Abstract
Hospital-acquired infections caused by viruses are a cause of considerable morbidity and occasional mortality in critically ill neonates. The intensive care environment allows for efficient spread of viral pathogens, and secondary cases among both patients and healthcare workers are frequently observed. We review the common viral causes of hospital-acquired infections in neonates, including rotavirus, respiratory syncytial virus, and others, discuss epidemiology and clinical syndromes, and summarize recommendations for control in outbreak situations. Chemoprophylaxis, isolation procedures, and care of affected staff are also addressed.
References
- 1.Baltimore RS. Vol. 22. 1998. Neonatal nosocomial infections; pp. 25–32. (Semin Perinatol). [Google Scholar]
- 2.Graman PS, Hall CB. Epidemiology and control of nosocomial viral infections. Infect Dis Clin North Am. 1989;3:815–841. [PubMed] [Google Scholar]
- 3.Gaynes RP, Edwards JR, Jarvis WR. Nosocomial infections among neonates in high-risk nurseries in the United States. National Nosocomial Infections Surveillance System. Pediatrics. 1996;98:357–361. [PubMed] [Google Scholar]
- 4.Cleary TG, Guerrand RL, Pickering LK. Microorganisms responsible for neonatal diarrhea. In: Remington JS, Klein JO, editors. Infectious diseases of the fetus and newborn infant. ed 5. Saunders; Philadelphia, PA: 2001. pp. 1249–1326. [Google Scholar]
- 5.Bern C, Martines J, de Zoysa I. The magnitude of the global problem of diarrhoeal disease: A ten-year update. Bull World Health Organ. 1992;70:705–714. [PMC free article] [PubMed] [Google Scholar]
- 6.Murphy AM, Albrey MB, Crewe EB. Rotavirus infections of neonates. Lancet. 1977;2:1149–1150. doi: 10.1016/S0140-6736(77)91538-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Chrystie IL, Totterdell BM, Banatvala JE. Asymptomatic endemic rotavirus infections in the newborn. Lancet. 1978;1:1176–1178. doi: 10.1016/S0140-6736(78)90967-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Ramachandran M, Vij A, Kumar R. Lack of maternal antibodies to P serotypes may predispose neonates to infections with unusual rotavirus strains. Clin Diagn Lab Immunol. 1998;5:527–530. doi: 10.1128/cdli.5.4.527-530.1998. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Chiba S, Yokoyama T, Nakata S. Protective effect of naturally acquired homotypic and heterotypic rotavirus antibodies. Lancet. 1986;2:417–421. doi: 10.1016/s0140-6736(86)92133-1. [DOI] [PubMed] [Google Scholar]
- 10.Glass RI, Stoll BJ, Wyatt RG. Observations questioning a protective role for breast-feeding in severe rotavirus diarrhea. Acta Paediatr Scand. 1986;75:713–718. doi: 10.1111/j.1651-2227.1986.tb10279.x. [DOI] [PubMed] [Google Scholar]
- 11.Duffy LC, Riepenhoff-Talty M, Byers TE. Modulation of rotavirus enteritis during breast-feeding. Implications on alterations in the intestinal bacterial flora. Am J Dis Child. 1986;140:1164–1168. doi: 10.1001/archpedi.1986.02140250090041. [DOI] [PubMed] [Google Scholar]
- 12.Velazquez FR, Matson DO, Calva JJ. Rotavirus infections in infants as protection against subsequent infections. N Engl J Med. 1996;335:1022–1028. doi: 10.1056/NEJM199610033351404. [DOI] [PubMed] [Google Scholar]
- 13.Rotbart HA, Levin MJ, Yolken RH. An outbreak of rotavirus-associated neonatal necrotizing enterocolitis. J Pediatr. 1983;103:454–459. doi: 10.1016/S0022-3476(83)80427-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Riedel F, Kroener T, Stein K. Rotavirus infection and bradycardia-apnoea-episodes in the neonate. Eur J Pediatr. 1996;155:36–40. doi: 10.1007/BF02115624. [DOI] [PubMed] [Google Scholar]
- 15.Hieber JP, Shelton S, Nelson JD. Comparison of human rotavirus disease in tropical and temperate settings. Am J Dis Child. 1978;132:853–858. doi: 10.1001/archpedi.1978.02120340029004. [DOI] [PubMed] [Google Scholar]
- 16.Appleton H, Buckley M, Robertson MH. A search for faecal viruses in new-born and other infants. J Hyg (Lond) 1978;81:279–283. doi: 10.1017/s0022172400025110. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Harris JS, Goldmann DA. Infections acquired in the nursery: epidemiology and control. In: Remington JS, Klein JO, editors. Infectious Diseases of the Fetus and Newborn Infant. ed 5. Saunders; Philadelphia, PA: 2001. pp. 1371–1418. [Google Scholar]
- 18.Prince DS, Astry C, Vonderfecht S. Aerosol transmission of experimental rotavirus infection. Pediatr Infect Dis J. 1986;5:218–222. doi: 10.1097/00006454-198603000-00012. [DOI] [PubMed] [Google Scholar]
- 19.Abad FX, Pinto RM, Bosch A. Survival of enteric viruses on environmental fomites. Appl Environ Microbiol. 1994;60:3704–3710. doi: 10.1128/aem.60.10.3704-3710.1994. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Zbinden R, Kunz J, Schaad UB. Incidence and diagnosis of rotavirus infection in neonates: Results of two studies. J Perinat Med. 1990;18:363–368. doi: 10.1515/jpme.1990.18.5.363. [DOI] [PubMed] [Google Scholar]
- 21.Grehn M, Kunz J, Sigg P. Nosocomial rotavirus infections in neonates: Means of prevention and control. J Perinat Med. 1990;18:369–374. doi: 10.1515/jpme.1990.18.5.369. [DOI] [PubMed] [Google Scholar]
- 22.Sattar SA, Jacobsen H, Rahman H. Interruption of rotavirus spread through chemical disinfection. Infect Control Hosp Epidemiol. 1994;15:751–756. doi: 10.1086/646852. [DOI] [PubMed] [Google Scholar]
- 23.Noble RC, Kane MA, Reeves SA. Postransfusion hepatitis A in a neonatal intensive care unit. JAMA. 1984;252:2711–2715. [PubMed] [Google Scholar]
- 24.Klein BS, Michaels JA, Rytel MW. Nosocomial hepatitis A. A multinursery outbreak in Wisconsin. JAMA. 1984;252:2716–2721. doi: 10.1001/jama.252.19.2716. [DOI] [PubMed] [Google Scholar]
- 25.Watson JC, Fleming DW, Borella AJ. Vertical transmission of hepatitis A resulting in an outbreak in a neonatal intensive care unit. J Infect Dis. 1993;167:567–571. doi: 10.1093/infdis/167.3.567. [DOI] [PubMed] [Google Scholar]
- 26.Rosenblum LS, Villarino ME, Nainan OV. Hepatitis A outbreak in a neonatal intensive care unit: Risk factors for transmission and evidence of prolonged viral excretion among preterm infants. J Infect Dis. 1991;164:476–482. doi: 10.1093/infdis/164.3.476. [DOI] [PubMed] [Google Scholar]
- 27.Tong MJ, Thursy M, Rakela J. Studies on the maternal-infant transmission of the viruses which cause acute hepatitis. Gastroenterology. 1981;80:999–1004. [PubMed] [Google Scholar]
- 28.American Academy of Pediatrics. ed 25. American Academy of Pediatrics; Elk Grove Villiage, IL: 2000. (2000 Red Book: Report of the Committee on Infectious Diseases). [Google Scholar]
- 29.Abzug MJ, Levin MJ, Rotbart HA. Profile of enterovirus disease in the first two weeks of life. Pediatr Infect Dis J. 1993;12:820–824. doi: 10.1097/00006454-199310000-00005. [DOI] [PubMed] [Google Scholar]
- 30.Jenista JA, Powell KR, Menegus MA. Epidemiology of neonatal enterovirus infection. J Pediatr. 1984;104:685–690. doi: 10.1016/s0022-3476(84)80944-0. [DOI] [PubMed] [Google Scholar]
- 31.McDonald LL, St. Geme JW, Jr, Arnold BH. Nosocomial infection with ECHO virus type 31 in a neonatal intensive care unit. Pediatrics. 1971;47:995–999. [PubMed] [Google Scholar]
- 32.Chambon M, Bailly JL, Beguet A. An outbreak due to echovirus type 30 in a neonatal unit in France in 1997: usefulness of PCR diagnosis. J Hosp Infect. 1999;43:63–68. doi: 10.1053/jhin.1999.0634. [DOI] [PubMed] [Google Scholar]
- 33.Takami T, Kawashima H, Takei Y. Usefulness of nested PCR and sequence analysis in a nosocomial outbreak of neonatal enterovirus infection. J Clin Virol. 1998;11:67–75. doi: 10.1016/s0928-0197(98)00022-1. [DOI] [PubMed] [Google Scholar]
- 34.Jankovic B, Pasic S, Kanjuh B. Severe neonatal echovirus 17 infection during a nursery outbreak. Pediatr Infect Dis J. 1999;18:393–394. doi: 10.1097/00006454-199904000-00023. [DOI] [PubMed] [Google Scholar]
- 35.Sato K, Yamashita T, Sakae K. A new-born baby outbreak of echovirus type 33 infection. J Infect. 1998;37:123–126. doi: 10.1016/s0163-4453(98)80165-5. [DOI] [PubMed] [Google Scholar]
- 36.Swender PT, Shott RJ. A community and intensive care nursery outbreak of coxsackievirus B5 meningitisAm J Dis Child. 1974;127:42–45. doi: 10.1001/archpedi.1974.02110200044006. [DOI] [PubMed] [Google Scholar]
- 37.Druyts-Voets E, Van Renterghem L, Gerniers S. Coxsackie B virus epidemiology and neonatal infection in Belgium. J Infect. 1993;27:311–316. doi: 10.1016/0163-4453(93)92329-u. [DOI] [PubMed] [Google Scholar]
- 38.Eisenhut M, Algawi B, Wreghitt T. Fatal Coxsackie A9 virus infection during an outbreak in a neonatal unit. J Infect. 2000;40:297–298. doi: 10.1053/jinf.2000.0650. [DOI] [PubMed] [Google Scholar]
- 39.Modlin JF. Perinatal echovirus infection: Insights from a literature review of 61 cases of serious infection and 16 outbreaks in nurseries. Rev Infect Dis. 1986;8:918–926. doi: 10.1093/clinids/8.6.918. [DOI] [PubMed] [Google Scholar]
- 40.Abzug MJ, Keyserling HL, Lee ML. Neonatal enterovirus infection: Virology, serology, and effects of intravenous immune globulin. Clin Infect Dis. 1995;20:1201–1206. doi: 10.1093/clinids/20.5.1201. [DOI] [PubMed] [Google Scholar]
- 41.Pasic S, Jankovic B, Abinun M. Intravenous immunoglobulin prophylaxis in an echovirus 6 and echovirus 4 nursery outbreak. Pediatr Infect Dis J. 1997;16:718–720. doi: 10.1097/00006454-199707000-00019. [DOI] [PubMed] [Google Scholar]
- 42.Pevear DC, Tull TM, Seipel ME. Activity of pleconaril against enteroviruses. Antimicrob Agents Chemother. 1999;43:2109–2115. doi: 10.1128/aac.43.9.2109. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 43.Rotbart HA, Webster AD. Treatment of potentially life-threatening enterovirus infections with pleconaril. Clin Infect Dis. 2001;32:228–235. doi: 10.1086/318452. [DOI] [PubMed] [Google Scholar]
- 44.Goldmann DA. Prevention and management of neonatal infections. Infect Dis Clin North Am. 1989;3:779–813. [PubMed] [Google Scholar]
- 45.Parrott RH, Kim HW, Brandt CD. Respiratory syncytial virus in infants and children. Prev Med. 1974;3:473–480. doi: 10.1016/0091-7435(74)90010-3. [DOI] [PubMed] [Google Scholar]
- 46.Hall CB, Kopelman AE, Douglas RG., Jr Neonatal respiratory syncytial virus infection. N Engl J Med. 1979;300:393–396. doi: 10.1056/NEJM197902223000803. [DOI] [PubMed] [Google Scholar]
- 47.Kilani RA. Respiratory syncytial virus (RSV) outbreak in the NICU: Description of eight cases. J Trop Pediatr. 2002;48:118–122. doi: 10.1093/tropej/48.2.118. [DOI] [PubMed] [Google Scholar]
- 48.Goldson EJ, McCarthy JT, Welling MA. A respiratory syncytial virus outbreak in a transitional care nursery. Am J Dis Child. 1979;133:1280–1282. doi: 10.1001/archpedi.1979.02130120072015. [DOI] [PubMed] [Google Scholar]
- 49.White MP, Mackie PL. Respiratory syncytial virus infection in special care nursery. Lancet. 1990;335:979. doi: 10.1016/0140-6736(90)91047-e. [DOI] [PubMed] [Google Scholar]
- 50.Kang JO, Kim CR. Nosocomial respiratory syncytial virus infection in a newborn nursery. J Korean Med Sci. 1997;12:489–491. doi: 10.3346/jkms.1997.12.6.489. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 51.Hall CB, Douglas RG., Jr Modes of transmission of respiratory syncytial virus. J Pediatr. 1981;99:100–103. doi: 10.1016/s0022-3476(81)80969-9. [DOI] [PubMed] [Google Scholar]
- 52.Leclair JM, Freeman J, Sullivan BF. Prevention of nosocomial respiratory syncytial virus infections through compliance with glove and gown isolation precautions. N Engl J Med. 1987;317:329–334. doi: 10.1056/NEJM198708063170601. [DOI] [PubMed] [Google Scholar]
- 53.Valenti WM, Clarke TA, Hall CB. Concurrent outbreaks of rhinovirus and respiratory syncytial virus in an intensive care nursery: Epidemiology and associated risk factors. J Pediatr. 1982;100:722–726. doi: 10.1016/s0022-3476(82)80571-4. [DOI] [PubMed] [Google Scholar]
- 54.Meissner HC, Murray SA, Kiernan MA. A simultaneous outbreak of respiratory syncytial virus and parainfluenza virus type 3 in a newborn nursery. J Pediatr. 1984;104:680–684. doi: 10.1016/s0022-3476(84)80943-9. [DOI] [PubMed] [Google Scholar]
- 55.Wilson CW, Stevenson DK, Arvin AM. A concurrent epidemic of respiratory syncytial virus and echovirus 7 infections in an intensive care nursery. Pediatr Infect Dis J. 1989;8:24–29. doi: 10.1097/00006454-198901000-00008. [DOI] [PubMed] [Google Scholar]
- 56.Hall CB, Geiman JM, Douglas RG., Jr Control of nosocomial respiratory syncytial viral infections. Pediatrics. 1978;62:728–732. [PubMed] [Google Scholar]
- 57.Isaacs D, Dickson H, O'Callaghan C. Handwashing and cohorting in prevention of hospital acquired infections with respiratory syncytial virus. Arch Dis Child. 1991;66:227–231. doi: 10.1136/adc.66.2.227. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 58.Snydman DR, Greer C, Meissner HC. Prevention of nosocomial transmission of respiratory syncytial virus in a newborn nursery. Infect Control Hosp Epidemiol. 1988;9:105–108. doi: 10.1086/645804. [DOI] [PubMed] [Google Scholar]
- 59.Mintz L, Ballard RA, Sniderman SH. Nosocomial respiratory syncytial virus infections in an intensive care nursery: Rapid diagnosis by direct immunofluorescence. Pediatrics. 1979;64:149–153. [PubMed] [Google Scholar]
- 60.Macartney KK, Gorelick MH, Manning ML. Nosocomial respiratory syncytial virus infections: The cost-effectiveness and cost-benefit of infection control. Pediatrics. 2000;106:520–526. doi: 10.1542/peds.106.3.520. [DOI] [PubMed] [Google Scholar]
- 61.Prevention of respiratory syncytial virus infections: Indications for the use of palivizumab and update on the use of RSV-IGIV. American Academy of Pediatrics Committee on Infectious Diseases and Committee of Fetus and Newborn. Pediatrics. 1998;102:1211–1216. doi: 10.1542/peds.102.5.1211. [DOI] [PubMed] [Google Scholar]
- 62.Cox RA, Rao P, Brandon-Cox C. The use of palivizumab monoclonal antibody to control an outbreak of respiratory syncytial virus infection in a special care baby unit. J Hosp Infect. 2001;48:186–192. doi: 10.1053/jhin.2001.1002. [DOI] [PubMed] [Google Scholar]
- 63.Sagrera X, Ginovart G, Raspall F. Outbreaks of influenza A virus infection in neonatal intensive care units. Pediatr Infect Dis J. 2002;21:196–200. doi: 10.1097/00006454-200203000-00007. [DOI] [PubMed] [Google Scholar]
- 64.Meibalane R, Sedmak GV, Sasidharan P. Outbreak of influenza in a neonatal intensive care unit. J Pediatr. 1977;91:974–976. doi: 10.1016/s0022-3476(77)80907-4. [DOI] [PubMed] [Google Scholar]
- 65.Cunney RJ, Bialachowski A, Thornley D. An outbreak of influenza A in a neonatal intensive care unit. Infect Control Hosp Epidemiol. 2000;21:449–454. doi: 10.1086/501786. [DOI] [PubMed] [Google Scholar]
- 66.Munoz FM, Campbell JR, Atmar RL. Influenza A virus outbreak in a neonatal intensive care unit. Pediatr Infect Dis J. 1999;18:811–815. doi: 10.1097/00006454-199909000-00013. [DOI] [PubMed] [Google Scholar]
- 67.Bauer CR, Elie K, Spence L. Hong Kong influenza in a neonatal unit. JAMA. 1973;223:1233–1235. [PubMed] [Google Scholar]
- 68.Goldmann DA. Epidemiology and prevention of pediatric viral respiratory infections in health-care institutions. Emerg Infect Dis. 2001;7:249–253. doi: 10.3201/eid0702.010220. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 69.Birenbaum E, Linder N, Varsano N. Adenovirus type 8 conjunctivitis outbreak in a neonatal intensive care unit. Arch Dis Child. 1993;68:610–611. doi: 10.1136/adc.68.5_spec_no.610. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 70.Finn A, Anday E, Talbot GH. An epidemic of adenovirus 7a infection in a neonatal nursery: Course, morbidity, and management. Infect Control Hosp Epidemiol. 1988;9:398–404. doi: 10.1086/645898. [DOI] [PubMed] [Google Scholar]
- 71.Piedra PA, Kasel JA, Norton HJ. Description of an adenovirus type 8 outbreak in hospitalized neonates born prematurely. Pediatr Infect Dis J. 1992;11:460–465. doi: 10.1097/00006454-199206000-00008. [DOI] [PubMed] [Google Scholar]
- 72.Abzug MJ, Levin MJ. Neonatal adenovirus infection: Four patients and review of the literature. Pediatrics. 1991;87:890–896. [PubMed] [Google Scholar]
- 73.Moisiuk SE, Robson D, Klass L. Outbreak of para-influenza virus type 3 in an intermediate care neonatal nursery. Pediatr Infect Dis J. 1998;17:49–53. doi: 10.1097/00006454-199801000-00011. [DOI] [PubMed] [Google Scholar]
- 74.Singh-Naz N, Willy M, Riggs N. Outbreak of parainfluenza virus type 3 in a neonatal nursery. Pediatr Infect Dis J. 1990;9:31–33. doi: 10.1097/00006454-199001000-00007. [DOI] [PubMed] [Google Scholar]
- 75.Ng W, Rajadurai VS, Pradeepkumar VK. Parainfluenza type 3 viral outbreak in a neonatal nursery. Ann Acad Med Singapore. 1999;28:471–475. [PubMed] [Google Scholar]
- 76.Sizun J, Soupre D, Legrand MC. Neonatal nosocomial respiratory infection with coronavirus: A prospective study in a neonatal intensive care unit. Acta Paediatr. 1995;84:617–620. doi: 10.1111/j.1651-2227.1995.tb13710.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 77.Gagneur A, Legrand MC, Picard B. Nosocomial infections due to human coronaviruses in the newborn. Arch Pediatr. 2002;9:61–69. doi: 10.1016/S0929-693X(01)00696-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 78.Gagneur A, Sizun J, Vallet S. Coronavirus-related nosocomial viral respiratory infections in a neonatal and paediatric intensive care unit: A prospective study. J Hosp Infect. 2002;51:59–64. doi: 10.1053/jhin.2002.1179. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 79.Gershon AA, Raker R, Steinberg S. Antibody to Varicella-Zoster virus in parturient women and their offspring during the first year of life. Pediatrics. 1976;58:692–696. [PubMed] [Google Scholar]
- 80.Friedman CA, Temple DM, Robbins KK. Outbreak and control of varicella in a neonatal intensive care unit. Pediatr Infect Dis J. 1994;13:152–154. [PubMed] [Google Scholar]
- 81.Gustafson TL, Shehab Z, Brunell PA. Outbreak of varicella in a newborn intensive care nursery. Am J Dis Child. 1984;138:548–550. doi: 10.1001/archpedi.1984.02140440032007. [DOI] [PubMed] [Google Scholar]
- 82.Mendez DB, Sinclair MB, Garcia S. Transplacental immunity to varicella-zoster virus in extremely low birth-weight infants. Am J Perinatol. 1992;9:236–238. doi: 10.1055/s-2007-994779. [DOI] [PubMed] [Google Scholar]
- 83.Raker RK, Steinberg S, Drusin LM. Antibody to varicella zoster virus in low-birth-weight newborn infants. J Pediatr. 1978;93:505–506. doi: 10.1016/s0022-3476(78)81180-9. [DOI] [PubMed] [Google Scholar]
- 84.Ng PC, Lyon DJ, Wong MY. Varicella exposure in a neonatal intensive care unit: Emergency management and control measures. J Hosp Infect. 1996;32:229–236. doi: 10.1016/s0195-6701(96)90149-8. [DOI] [PubMed] [Google Scholar]
- 85.Saiman L, LaRussa P, Steinberg SP. Persistence of immunity to varicella-zoster virus after vaccination of healthcare workers. Infect Control Hosp Epidemiol. 2001;22:279–283. doi: 10.1086/501900. [DOI] [PubMed] [Google Scholar]
- 86.Seward JF, Watson BM, Peterson CL. Varicella disease after introduction of varicella vaccine in the United States, 1995–2000. JAMA. 2002;287:606–611. doi: 10.1001/jama.287.5.606. [DOI] [PubMed] [Google Scholar]
- 87.Kimberlin DW, Lin CY, Jacobs RF. Natural history of neonatal herpes simplex virus infections in the acyclovir era. Pediatrics. 2001;108:223–229. doi: 10.1542/peds.108.2.223. [DOI] [PubMed] [Google Scholar]
- 88.Linnemann CC, Jr., Buchman TG, Light IJ. Transmission of herpes-simplex virus type 1 in a nursery for the newborn. Identification of viral isolates by D.N.A. “fingerprinting”. Lancet. 1978;1:964–966. doi: 10.1016/s0140-6736(78)90251-9. [DOI] [PubMed] [Google Scholar]
- 89.Hammerberg O, Watts J, Chernesky M. An outbreak of herpes simplex virus type 1 in an intensive care nursery. Pediatr Infect Dis. 1983;2:290–294. doi: 10.1097/00006454-198307000-00007. [DOI] [PubMed] [Google Scholar]
- 90.Yamamoto AY, Mussi-Pinhata MM, Cristina P. Congenital cytomegalovirus infection in preterm and fullterm newborn infants from a population with a high seroprevalence rate. Pediatr Infect Dis J. 2001;20:188–192. doi: 10.1097/00006454-200102000-00014. [DOI] [PubMed] [Google Scholar]
- 91.Adler SP. Molecular epidemiology of cytomegalovirus: A study of factors affecting transmission among children at three day-care centers. Pediatr Infect Dis J. 1991;10:584–590. [PubMed] [Google Scholar]
- 92.Spector SA. Transmission of cytomegalovirus among infants in hospital documented by restriction-endonuclease-digestion analyses. Lancet. 1983;1:378–381. doi: 10.1016/s0140-6736(83)91499-x. [DOI] [PubMed] [Google Scholar]
- 93.Adler SP, Baggett J, Wilson M. Molecular epidemiology of cytomegalovirus in a nursery: Lack of evidence for nosocomial transmission. J Pediatr. 1986;108:117–123. doi: 10.1016/s0022-3476(86)80785-5. [DOI] [PubMed] [Google Scholar]
- 94.Dworsky ME, Welch K, Cassady G. Occupational risk for primary cytomegalovirus infection among pediatric health-care workers. N Engl J Med. 1983;309:950–953. doi: 10.1056/NEJM198310203091604. [DOI] [PubMed] [Google Scholar]
- 95.Brown J, Froese-Fretz A, Luckey D. High rate of hand contamination and low rate of hand washing before infant contact in a neonatal intensive care unit. Pediatr Infect Dis J. 1996;15:908–910. doi: 10.1097/00006454-199610000-00016. [DOI] [PubMed] [Google Scholar]
- 96.Oelberg DG, Joyner SE, Jiang X. Detection of pathogen transmission in neonatal nurseries using DNA markers as surrogate indicators. Pediatrics. 2000;105:311–315. doi: 10.1542/peds.105.2.311. [DOI] [PubMed] [Google Scholar]