Thursday, November 01, 2018

DOH: 2nd NJ Facility Reporting Adenovirus Outbreak & 10th Fatality At Wanaque Center


Adenoviruses - of which there are dozens - are a common cause of (generally mild) respiratory illnesses in both adults and children.  Serious illness can sometimes occur however, particularly in immunocompromised or medically fragile individuals.
For the past 9 days we've been following an Adenovirus 7 outbreak in the pediatric unit of a nursing and rehabilitation center in Haskell, NJ; one that has resulted in more than 2 dozen infections and - as of this morning - 10 deaths
The New Jersey Department of Health has also announced another (apparently milder) outbreak of an as-yet, unidentified adenovirus, in another pediatric facility in Voorhees, NJ.   Preliminary testing suggests this is not adenovirus 7.

Excerpts from 2 press releases.  First, on the second facility now reporting adenovirus cases.

Department of Health Awaits CDC Lab Results of Adenovirus Outbreak at Voorhees Pediatric Facility

Preliminary Results Rule Out Type 7

The Department of Health is awaiting additional laboratory test results from the Centers for Disease Control and Prevention (CDC) regarding four confirmed cases of adenovirus among pediatric patients at Voorhees Pediatric Facility in Voorhees. But, preliminary test results have ruled out Type 7, which caused the severe outbreak at the Wanaque Center for Nursing and Rehabilitation.

“The pediatric patients in Voorhees do not have the severity of illnesses we’re seeing among residents at the Wanaque Center for Nursing and Rehabilitation,” Health Commissioner Dr. Shereef Elnahal said. “While we cannot release private medical information, these patients in Voorhees are not in critical condition.” Dates of illness onset range between Oct. 20 and 27.

The Department, in conjunction with the Camden County Health Department, has been working with the facility to provide infection control recommendations and identify other possible illnesses since the facility notified the Department of a case of adenovirus in a resident on Oct. 26. “With any report of an outbreak of respiratory illness in a facility, public health officials collect data to confirm and characterize it as an outbreak,” Commissioner Elnahal said. “State and local public health officials have been working closely with Voorhees on this adenovirus outbreak.”
(Continue . . . )

A second press release updates the Wanaque outbreak.

NJ Department of Health confirms 10th death of Wanaque Center for Nursing and Rehabilitation Resident

A 10th medically fragile child confirmed to have the adenovirus infection has passed away. The child had been a resident of the Wanaque Center for Nursing and Rehabilitation in Haskell.

To date, a total of 27 pediatric cases have been associated with this outbreak. In addition, a staff member at the facility — who has since recovered — also became ill as part of the outbreak. The child had become ill before Oct. 22.

To date, the individuals associated with the outbreak became ill between Sept. 26 and Oct. 29. The affected children had severely compromised immune systems — including respiratory problems — before the outbreak began.

Adenovirus has an incubation period of two to 14 days, meaning that symptoms typically appear two to 14 days after exposure to the virus. This later onset of illness is not unexpected due to the long incubation period of adenovirus. The Department will not consider the outbreak over until four weeks after the last illness onset.

The facility will not admit new residents for the duration of the outbreak.

This is an active investigation of an outbreak of adenovirus so it is possible that lab tests will confirm additional cases. A Department of Health Communicable Disease Service staff member is on site at the facility and monitoring the outbreak. The Centers for Disease Control and Prevention (CDC) is assisting with lab testing and expertise.

“The loss of these young lives is heartbreaking, and our thoughts are with the families who are affected,” Health Commissioner Dr. Shereef Elnahal said. “We are working closely with the facility to conduct respiratory illness surveillance and ensure all infection control protocols are continuously followed. We are also engaging in discussions with the Centers for Medicare & Medicaid Services (CMS) on standards for these facilities.”

A Department of Health team of infection control experts and epidemiologists will visit University Hospital and four pediatric long-term care facilities — including Wanaque — in November to conduct training and assessments of infection control procedures, Commissioner Elnahal announced earlier this week.

(Continue . . .)

We've looked at severe adenovirus outbreaks in the past, including a multi-state outbreak of virulent serotype Ad14 a dozen years ago (see 2007 MMWR Acute Respiratory Disease Associated with Adenovirus Serotype 14 --- Four States, 2006—2007) and in 2012, China: Hebei Outbreak Identified As Adenovirus 55.

In 2016, we looked at a report in the EID Journal: Human Adenovirus Associated with Severe Respiratory Infection, Oregon, USA, 2013–2014, that described a relatively large outbreak in the Pacific Northwest.
During October 2013–July 2014, Oregon health authorities identified 198 persons with respiratory symptoms and an HAdV-positive respiratory tract specimen. Among 136 (69%) hospitalized persons, 31% were admitted to the intensive care unit and 18% required mechanical ventilation; 5 patients died. 

Molecular typing of 109 specimens showed that most (59%) were HAdV-B7, followed by HAdVs-C1, -C2, -C5 (26%); HAdVs-B3, -B21 (15%); and HAdV-E4 (1%). Molecular analysis of 7 HAdV-B7 isolates identified the virus as genome type d, a strain previously identified only among strains circulating in Asia. 
The authors warned:

Patients with HAdV-B7 were significantly more likely than those without HAdV-B7 to be adults and to have longer hospital stays. HAdV-B7 might be reemerging in the United States, and clinicians should consider HAdV in persons with severe respiratory infection.

When respiratory viruses like Adenovirus 7 cause illness and/or deaths in the broader community they often go unnoticed or are assumed to be due to a cold or influenza. 
When they happen in an institution populated with medically fragile individuals, outcomes are often more serious, and outbreaks more easily identified. 
Adenoviruses, rhinoviruses, parainfluenza viruses, and a host of other non-influenza viruses typically outnumber influenza viruses year round, and even during the height of the 2009 H1N1 pandemic, roughly 70% of the respiratory samples sent to the CDC for analysis were not positive for the influenza virus (see ILI’s Aren’t Always The Flu).

Graph based On CDC Flu Data early October 2009
Good reasons why practicing good flu hygiene (washing hands, covering coughs, & staying home if sick) should be a year-round practice, even if you've had your flu shot.

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