How should a nursing home manage a confirmed or suspected respiratory syncytial virus (RSV) outbreak, including infection control, vaccination, prophylaxis, and treatment?

Managing an RSV Outbreak in a Nursing Home

Immediately implement strict contact isolation precautions with hand hygiene, glove and gown use, patient cohorting, and staff cohorting—these measures form the foundation of outbreak control and have been consistently effective in preventing RSV transmission in institutional settings. 1

Immediate Infection Control Measures

Hand Hygiene (Most Critical)

• Wash hands after every patient contact and after touching any respiratory secretions or potentially contaminated surfaces, regardless of whether gloves were worn 1
• Use alcohol-based hand rubs as the preferred method for hand decontamination 2
• Hand hygiene compliance is the single most important measure but historically poor among healthcare workers, necessitating additional protective layers 1, 2

Personal Protective Equipment Requirements

• Wear gloves when handling any resident with confirmed or suspected RSV infection and when touching any surfaces in their environment 1
• Change gloves between each resident contact and after handling respiratory secretions before touching another resident 1
• Wash hands immediately after removing gloves—gloves alone are insufficient 1
• Wear a gown when clothing could be soiled by respiratory secretions (which is common when handling elderly residents with RSV), and change the gown after contact before caring for another resident 1
• Eye-nose protection has shown effectiveness in some studies, though this remains an unresolved recommendation 1

Patient Management and Cohorting

Isolation and Room Assignment

• Place residents with confirmed RSV in private rooms when possible, or cohort them together in a designated area separate from uninfected residents 1
• If private rooms are unavailable, place RSV-positive residents together with no other infections present 1
• Perform rapid diagnostic testing on residents with respiratory symptoms to facilitate early identification and appropriate cohorting 1

Limiting Resident Movement

• Restrict movement of infected residents to essential purposes only 1
• When transport is necessary, ensure residents do not touch other persons or environmental surfaces with hands contaminated by respiratory secretions 1

Staffing Protocols

Staff Cohorting During Outbreak

• Assign dedicated staff to work exclusively with RSV-infected residents and restrict these staff from caring for uninfected residents 1
• Similarly, restrict staff caring for uninfected residents from providing care to infected residents 1

Staff Illness Management

• Immediately restrict healthcare workers with acute upper respiratory symptoms (sneezing, coughing) from caring for any residents, as they pose significant transmission risk 1
• When feasible, perform rapid diagnostic testing on symptomatic staff to determine their work status promptly 1

Visitor Restrictions

• Do not allow any visitors with respiratory infection symptoms to enter the facility 1
• This applies particularly to visitors of immunosuppressed or cardiac residents who are at highest risk 1

Diagnostic and Surveillance Strategy

Rapid Testing Implementation

• Establish mechanisms to promptly alert facility personnel of increased RSV activity in the local community 1
• During December through March (peak RSV season) and during community outbreaks, perform rapid diagnostic testing on all residents with respiratory symptoms at admission or symptom onset 1
• Rapid diagnostic tests (immunofluorescence or enzyme immunoassays) provide results within hours, enabling faster cohorting decisions 1
• Test sensitivity and specificity range from 80-95%, which is acceptable for infection control purposes 1

Admission Management During Outbreak

• Postpone elective admissions of uninfected residents at high risk for RSV complications during active outbreaks 1
• High-risk residents include those with chronic cardiopulmonary conditions, immunosuppression, or diabetes 1

Treatment Approach for Infected Residents

• Provide supportive care focusing on hydration assessment and oxygen supplementation when oxygen saturation falls persistently below 90% 2
• Use acetaminophen or ibuprofen for fever or pain management 2
• Do not use bronchodilators, corticosteroids, or ribavirin routinely—these have no proven benefit in elderly RSV patients and ribavirin is reserved only for severely immunocompromised patients 2
• Avoid antibiotics unless specific bacterial co-infection is documented 2

Vaccination Considerations

• RSV vaccines are now available for adults 60 years and older and for those 18-59 years with increased risk factors (diabetes, chronic lung or heart disease) 3
• Vaccination should be offered to all eligible nursing home residents as a preventive strategy, though it does not treat active infection 3
• Palivizumab has no therapeutic benefit for established RSV infection and should not be used for treatment or outbreak control in elderly populations 2, 4

Common Pitfalls to Avoid

Inadequate Hand Hygiene Compliance

• Studies consistently show poor hand hygiene compliance among healthcare workers, which is why layered protections (gloves, gowns, cohorting) are essential 1
• Gloves provide benefit primarily by reminding staff not to touch their eyes or nose, but only if changed between patients 1

Delayed Isolation

• Failure to promptly implement contact precautions leads to rapid nosocomial spread 5
• RSV transmission risk in nursing home outbreaks ranges from 30-40% of residents, with case-fatality rates of 8-34% in elderly populations 6, 7

Inadequate Communication

• Clear, consistent, and proactive communication across all staffing levels and with residents is essential for intervention acceptability and compliance 8
• Staff concerns about assignment changes and care continuity must be addressed through transparent communication 8

Expected Outbreak Characteristics

• Nursing home RSV outbreaks typically extend over 6 weeks and can affect 40% of residents 6
• Pneumonia develops in approximately 15% of infected residents, with 12% requiring hospitalization 7
• Multiple pathogens may be detected in 38% of respiratory outbreaks, so consider co-infections 7
• Clinical findings (cough, fever, coryza) are nonspecific and cannot distinguish RSV from other respiratory pathogens without testing 7