# 4530
In medicine, one always looks first to the most common, or likely, cause of a patient’s chief complaint before considering something exotic. The old adage, that `When walking in Central Park, if you hear hoof beats, expect horses, not zebras’ is drummed into every medical student.
It is only when you eliminate the simplest explanation that you move to the next most-likely cause of a patient’s illness.
And so, when a series of extremely elderly residents in a long-term nursing facility on Vancouver Island began to fall seriously ill from a respiratory ailment earlier this month, naturally the first thoughts were that it was influenza A or B.
But testing has ruled out these two most likely suspects, and doctors and epidemiologists are now looking for a different explanation.
Influenza viruses, of course, make up only a small percentage of known respiratory viruses (see ILI’s Aren’t Always The Flu).
The list of viral pathogens that can cause ILI's (`influenza-like Illnesses') is a long one, and includes adenoviruses, influenza viruses, human metapneumovirus, parainfluenza viruses, respiratory syncytial viruses, and rhinoviruses.
Yesterday the press – particularly in Canada – picked up this story.
A hat tip to RoRo, Alert, Laidback Al, Tetano, and others on FluTrackers for starting this thread to track the progress of this investigation.
This report from the Canadian Press, followed by a press release from the local health authority.
Virus kills nine at Victoria hospital
Influenza-like virus has made 19 ill; H1N1 has been ruled out
Victoria, BC — Last updated on Tuesday, Apr. 27, 2010 6:26PM EDT
Nine residents have died since April 5 at a Victoria hospital where an influenza-like illness has been detected, says the Vancouver Island Health Authority.
Spokeswoman Suzanne Germain said Tuesday that 19 people have become ill since the respiratory outbreak began at Glengarry Hospital, which is home to frail and elderly patients, many with multiple pre-existing conditions.
“While we know that nine people who died had the symptoms we don't know if that was what ultimately caused them to die,” she said of the patients, who were in their 80s and 90s.
Lab tests have confirmed that the illness is not H1N1 or influenza A and B, but further tests are being conducted to try and find out what kind of illness is involved, she said.
The Vancouver Island Health Authority (VIHA) has released the following statement:
Respiratory Outbreak at Glengarry Hospital
April 27, 2010
VICTORIA – The Chandler Unit at Glengarry Hospital in Victoria is experiencing a respiratory outbreak which has affected a total of 19 residents. The Vancouver Island Health Authority (VIHA) is asking family and friends to consider not visiting the facility at this time, especially if they are sick. If they do visit, they will be asked to clean their hands on entering the facility and affected unit as well as follow other precautions as directed by staff.
The Chandler Unit at Glengarry has also been experiencing a Norovirus outbreak since April 6. Some patients on the unit began developing respiratory symptoms at the end of March, but these were often mild and not readily distinguished from the Norovirus symptoms in this group of elderly and often cognitively impaired residents. The respiratory outbreak was declared on April 22 after an increase in the number of cases and several deaths occurred.
Since April 5, nine residents with the respiratory symptoms have passed away. Each of these residents was elderly and frail with multiple medical challenges. Five of these residents were already receiving palliative care. Medical reviews are underway on all cases to determine what role the respiratory condition may have played – if any – in the deaths.
“We take outbreaks in residential care facilities very seriously because the frail, elderly population is more susceptible to serious complications and even death from illnesses,” said Dr. David Forrest, Associate Medical Director, Infection Prevention and Control with VIHA. “The fact that no staff have been affected by this illness would suggest it is a mild illness in most people that is affecting our frail elderly residents more.”
Lab tests have not yet confirmed the organism involved in the respiratory condition, but influenza A and B and H1N1 have been ruled out. Further testing is underway at the VIHA laboratory as well as at the BC Centre for Disease Control in Vancouver. Results are expected later this week.
“While the cause of the illness is not yet known, residential care facilities reflect the community. There are many viruses circulating in the community this time of year, including rhino- and noro-viruses. When they are introduced into the residential care setting they can have a significant impact on residents and staff,” said Dr. Forrest. “We would like to remind people not to visit when they are not feeling well. In addition, since many infections such as influenza can be prevented by vaccination, immunization is important to prevent the development of such outbreaks and deaths.”
VIHA has notified family members of this latest outbreak. Heightened infection control measures are in place to prevent its spread.
These measures include:
- Limiting contact between residents (residents are isolated to their rooms)
- Closing all dining rooms (meals are being served to residents in their rooms)
- Limiting visitors to one family member per resident.
- Requiring visitors to wear protective equipment and to follow strict hand hygiene practices (e.g. mask, gown and gloves when visiting someone with symptoms).
- Restricting visitors to loved one’s room only; no visits in common areas.
- Cancelling special events and restricting movement for residents who smoke.
- Requiring staff to wear protective equipment and to follow strict infection control practices (e.g. mask with visor, gown, gloves).
- Restricting staff who have been working on the Chandler Unit from working in other residential care sites in back-to-back shifts.
- Adding housekeeping staff and enhancing housekeeping with additional infection control cleaning protocols (such as enhanced cleaning of frequent touch areas, changing of privacy curtains).
- Maintaining a previous closure to new admissions that was put in place April 6 due a Norovirus outbreak.
Residents who contract respiratory symptoms are being carefully monitored and treated as appropriate, depending on their care plan, their wishes, or the wishes of their family. Where requested and appropriate, a resident may be transferred to hospital for additional care such as intravenous antibiotic care.
Glengarry has a total of 140 beds. Only the Chandler Unit (70 beds) is affected by the respiratory outbreak.
