Infection Control & Hospital Epidemiology
transmission and to differentiate prolonged HRV shedding periods from reinfections with a different strain.4 Marcone et al4 reported an HRV outbreak involving 6 preterm NICU patients whose genotyping identified 4 different and 2 identical strains, pointing to nosocomial transmission of the latter.4 Reid et al3 described a neonatal HRV outbreak involving 8 patients. Screening of asymptomatic patients allowed them to detect 4 of these cases, which could otherwise have been unidentified sources of further transmission. These studies show a potential adjunctive role of genotyping in outbreak investigations. Nonetheless, genotyping should not override the use of a case definition combined with the epidemiologic context to establish the presence of an outbreak. Similarly to previously described HRV outbreaks, 5 of our 7
patients presented mild respiratory symptoms.1,3,4 However, our case of HRV-associated mortality progressed from no respiratory support tomechanical ventilation, showing the potential severity of HRV outbreaks in vulnerable populations.9 Among outbreak cases, this patient was the only baby born at term and the only patient without active pulmonary comorbidities. However, the presence of HRV bronchiolitis in the context of underlying symptomatic progressive hypertrophic cardiomyopathy likely contributed to his evolution to respiratory failure and death. This study has several limitations. Asymptomatic or very mild
HRV infections may not have been recognized because no sys- tematic screening was undertaken. Furthermore, we did not test symptomatic family members, visitors, and HCWs for HRV during the outbreak; thus, we could not fully determine the sources of nosocomial HRV transmission. Nonetheless, our epi- demiologic and viral sequencing data demonstrate multiple dis- tinct introductions of HRV into our NICU and possible secondary transmission. Given the observed morbidity of HRV infection in NICU patients and potential for severe outcomes, these cases underscore the importance of HCW and visitor hand hygiene and respiratory hygiene, as well as HCW compliance to additional precautions, especially during community HRV out- breaks, which may not occur during periods typically associated with high levels of respiratory virus circulation. The MCH NICU has since continued to reinforce additional measures to prevent outbreaks and to limit their extent, namely by cohorting infected infants and through sensitizing parents and HCWs.
Financial support. J. Papenburg and P. Fontela are supported by Chercheur- Boursier clinician career awards from the Fonds de recherche Québec santé. G. Boivin is the holder of the Canada Research Chair on Influenza and other
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Respiratory Viruses. C. Quach is supported by the Chercheur-Boursier de mérite career award from the Fonds de recherche Québec santé.
Conflicts of interest. J. Papenburg acknowledges receiving consulting/honor- aria fees or research grant funding outside of the current work fromthe following companies: AbbVie, BD Diagnostics, Cepheid, MedImmune, Hoffmann-La Roche, and Jannsen Pharmaceutical. C. Caya acknowledges receiving honoraria fees outside of the current work from Roche Diagnostics Canada. G. Boivin has received research grants from Gilead and BioCryst for unrelated work. The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subjectmatterormaterials discussed in the manuscript apart from those disclosed.
Supplementary material. To view supplementary material for this article, please visit
https://doi.org/10.1017/ice.2018.311
References
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2. Quach C, Shah R, Rubin LG. Burden of healthcare-associated viral respiratory infections in children’s hospitals. J Pediatric Infect Dis Soc 2018;7:18–24.
3. Reid AB, Anderson TL, Cooley L, Williamson J, Mcgregor AR. An outbreak of human rhinovirus species C infections in a neonatal intensive care unit. Pediatr Infect Dis J 2011;30:1095–1096.
4. Marcone DN, Carballal G, Irañeta M, Rubies Y, Vidaurreta SM, Echavarría M. Nosocomial transmission and genetic diversity of rhinovirus in a neonatal intensive care unit. J Pediatr 193:252–255.
5. Greninger AL, Waghmare A, Adler A, et al. Rule-out outbreak: 24- hour metagenomic next-generation sequencing for characterizing res- piratory virus source for infection prevention. J Pediatr Infect Dis Soc 2017;6:168–172.
6. AlGhounaim M, Xiao Y, Caya C, Papenburg J. Diagnostic yield and clinical impact of routine cell culture for respiratory viruses among children with a negative multiplex RT-PCR result. J Clin Virol 2017;94:107–109.
7. Kumar S, Stecher G, Tamura K. MEGA7: Molecular Evolutionary Genetics Analysis version 7.0 for bigger datasets. Molec Biol Evol 2016;33:1870–1874.
8. Julian S, Burnham CA, Sellenriek P, et al. Impact of neonatal intensive care bed configuration on rates of late-onset bacterial sepsis and methicillin- resistant Staphylococcus aureus colonization. Infec Control Hosp Epidemiol 2015;36:1173–1182.
9. Zinna S, Lakshmanan A, Tan S, et al. Outcomes of nosocomial viral respiratory infections in high-risk neonates. Pediatrics 2016;138.
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