Table 3.
Effectiveness of infection control measures in preventing nosocomial RSV transmission to patients, ordered by intervention type
| Author, publication year | Intervention type | Interventiona | Control | Transmission risk in intervention group (patients)b | Transmission risk in control group (patients)b | Statistics (e.g. risk ratio, rate ratio, P‐value) |
|---|---|---|---|---|---|---|
| Garcia, 199754 | Multicomponent | Multifaceted infection control strategy including screening of symptomatic patients, isolation, cohorting, gloves and masks, screening and restriction of visitors, staff screening, staff training | Pre‐intervention – Ward A: contact precautions (use of disposable gloves and gowns when caring for RSV patients). Ward B: protected environment with laminar airflow rooms, reverse isolation and no visitors | 1·4% | 6·3% | Risk ratio in control versus intervention periods: 4·5 (95% CI: 1·5–13·5, P < 0·01) |
| Hall, 197851 | Multicomponent | Isolation or cohorting of symptomatic infants, handwashing, gowns (for staff attending infants with respiratory symptoms), staff cohorting, isolation of high‐risk infants, limitation of visitors | Data from a previous study in the same hospital used as a comparison group. During this previous period, infants were on a large open ward with symptomatic infants confined to their cubicles. Movement of staff and visitors between cubicles was not limited. Handwashing and gowns were supposed to be employed but were not monitored. Other infection control procedures were not routinely utilised | 19% | 45% | Risk in infants during intervention versus control period: P < 0·01 |
| Isaacs, 199116 | Multicomponent | Admissions with suspected RSV placed in a separate screened‐off area, staff cohorting, handwashing including alcohol rub, parents/visitors instructed on handwashing told to keep older siblings with colds away from play areas, staff instructed on importance of handwashing, reinforced on ward rounds | ‘Standard procedures’ which included gowns for nurses but no cohorting or educational programme to emphasise the importance of handwashing to staff and visitors | Period 2 (post‐intervention): 0·59%, Period 3 (post‐intervention): 1·1% | Period 1 (pre‐intervention): 4·2% | Authors state: ‘The difference between the first and second periods (P < 0·001) and between the first and third periods (P < 0·01) was significant, but not between the second and third periods (P = 0·5)’ |
| Karanfil, 199956 | Multicomponent | Two‐stage control plan: Stage 1 begins when the first RSV case of the season is admitted to the centre – guidelines sent to all staff and samples sent for RSV culture for any children <2 years admitted with bronchiolitis or pneumonia. Pending laboratory results, the child is placed on paediatric droplet precautions (isolation and gloves for anyone entering the patient's room plus masks and gowns for close patient contact). Stage 2 begins when the 5th patient hospitalised from the community is identified – all children <2 years with any respiratory symptoms are placed on droplet precautions and tested for RSV | Gowns and gloves for patient contact. Private room not required | During the two seasons after implementation of the control programme: 7·2% (95% CI: 4·1%‐10·2%) of RSV cases were nosocomially transmitted | During the 2 seasons before the control programme: 16·5% (95% CI: 10·7–22·2%) of RSV cases were nosocomially transmitted | P = 0·002, uncorrected χ2. Authors also note ‘The control program's success also has been sustained during the 6 years it has been in place. A χ2 test for trend shows a continued decrease in the proportion of cases nosocomially acquired when the six RSV seasons after the intervention are compared with the average of the 2 years before the control program (P < 0·0001)’ |
| Krasinski, 199046 | Multicomponent | Rapid RSV screening and assignment to a cohort at admission for all patients. Restricted visitation. Gowns used for patient contact when soiling was likely. Staff infection control memoranda/education. Gloves/masks were not used | No routine RSV screening on admission, category‐specific isolation practices | January–April 1987 (with screening): 1·23 cases per 1000 patient‐days, and September 1987–April 1988 (with screening): 0·46 per 1000 patient‐days | November–December 1986 (before screening programme): 7·17 cases per 1000 patient‐days | P‐value comparing January–April 1987 (intervention) with November–December 1986 (control): 0·026; and comparing September 1987–April 1988 (intervention) to November–December 1986 (control): 0·007 |
| Langley, 199752 | Multicomponent | Study compares data for 9 different centres with different infection control measures. All centres isolated RSV‐positive patients in single rooms or cohorted them. Centre 1: gowns (for direct patient contact), gloves (for direct patient contact), masks (for direct patient contact); Centre 2: gowns (for anyone entering room), gloves (for direct patient contact), masks (if aerosolised ribavirin being administered); Centre 3: gowns (for direct patient contact), no gloves, masks (for direct patient contact); Centre 4: gowns (for direct patient contact), no gloves, masks (if aerosolised ribavirin being administered); Centre 5: gowns (for direct patient contact), gloves (for direct patient contact), masks (for direct patient contact); Centre 6: gowns (for direct patient contact), gloves (for direct patient contact), masks (for anyone entering room); Centre 7: gowns (for anyone entering room), gloves (for direct patient contact), masks (if aerosolised ribavirin being administered); Centre 8: gowns (for direct patient contact), gloves (for direct patient contact), masks (if aerosolised ribavirin being administered); Centre 9: gowns (for anyone entering room), gloves (for direct patient contact), masks (for anyone entering room, only if aerosolised ribavirin being administered) | Note: There is no single control group. Please see details of the various intervention groups (previous box) | Nosocomial ratio (i.e. number of nosocomial RSV cases/all RSV cases): Centre 1: 3·8; Centre 2: 8·8; Centre 3: 5·5; Centre 4: 5·0; Centre 5: 3·2; Centre 6: 2·8; Centre 7: 9·0; Centre 8: 7·8; Centre 13·0 | Note: There is no single control group. | Authors state: ‘No isolation policy was associated with decreased nosocomial ratio, although gowning for any entry to the patient's room was associated with increased risk of RSV transmission (incidence rate ratio: 2·81; 95% confidence interval: 1·65,4·77; P < .000) in the multivariate Poisson’ |
| Macartney, 200048 | Multicomponent | Early recognition of patients with respiratory symptoms (high index of suspicion, laboratory testing), patient isolation where possible (otherwise patients were cohorted), staff cohorting, contact precautions for all patients with symptoms of viral respiratory tract infection (handwashing, gowns and gloves for staff), visitation restrictions, staff education and compliance monitoring | Methods used for prevention of RSV varied among patient care units. Screening of patients for RSV infection occurred; however, the use of barrier methods for isolation and cohorting of patients and nursing staff was inconsistent | 0·73 cases per 1000 hospital days at risk | 0·98 cases per 1000 hospital days at risk | Mantel–Haenszel relative risk in post‐intervention versus pre‐intervention period, stratified by intensity of exposure: 0·61 (95% CI: 0·53–0·69) |
| Madge, 199218 | Multicomponent | All children screened within 18 hours of admission during the three RSV seasons. Cohort nursing and/or gloves and gowns (for all contacts with patients) | All children screened within 18 hours of admission during the three RSV seasons. No special precautions (handwashing after all contacts and gowns/gloves for contact with bodily fluids) | Gowns/gloves (winter 1/2): 28%, Cohort nursing (winter 1/2): 19%, Cohort nursing/gowns/gloves (winter 1/2): 3% | 26% | Authors state ‘Nosocomial transmission rate was significantly reduced by the combination of cohort nursing and wearing of gowns/gloves for all contacts of RSV‐infected children (P = 0·0022). Neither intervention alone resulted in a significant reduction’ |
| Page, 200761 | Multicomponent | RSV isolation policy (introduced in 1996), followed by a review of the policy several years later with education emphasised, the initiation of a comprehensive hand‐hygiene programme | Not specified, assume standard procedures | After implementation of new RSV isolation policy: 4 cases in the first 4 years, 6 cases in 2000‐2001, 3 cases in 2001‐2002. After review of policy: 0 cases in the subsequent 4 RSV seasons | Seven cases in winter of 1995 | Not reported |
| Raad, 199759 | Multicomponent | Multifaceted infection control strategy, including masking and droplet precautions (not standard practice), isolation, strict adherence to measures such as handwashing, gloving and gowning by anyone entering patient's rooms, masks for close contact with patients, screening symptomatic patients, visitor screening and restrictions, staff education | Standard procedures including handwashing, gloving and gowning. Droplet isolation precautions, such as masking were not recommended | Period 2 (1996, second year post‐intervention): incidence 0·2 cases per 1000 patient‐days | Period 1 (1994, pre‐intervention): incidence of 1·4 cases per 1000 patient‐days | Not reported |
| Hall, 197753 | Multicomponent | Following a move to a new hospital – isolation or cohorting of children with respiratory disease, gowns, strict handwashing, children not allowed to visit wards, objects (e.g. sheets, trays) considered as contaminated | Infants with respiratory illness confined to cribs | ‘About 10%’ | 32% | Not reported |
| Simon, 200649 | Multicomponent | Multicomponent strategy including staff education, increased RSV vigilance, isolation or cohorting of infected patients, strictly enforced contact precautions (hand disinfection, gowns, masks and gloves, disinfection of non‐critical nursing items), and daily disinfection of hand contact surfaces in the isolation room. Compliance of healthcare workers and parents was routinely monitored | Not specified, assume standard procedures | 2000–2001 (post‐intervention): 14·6% (n = 13); and 2001–2002 (post‐intervention): 3·6% (n = 2) | 1999–2000 (pre‐intervention): 17·4% (n = 24) | P = 0·039 comparing the first and the last season |
| Snydman, 198860 | Multicomponent | Active surveillance, admission and transfer policy guidelines, patient isolation or cohorting, nursing staff cohorting, respiratory precautions on suspicion of respiratory illness, gowns, gloves and masks on contact, winter visiting policy (screening of visitors and visitation limitations), construction of segregate areas | Previous infection control policy (CDC guidelines were in use; private room and gown on contact) | 1984–1985 (post‐intervention): 0 cases in 668 patient‐days at risk, and in 1985–1986 (post‐intervention): 0 cases in 1020 patient‐days at risk | 1983–1984 (pre‐intervention): 7 cases in 875 patient‐days at risk | Transmission rate 1984–1986 (post‐intervention) versus 1983–1984 (pre‐intervention): P = 0·0016 |
| Gala, 198645 | PPE | Eye–nose goggle worn by all staff when entering the room of any infant with respiratory symptoms | Standard procedures (handwashing, isolation and cohorting) | 5·9% | 42·9% | χ2: P = 0·04 |
| Hall, 198115 | PPE | Gowns and masks with a change of gowns between infant contacts | Standard procedures (handwashing, isolation or cohorting of infected infants, staff cohorting, restricting young visitors, restricting patient contacts) | 32·0% | 40·7% | Authors state: ‘The rate of nosocomial infection occurring in the first period is not significantly different from that of the second period’ (no statistics provided) |
| Leclair, 198747 | PPE | Gloves and gowns, with staff compliance monitoring, for direct contact with any child with suspected or known RSV infection (compliance = 81%) | No monitoring of staff compliance with gowns and gloves for direct contact with any child with suspected or known RSV infection (compliance = 38·5%) | Incidence per 1000 patient‐days: 3·1 | Incidence per 1000 patient‐days: 6·4 | Relative risk in control versus intervention periods (adjusted for intensity of exposure to nosocomial RSV): 2·9 (95% CI: 1·5‐5·7) |
| Katz, 200957 | RSV prophylaxis | RSV prophylaxis (RSV‐Ig or palivizumab) for high‐risk infants in addition to standard procedures | Standard infection control procedures including use of single rooms or cohorting of infected infants and droplet/contact isolation | Period 2 (post‐RSV prophylaxis with RSV‐Ig): 3·1 per 10 000 patient‐days, Period 3 (post‐RSV prophylaxis with palivizumab): 0·63 per 10 000 patient‐days | Period 1 (pre‐intervention): 2·1 per 10 000 patient‐days | Rate ratio period 1 versus period 2: 0·67 (95% CI: 0·03‐14·0, P = 0·76); and period 1 versus period 3: 3·3 (95% CI: 0·16‐68, P = 0·37) |
| Lavergne, 201158 | Isolation strategy | Enhanced seasonal infection control programme – same as the ‘targeted infection control program’ (applied to the control group) but all patients hospitalised during the RSV season were isolated until discharge | Standard ‘targeted infection control program’ (isolation was applied only to patients with severe neutropenia (<500/mm3) or presenting symptoms of upper and/or lower respiratory tract infection). Infection control measures comprised: private rooms with filtered air positive pressure ventilation, mandatory handwashing, screening all people entering ward for respiratory symptoms, visitation restrictions, patients forbidden to leave rooms except for special examinations, mandatory masks, gowns and gloves for all, RSV patients moved to negative pressure rooms for, for example, ribavirin treatments, rapid diagnosis of infection | 3·9 cases per 1000 admissions | 42·8 cases per 1000 admissions | Relative risk in intervention versus control period: 0·09 (95% CI: 0·02–0·38) |
| Gardner, 197355 | Isolation strategy (ward design) | Wards composed almost entirely of individual cubicles | Open wards with some cubicles | Cross‐infection rate (number of cross‐infections × 106/((number at risk × mean stay) × (number infected × their mean stay)): 4·2 | Cross‐infection rate: 7·1 | Not reported. Authors state that the numbers of cross‐infections were too small to make statistical comparisons. |
RSV, respiratory syncytial virus; NICU, neonatal intensive care unit; CDC, United States Centers for Disease Control and Prevention.
a
Note that interventions were generally applied in addition to the ‘standard precautions’ used for the control group.
b
Or other measure of nosocomial RSV transmission as specified (if transmission risk not reported).