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| Volume 1, Issue 9 | OCTOBER 2002 |
| Inside This Issue | |||||
| 1 | Respiratory Syncytial Virus | ||||
| 2 | Updates and Announcements | ||||
Medical Information Fact Sheet
Respiratory Syncytial Virus (RSV):
RSV is a labile paramyxovirus that produces characteristic fusion of human cells in tissue culture-the Syncytial effect. Two subtypes, A and B, have been identified. Subtype B is an asymptomatic strain of the virus that most of the population experiences. Subtype A is most predominate in outbreaks and generally more clinically severe.
RSV affects the upper and lower respiratory tracts, but is most prevalent in the lower respiratory illnesses such as pneumonia and bronchiolitis. RSV bronchiolitis is one of the most severe illnesses and is associated with signs and symptoms of small airway obstruction which can be detrimental to small children with smaller airways. It is important to know the signs and symptoms associated with bronchiolitis so it may be recognized before it becomes life threatening.
RSV is one of the most common causes of pneumonia in young children. The incidence is greatest from birth to age three.
Risks:
The National Center for Infectious Disease and the Center for Disease Control (CDC) recommend that during RSV season, providers should consider RSV as a cause of acute respiratory illness in adults and children. Pneumonia and bronchiolitis are the most common types of respiratory illness and are most prevalent in children ages 2-6 months. However any age child with an underlying cardiac or pulmonary disease whom are immunocompromised (decreased immune system function) are at risk for serious complications from a RSV infection.
Other factors contributing to increased risk of RSV infection include:
- Premature infants and infants less than 6 weeks of age
- Infants with congenital heart disease
- Infants with chronic lung conditions including Bronchopulmonary dysplasia (BPD) and cystic fibrosis
- Immunodeficiency (decrease immune system function)
- Lower socioeconomic status and crowded living conditions
- Exposure to passive cigarette smoke
- Attendance in day care setting
- Presence of older siblings in the home
- Infants who are not breastfed
Distinct symptoms of RSV bronchiolitis include:
- Runny nose (rhinorrhea)
- Wheezing and coughing (can last several months in severe cases)
- Irritability and restlessness (usually in those with impending respiratory failure)
- Low grade fever (102°F); but can be as high as 104° if concurrent illness such as otitis media is present.
- Nasal flaring and refractions are indicative of airway obstruction. The chest may expand more than usual therefore displacing some organs downward making it possible to feel them at a location below where they may be normally found (i.e. the liver and spleen).
- X-rays findings are not indicative of disease, but often show air trapping and hyperinflation or appear normal.
- Apnea, usually as an initial presenting symptom in short episodes. It occurs in 20%-25% of young infants.
- Nail bed cyanosis (blue discoloration of fingernails due to lack of oxygen) in severely affected infants.
Symptoms usually resolve in 5-7 days. However this time frame does not exclude the patient from being classified as "severely infected" and patients with underlying illness or disease states should be considered for early treatment with an antiviral such as Virazole (See Treatment for further information on these medications).
For confirmation of RSV, proper testing of the patient's respiratory secretions will positively identify RSV and rule out bacterial infection. Definitive diagnosis is based on detection of virus or viral antigens in respiratory secretions. Antigens are specific proteins on cells that identify the cell as self or non-self, and identify the type of cell (e.g. skin, kidney). Therefore the best way to identify RSV is to use rapid diagnostic tests that look at antigen detection (direct antigen tests). The results are produced in hours, therefore allowing early detection and early appropriate treatment.
X-rays are not typically used in diagnosing RSV infection but they have been used to determine the severity of the illness.
Outbreaks of disease caused by RSV occur on a yearly basis, mostly during winter months, with epidemics lasting five months.
RSV is easily transmitted by respiratory droplets from coughing or sneezing or through contact with nasal secretions, and may even be transmitted indirectly by contact with contaminated objects, such as bathroom fixtures or clothing. The eyes and nose are the most common site of access for the virus to get in the body.
Since RSV is relatively easy to transfer through casual contact, family members often pass it on to one another. Hospital staff are also frequent method of transmission. A simple way to prevent spreading the disease is through hand washing.
Another factor that makes the spread of RSV unavoidable is the period of viral shedding (release of the virus from the infected person). Viral shedding may occur one to two days before symptoms appear and can last as long as two weeks after onset of symptoms. This means that the infected person is spreading the virus to others before they know they are sick and for an extended period after they have symptoms. The period is greater and prolonged for children who are immunocompromised. The incubation period is generally three to five days for most people. Incubation in the interval between time of exposure to infection and appearance of first symptom.
Since the virus can be transmitted before symptoms appear and continue after onset of symptoms it is important to know the risk factors as well as timing of the RSV infection season. This will help physicians to decide to test for RSV and subsequently manage the illness at its earliest stages.
It is necessary to relieve symptoms and reduce likelihood of long term illnesses caused by RSV.
Treatment of mild cases is focused on relieving symptoms: cough and cold medicines and bronchodilators such as metaproterenol or albuterol help to relieve chest congestion and wheezing. Other studies suggest that using epinephrine and ipratropium bromide may have a clinical role in the management of acute bronchiolitis.
For more severe cases hospitalization and antiviral therapy may be indicated.
Treatment at home manages RSV infection by controlling symptoms and making the patient comfortable.
For respiratory/breathing difficulties:
- Air temperature between 70 & 72 degrees so the air is not overly dry
- No smoking near patient
- Mist treatment is not recommended as it may do more harm than good
For nasal obstruction:
- Frequent and vigorous nasal suctioning of secretions will keep nasal airway clear and reduce infant fatigue from trying to breath through a mucous obstruction
- Saline nose drops can be used to loosen mucous in the nose. Petroleum jelly may soothe irritated nostrils
For dehydration:
- Maintain fluids, as fever and tachypnea (increased respiratory rate) predispose to dehydration
For fever:
- Use non-aspirin medications such as acetaminophen
When is hospitalization necessary?
Parents should be advised to contact their physician if any of the following is present in their child:
- Fever over 101 degrees
- Thick nasal discharge that is yellow, green or gray
- Cough that lasts more than four days
- Cough that produces yellow, green or gray mucous
- Chest pain
- Difficulty breathing
- Rapid breathing
- Bluish or gray color of the lips, skin or fingernails
- Reduced alertness
In these cases, the patient may need to be hospitalized and treatment with antivirals may be indicated. In the hospital, the patient may receive one or more of the following treatments:
- Pulse oximetry-measures oxygen levels in the blood. If oxygen levels are less than 95%, humidified oxygen may be delivered by mask, tent or nasal tubing
- I.V. fluids to battle dehydration
- Vigorous suctioning of nasal secretions
- Viral medications such as Virazole
- Mechanical ventilation for those with impending respiratory failure
Virazole is the only approved antiviral treatment for RSV. Virazole is only given in hospitals for treatment of severe RSV infection. It is given by means of an aerosol generator. The machine distributes the medication through the patient's oxygen mask or tent.
To prevent infection or re-infection with RSV a Synagis injection may be given. The medication works by helping your body make antibodies to protect it against RSV infection. The medication should be given to those at risk for RSV infection. This medication focuses more on prevention of illness rather than treatment. The medication must be given monthly usually during RSV season which runs from October through May. The effectiveness of the medication may decrease if not given monthly. The child should receive the injection even if they have RSV.
If children do succumb to the infection a second time, the symptoms are much milder. Following infection with RSV does not necessarily make children more susceptible to other infections later such as pneumonia. Many children will handle their next respiratory infection with no more difficulty than the average child. A few children, however, appear to more susceptible to subsequent respiratory problems. Susceptibility may relate, however, to some other underlying medical condition or allergy.
RSV info Center. (2002, February 4). Diagnosing and Managing RSV. Retrieved on February 4, 2002 from the World Wide Web: http://www.rsvinfo.com
HCPCFC PROGRAM UPDATES and ANNOUNCEMENTS!!!
We would like to welcome back Doris Wurah. She is a Public Health Nurse that is here temporarily. While she is with us she will be covering the Metro Region.
Welcome Back Doris!!!
If anyone has any needs or questions related to the Hemet/Banning Region, please contact William Chavez, Sr. PHN.
Editor: Kristen Thompson, PHN; and Karen MacLeod, PHN
Contributors: Kim Robitaille, PHN, MSN, Assistant Nurse Manager; and Judy Earp, MHA, Director of Public Health Nursing.
