age with cyanotic or complicated congenital heart disease (5 doses)
      • Especially if they are on medication for CHF
      • Especially if they have pulmonary hypertension
    • Infants and children younger than 24 months of age who have been treated for chronic lung disease within 6 months of the start of RSV season (5 doses)

Parent Education

  • Teach proper hand hygiene.
  • Discuss benefits of breastfeeding.
  • Discuss importance of avoiding tobacco smoke.
    • Direct exposure
    • Secondhand exposure
  • Discuss importance of avoiding crowds.
  • Discuss importance of avoiding travel.
  • Review measures to prevent spread of RSV.
    • Daycare environment
    • Pediatrician office environment
    • Home environment
    • Avoiding infected persons
  • Review Synagis prophylaxis for qualified infants.
    • Provide written information.
    • Enroll infant in Synagis prevention program.

References

  1. Bracht, M., Basevitz, D., Cranis, M., Paulley, R. & Paes, B. Practical Resources for Nurses and Other Health Care Providers Involved in the Care of Children at Risk for Respiratory Syncytial Virus Infection. 2012. Neonatal Network. 31 (6), p 387-392.
  2. Bracht, M., Heffer, M., & O'Brien, K. Preventing RSV Infection. 2005. Advances in Neonatal Care. 5(1), p. 50-51.
  3. Bracht, M., Basevitz, D., Cranis, M., Paulley, R. & Paes, B.Strategies for Reducing the Risk of Respiratory Syncytial Virus Infection in Infants and Young Children. 2012. Neonatal Network, 31 (6), p.357-368.
  4. CDC Guidelines: Respiratory Syncytial Virus Infection
  5. American Academy of Pediatrics Clinical Practice Guideline: Diagnosis and Management of Bronchiolitis
  6. RSV Info Center: Respiratory Syncytial Virus

Test and Evaluation

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