1. No category

 Special Focus on
Respiratory Syncytial Virus (RSV)
Strategies for Reducing the Risk of
Respiratory Syncytial Virus Infection
in Infants and Young Children:
A Canadian Nurses’ Perspective
Marianne Bracht, RN, RSCN
Debbie Basevitz, RN
Marilyn Cranis, RN
Rose Paulley, BN
Bosco Paes, MBBS, FRCPI, FRCPC
R
pneumonia, hospitalization, and even death in preterm infants
children by two years of age and is the leading and other high-risk children.2–6 Aside from concerns regardcause of pediatric lower respiratory tract infections (LRTIs)
ing acute disease, RSV infection in infancy is a risk factor
worldwide.1 A recent systematic
for the development of other
review estimated that in 2005, a
medical conditions later in life.
total of 33.8 million new cases
Numerous epidemiologic and
Abstract
of RSV-associated LRTIs were
clinical studies have found that
Respiratory syncytial virus (RSV) infections are prevalent
diagnosed globally in children
RSV-induced LRTI in infancy
globally and can cause substantial morbidity in infants and
,5 years of age.1 Approximately
predisposes children to recurrent
young children. The virus is easily transmitted by direct
hand-to-hand contact and can lead to serious respiratory
96 percent of these infections
Continuing Nursing Education
disease and hospitalization, particularly in premature infants
occurred among children in
(CNE) Credit
and
children
with
certain
medical
conditions.
Educating
developing countries. In addiA total of 3.1 contact hours may be
families
with
young
children,
especially
those
in
remote
rural
tion, an estimated 66,000 –
earned as CNE credit for reading the
regions, regarding the potential adverse health outcomes of
199,000 children ,5 years
articles in this issue identified as CNE
RSV infection and measures to reduce the risk of transmitting
and for completing an online post-test
of age died from severe RSV
or acquiring RSV has been a key focus of the health care
and ­e valuation. To be successful the
disease; most (99 percent) of
learner must obtain a grade of at least
system in Canada. Geographic, cultural, and socioeconomic
these reported deaths occurred
80% on the test.
factors present formidable challenges to the execution of this
in nonindustrialized nations.1
endeavor. Therefore, it is critical to develop and systematically
Disclosure
A lt hough R SV infect ion
implement effective educational programs for both families
Jamie L. Kistler, PhD, provided medical
writing and editorial support to the
manifests as mild, cold-like upper
and health care providers. In Canada, nurses play a critical
authors of this article. She is an employee
role in education and counseling. In this review, we share
respiratory tract symptoms in
of Complete Publication Solutions,
our
perspectives
and
suggest
empirical
practices
that
may
be
most full-term infants and older
LLC, which received financial support
applicable worldwide.
from Abbott for the preparation of this
children, it can lead to severe
article. See the Acknowledgments section
LRTIs such as bronchiolitis and
espiratory syncytial virus (RSV) affects near ly
a ll
for full details.
Accepted for publication May 2012.
N E O N ATA L   N E T W O R K
VOL. 31, NO. 6, NOVEMBER/DECEMBER 2012
© 2012 Springer Publishing Company 357
http://dx.doi.org/10.1891/0730-0832.31.6.357
wheezing, bronchial hyperreactivity, obstructive sleep apnea,
and asthma.7,8 In addition, hospitalization for RSV infection
before the age of two has been shown to be an inde­pendent
risk factor for the development of asthma.9 Although the
link between RSV infection and short- and long-term airway
obstruction and airway hyperreactivity has been clearly established in animal models,10,11 there is ongoing debate regarding the causal relationship between RSV and asthma in
children.12,13 It is likely that several factors play a role in determining the risk for respiratory morbidity, including family
history of atopy, genetic predisposition, immune modulation
of the airways postinfection, and baseline lung function prior
to an LRTI.13–22 Regardless of the underlyig etiology, studies
have shown that children infected with RSV are more likely
to experience wheezing during their first year of life23 and to
develop recurrent wheezing by six years of age.24 Although
wheezing generally resolves during adolescence,24 features of
asthma may persist until 18 years of age.25
In addition to respiratory morbidity, RSV infections
are associated with a negative impact on children’s overall
health-related quality of life26,27 and a significant increase
in health care resource use and mortality. 28 The impact of
RSV-associated hospitalizations on the emotional well-being
of the family is also substantial. Levels of stress and anxiety
have been shown to increase among caregivers of patients
hospitalized for RSV disease, with these effects extending
as long as 60 days posthospitalization.27 This stress may be
attributed to several factors, including caregiver response to
the child experiencing symptoms of RSV infection; anxiety
and concern regarding the child’s admission to a pediatric
intensive care unit (PICU) or diagnostic or treatment procedures the child must undergo; separation of the child from
the home and family during the hospital stay; and disruption of daily routine and sleep schedule.27 Direct and indirect
costs of RSV-associated hospitalizations, including time and
financial burdens on the family (for travel costs, lost work
time, or child care expenses) can also be significant.29
Canada is not an exception to the high prevalence and
impact of RSV disease. During recent RSV seasons in
Canada, the average annual hospitalization rate because
of RSV disease was estimated to be as high as 2,100 per
100,000 in infants ,6 months of age. 30 By comparison,
hospitalization rates attributed to inf luenza during this
same time period were lower regardless of age group, with
the highest rates of ­i nfluenza-associated hospitalizations
seen among infants six to 11 months of age (200 per
100,000).30 Remote communities in northern Canada, in
particular, have some of the highest rates of RSV-associated
hospitalizations in the world.31 A retrospective study of the
northern Canadian communities examined hospitalization
rates because of LRTI in infants and found that 29 percent
of all admissions tested positive for RSV. 31 In this study,
the hospitalization rate from an almost exclusive Inuit
population was a remarkable 590 admissions per 1,000 live
births.31
SEASONALITY OF RESPIRATORY
SYNCYTIAL VIRUS INFECTIONS
The timing of the RSV season and peak incidence of infections varies substantially by geographic region. In countries like
Canada and the United States with a temperate climate, most
RSV infections generally occur in the winter months, between
December and March (Figure 1).32–34 Warmer regions are often
associated with an earlier onset and/or longer duration of the
RSV season.35 Tropical and subtropical regions generally experience peak periods of RSV infection during the first half of the
year, sometimes in association with the rainy season; however,
timing is quite variable and in some countries, RSV outbreaks
occur year-round.36–39 The World Health Organization has
published methodologies to assist in the diagnosis of RSV
infection, surveillance of RSV-related LRTIs, and determination of seasonal variations in RSV outbreaks.4 Surveillance
programs are critical to help anticipate future onset of the RSV
season and control RSV outbreaks through timed implementation of infection control measures and programs that supplement year-round educational initiatives.
RISK FACTORS FOR ACQUIRING
RESPIRATORY SYNCYTIAL VIRUS AND/
OR DEVELOPING SERIOUS RESPIRATORY
SYNCYTIAL VIRUS DISEASE
Although all infants and young children are at risk for
acquiring RSV and developing subsequent respiratory disease,
certain demographic, clinical, and environmental risk factors
are associated with increased risk (Table 1).35 The number
of patients with these risk factors is large. For prematurity
alone, 8 percent (.30,000) of the 376,000 infants born in
Canadian hospitals between 2009 and 2010 were born before
37 completed weeks’ gestation.40 It is important to note that
even in children without these additional risk factors, serious
RSV disease is still a significant cause of hospitalization. In a
large surveillance study of U.S. children ,5 years of age, only
34 percent of hospitalizations caused by documented RSV
infection were in children with high-risk medical conditions,
including prematurity (,36 weeks’ gestation) and chronic
pulmonary, cardiac, kidney, or immunodeficiency disease.41
This suggests that strategies and education targeting only
these “high-risk” children may not adequately impact the
overall burden of RSV infection.41 In this review article, we
share our perspectives on strategies to prevent the spread of
RSV and reduce the risk of serious RSV disease among all
infants and young children, including effective approaches
for education of health care staff and caregivers. Useful educational tools and additional resources can be found in a
companion article in this special issue.42
REDUCING THE RISK OF RESPIRATORY
SYNCYTIAL VIRUS INFECTION IN CANADA
The Role of the Nurse in Education
In the Canadian health care system, nurses play a central
role in the education of families, caregivers, and health care
N E O N ATA L   N E T W O R K
358 NOVEMBER/DECEMBER 2012, VOL. 31, NO. 6
FIGURE 1 n National trends in RSV antigen detection in (A) Canada (September 2009–August 2010) and (B) the United States
(November 2010–October 2011).33,34
A. Canada
Total Tests
December–March
7500
30
5000
20
2500
10
0
0
9-05-09
10-03-09 10-31-09 11-28-09 12-26-09
1-23-10
2-20-10
3-20-10
4-17-10
5-15-10
6-12-10
7-10-10
Percentage of Positive Tests
40
10000
8-07-10
B. United States
Percentage of Positive Tests
30
25
Antigen Detection
Virus Isolation
20
December–March
15
10
5
11
11
9-
5-
-2
10
-1
1
-1
10
-1
-1
1
10
11
17
3-
9-
-1
1
9-
11
20
6-
8-
-1
1
8-
11
23
9-
7-
-1
1
7-
11
25
6-
-1
1
11
-
6-
-1
1
28
5-
-1
1
14
30
4-
5-
-1
1
11
16
2-
4-
-1
1
4-
11
19
5-
3-
-1
1
3-
11
19
5-
2-
-1
1
2-
11
22
1-
10
8-
1-
10
5-
12
-2
0
12
-1
1-
-1
-1
11
-
13
11
-
27
0
0
Abbreviation: RSV 5 respiratory syncytial virus.
staff. Nurses have regular contact with patients and caregivers
and this hands-on experience, including education and counseling of families, can be shared with colleagues. Bedside
nurses in particular, through their direct contact with families, can establish a unique bond and strong level of trust—
characteristics that are often essential for effective counseling
and education of caregivers. This relationship allows for more
effective one-on-one counseling, as well as education by the
broader health care team to better meet the learning needs
of the caregivers.
It is important to note that in Canada, which consists
of ten different provinces and three territories, expansive
TABLE 1 n Demographic, Clinical, and Environmental Factors That Increase the Risk of Acquiring RSV and/or Developing
Serious RSV Disease
Demographic Factors
birth102–104
• Premature
• Male gender105,106
• Low birth weight for gestational age107
• ,12 weeks of age at start of RSV season102,104
• Twins or higher multiples108
Clinical Factors
Environmental Factors
conditions109–112
• CLD, other respiratory
• CHD, cardiac anomaly6,111,113
• Cystic fibrosis112,114
• Down syndrome115,116
• Neuromuscular disease112,117,118
• Immunodeficiency117,119
• Congenital malformations*,112,120
• Day care attendance104
• School-age siblings102,121
• High number of people in the home or
sharing a bedroom105,108
• Lack of breastfeeding121
• Tobacco smoke exposure102,122,123
• Use of wood burning stoves†,124,125
• Nosocomially acquired RSV6,126
Abbreviations: CLD 5 chronic lung disease of prematurity; CHD 5 congenital heart disease; RSV 5 respiratory syncytial virus.
*Includes spina bifida without anencephaly; cleft lip and palate; agenesis; hypoplasia; dysgenesis of the lung, larynx, trachea, and bronchi;
malformations of the gastrointestinal tract and urinary system; and biliary atresia.112,120
†Studies demonstrated an increased risk of lower respiratory illness (not specific to RSV-associated disease).
N E O N ATA L   N E T W O R K
VOL. 31, NO. 6, NOVEMBER/DECEMBER 2012 359
networking among nurses has been a critical component of
the development of national, regional, and local RSV educational programs. This collaboration and networking allows
sharing of best practices, access to updated health care information and research, and knowledge of policies and procedures at other hospitals, clinics, and/or physicians’ offices
that can be applied broadly. National, regional, and local
pre- and post-RSV season meetings among nurses and other
health care providers serve as an effective forum for establishing contacts and expanding the health care network, building on existing educational and risk reduction programs, and
discussing needs for future research initiatives.
KEY INFORMATION REGARDING
RESPIRATORY SYNCYTIAL
VIRUS INFECTION AND RISK
REDUCTION STRATEGIES
Whether a nurse or other health care provider is responsible for education, it is important that ongoing instruction
and educational materials regarding RSV infection and risk
reduction be provided to both health care staff members as
well as caregivers with young children. Key areas of focus
should include (a) strategies for reducing the spread of RSV
in the hospital and the home, (b) mechanisms of viral transmission, (c) recognition of symptoms of RSV-related disease,
and (d) strategies to cohort and isolate children when there
is an RSV infection. It is also important to emphasize that
RSV infection does not confer protective immunity and children may become re-infected, most often before the age of
24 months.43 In older children and adults, the symptoms of
RSV infection are generally mild and cold-like (e.g., cough,
low-grade fever, stuffy or runny nose) and appear within four
to five days. 2,3,44 As discussed, all infants and young children are at risk of developing RSV disease; however, those
with certain risk factors have increased susceptibility to development of LRTIs, such as bronchiolitis and pneumonia.35
Severe symptoms include high fever, nasal f laring, severe
cough, wheezing, difficulty breathing and/or shortness of
breath, apnea, and hypoxia with possible cyanosis. 2,3,44,45
Infants often seem irritable, listless, and have a decreased
appetite because of these symptoms, predominantly because
young infants are obligatory nasal breathers and congestion
of the nares impedes normal coordinated sucking and swallowing activity.2,3 Caregivers should be educated to recognize
the more severe signs of RSV disease that require immediate
medical attention, such as apnea, tracheal tug, nasal flaring,
grunting, wheezing, apparent lethargy, difficulty feeding,
and cyanosis.2,46
Respiratory syncytial virus is actively shed in saliva and
nasopharyngeal secretions from infants and young children with LRTIs.47 These secretions contain high levels of
the virus, which last from several days up to three weeks.47
Viral spread occurs most commonly by direct hand-to-hand
contact. Indirect transmission is also possible; for example,
touching a surface contaminated with droplets of infected
nasal or oral secretions from a cough or sneeze.48 The virus
remains stable for up to seven hours on nonporous surfaces
and approximately 10–20 minutes on skin.49 Strategies for
reducing the risk of spreading RSV infection can be tailored
for various settings such as the home, day care, hospital, or
physician’s office or outpatient clinic (Figure 2). Regardless
of the setting, proper hand hygiene and cleaning surfaces
that may be exposed to infected secretions, including handheld devices and keyboards, are important and simple steps
that can be taken to reduce the risk of transmitting the virus.
Because RSV rapidly gains entry through the membranes
lining the eyes, nose, and mouth, individuals often become
infected when they unknowingly touch infected secretions
with their hands and subsequently touch these areas. Thus,
the use of a catchphrase in educational materials such as
“Where have your hands been and where are they going?”
can be a great reminder for health care staff and caregivers
to wash their hands regularly. Nurses can collaborate with
infection control teams or other health care staff to develop
brochures and posters on hand hygiene that are displayed
year-round in public areas, such as elevators, waiting areas,
and patient rooms. The toolkit in this issue provides an
example poster that includes information on hand hygiene,
as well as key educational points for caregivers and steps to
help reduce the spread of RSV in the hospital setting.
EDUCATIONAL STRATEGIES
FOR HEALTH CARE STAFF
Programs to educate health care staff are important for
minimizing the spread of viral infections and can be directed
by nurses or other health care providers. Educational campaigns related to viral risk reduction measures should take
place year-round in the hospital, clinic, and physicians’
offices, but should be reemphasized just prior to and during
the RSV season (e.g., November–March in Canada). These
campaigns, which can be extended to other settings such
as day care centers, might include distribution of posters,
brochures, and other educational materials, development of
training websites or discussion forums, and presentation of
educational programs. Recommended topics include standard practices for preventing or reducing the spread of respiratory viruses; basic infection control measures; recognition
of respiratory symptoms among caregivers and staff members
that would require restriction of visitors and work abstinence,
respectively, to reduce viral spread; procedures for isolating
patients with a viral infection; key demographic and clinical
factors that may increase a child’s risk of acquiring RSV or
developing serious respiratory disease; national or regional
guidelines for identification of high-risk patients; and guidance for effective education of caregivers.
In the hospital setting, adherence to basic risk reduction
strategies (see Figure 2) has been demonstrated to successfully reduce RSV nosocomial infections.50 Such strategies,
which should align with hospital infection prevention policies, include diligent hand hygiene with any patient contact;
N E O N ATA L   N E T W O R K
360 NOVEMBER/DECEMBER 2012, VOL. 31, NO. 6
FIGURE 2 n Strategies to reduce the risk of acquiring and/or transmitting RSV.
In the Home
✓ Practice good hand hygiene.
Wash hands thoroughly with
soap and warm water (or hand
sanitizer if hands are not
soiled) before touching an
infant
✓ If possible, avoid day care
✓ If possible, avoid crowded
areas
✓ Breastfeed infants
✓ Avoid exposure to tobacco
smoke
✓ Avoid travel (especially by air)
during the RSV season
✓ Clean/sanitize toys and books
regularly
If RSV infection occurs:
✓ If caregivers are sick, minimize
close contact (avoid kissing)
and always wash hands before
touching the infant/child
✓ Try not to share toys when one
child is ill–clean toys before
any sharing
✓ Keep infant/child away from
those who are sick
✓ Do not allow visitors who are
sick
In the Hospital
✓ Practice good hand hygiene–
In the Clinic/
Physician’s Office
✓ Practice good hand hygiene–
before and after any patient
contact
before and after any patient
contact
✓ Educate caregivers on hand
✓ Educate caregivers on hand
hygiene; encourage
breastfeeding; discuss other
strategies for risk reduction
hygiene; encourage
breastfeeding; discuss other
strategies for risk reduction
If RSV infection occurs:
✓ Follow appropriate infection
control guidelines
✓ Promptly identify and isolate
any infant, child, adult patient,
or caregiver with any cold
or respiratory symptoms
(e.g., sneeze, cough, runny
nose, fever)
✓ Promptly screen/test to identify
the specific virus
✓ Once the virus is isolated,
cohort patients and staff, if
possible
✓ Wear gloves, gowns, and
masks when there is a
respiratory infection; change
between patient contact
✓ Restrict visitors (caregivers
should not visit the hospital
unless healthy)
✓ Clean/sanitize toys and books
regularly–ideally, have
caregivers bring their own toys
and books to the child’s
appointment
✓ Routinely disinfect other
susceptible surfaces (i.e., those
exposed to hand contact or
droplets from infected coughs)
in the waiting room and office
If RSV infection occurs:
✓ Follow appropriate infection
control guidelines
✓ Promptly identify and isolate all
persons with respiratory
symptoms (including patients
and caregivers)
✓ Wear gloves, gowns, and
masks when there is a
respiratory infection; change
between patient contact
Different measures of infection control are relevant for various settings, as shown. In each case, emphasis on good hand washing techniques is
important because this is the primary means for reducing the spread of RSV. If RSV infection does occur, separate measures are recommended for
reducing further transmission.
Abbreviation: RSV 5 respiratory syncytial virus.
immediate isolation of patients at the first sign of respiratory
illness such as cough, runny nose, fever, apnea, and wheezing; restriction of visitors; protective measures when isolation
is required (wearing of gloves, gowns, and masks and changing between patients); and cohorting of hospital personnel to
care for isolated patients.51,52 Infectious respiratory secretions
are easily spread by patients, caregivers, and health care staff
in a hospital setting. Although specific barrier methods for
isolation of RSV-positive patients vary, a study of Canadian
pediatric hospitals found that in all cases, patients were isolated to a single room or cohorted with other RSV-positive
patients to avoid further spread of infection.53
Educational campaigns regarding RSV risk reduction
should be conducted in accordance with general infection
prevention policies, whether in a hospital, physician’s office, or
clinic. Consistent with national recommendations, these policies provide specific information on, for example, various types
of infections, possible routes of transmission, and the necessary duration of precautionary measures; proper hand washing
techniques; use of personal protective equipment (e.g., gowns,
gloves, masks); techniques for disinfecting, sterilizing, or cleaning infected surfaces, toys, and so forth; and identification of
patients who require isolation. Many resources are available to
provide guidance on general infection prevention in various
health care settings, including policies and recommendations
from the Public Health Agency of Canada,54 the Canadian
Paediatric Society, 55 the Centers for Disease Control and
Prevention,56,57 and the American Academy of Pediatrics.58
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VOL. 31, NO. 6, NOVEMBER/DECEMBER 2012 361
SPECIFIC RISK REDUCTION
STRATEGIES FOR CAREGIVERS
Education of family and caregivers by nurses or other
health care providers is critical to minimize the spread of
respiratory infections both in the hospital and once the child
is transferred home. The incidence of RSV infection is greatest during the winter months in Canada and other temperate
climates, but strategies to reduce the risk of any viral infection
should be emphasized all year. Educating families regarding
simple strategies for minimizing exposure to RSV is imperative. In addition to training on hand-washing techniques,
caregivers should be reminded not to bring any infant or
young child, especially those who are at high risk of acquiring
RSV or developing serious respiratory disease, to places where
many people frequent or where exposure to other sick individuals (children or adults) might be difficult to avoid, such as
day care or family gatherings. Because crowded areas cannot
always be avoided, care providers should be counseled on
strategies to minimize the possibility of RSV transmission in
these settings. Written educational guides, such as the Family
Teaching Toolbox59,60 shown in Figure 3, can be provided to
caregivers year-round, in addition to instituting educational
sessions to review the materials and help answer any questions they may have. Such educational guides should concisely
summarize the most critical information about RSV, modes
of viral transmission, clinical symptoms and consequences of
infection, strategies to reduce the risk of acquiring or spreading RSV, and resources for additional information.
FIGURE 3 n Sample RSV educational guide: the Family Teaching Toolbox.
A portion of the RSV Parent Education and Communication Toolkit, developed by Bracht et al.,60 is shown. The entire toolkit consists of three
informational letters provided to caregivers prior to and during the RSV season, each of which is accompanied by an educational pamphlet. The
Family Teaching Toolbox portion of this pamphlet provides an overview of RSV, its symptoms, preventative measures, and resources for further
information.
Abbreviation: RSV 5 respiratory syncytial virus.
Adapted from Bracht M, Heffer M, O’Brien K. Family teaching toolbox. Preventing respiratory syncytial virus (RSV) infection. Adv Neonatal Care.
2005;5(1):50–51. Copyright by the National Association of Neonatal Nurses. Reprinted with permission.
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362 NOVEMBER/DECEMBER 2012, VOL. 31, NO. 6
IMPORTANT CONSIDERATIONS
FOR EFFECTIVE COUNSELING AND
EDUCATION OF CAREGIVERS
Low Literacy Skills
Written information is an important component of the
education of the infant’s caregivers. Literacy skills are necessary to understand medical information that is often complex
or specialized; for example, clinical and demographic risk
factors for RSV disease, recognition of LRTI symptoms,
potential adverse health outcomes, and risk reduction measures. Suboptimal literacy presents a significant challenge
for health care providers in effectively educating caregivers.
Importantly, the inability of caregivers to adequately read
and comprehend medical information may translate into
decreased use of risk reduction measures, reduced adherence to treatment regimens, and subsequently poorer health
outcomes for their child/children.61–63 Lack of understanding because of low literacy skills may be compounded by
other factors, such as anxiety or stress often associated with
making health care decisions.64 Many infants or young children who are at high risk of acquiring RSV and/or developing serious respiratory illness have other underlying clinical
conditions that may heighten this level of anxiety.
Although literacy rates vary by country, both literacy and
health literacy, which are separate but related measures, are
considered suboptimal among adults in many regions of the
world. For example, in Canada, approximately 9 million
people between the ages of 16 and 65 years are estimated
to be at a low literacy level, with overall rates varying substantially among the different Canadian provinces.65 In particular, 60 percent of people older than the age of 16 are
considered to be “health illiterate” based on standard criteria such as the International Adult Literacy and Skills Survey
health literacy scale.65 Similarly, a recent survey of American
adults (.16 years of age) found that approximately 40 percent
of participants were at a basic or below basic health literacy
­level.66 Skill levels in these categories ranged from a demonstrated understanding of written information when presented
in short prose text and simple documents to complete illiteracy in the English language.66
It is important for health care providers to acknowledge
that family members or other care providers with low literacy
skills may be too embarrassed to ask for assistance in interpreting written medical information. Thus, educational materials
should consistently be prepared with low-literacy readers in
mind. A good policy for preparing educational brochures or
other written materials is to use plain language, avoid technical jargon, and minimize the use of statistics.67 Materials
should be written at a sixth-grade reading level or less68 and
incorporate symbols, pictograms, and illustrations whenever
possible to improve understanding.69 This so-called “plain
language approach” ensures that the most pertinent information is provided in a concise, easy-to-read format.64 Having
the infant’s caregivers participate in the development of educational materials may increase their use and help ensure
broader understanding.70 Numerous tools and resources
are available to provide guidance in the preparation of educational materials appropriate for patients or care providers
with low health literacy. Helpful resources include a plain language thesaurus71 and “Simply Put” guide72 available from
the U.S. Centers for Disease Control and Prevention, which
provide simplified medical terminology for the development
of written and verbal communication materials targeted
to nontechnical audiences. A recent comprehensive review
article by Menghini73 outlines strategies for the development
of educational tools specific for caregivers of infants in the
NICU. These recommended strategies, many of which can be
applied broadly to the health education of caregivers, are centered on the need for written materials to be easily readable, as
well as culturally sensitive. Numerous resources are provided
in this article, including health literacy websites, published
family teaching tools, methods for evaluating readability of
educational tools, and recommendations to assess caregivers’
reading and comprehension abilities.73 Finally, it should be
noted that many initiatives are underway in Canada, at the
national, provincial, and local levels, to improve health literacy using various approaches. These include programs and
workshops targeted toward low-literacy caregivers, provision
of health information through plain language pamphlets,
preparation of educational materials written in nonnative languages, and use of nontraditional means of communication
such as comic books and audiovisual media.65
CULTURAL DIFFERENCES
It is clear that effective communication between health
care providers and caregivers can also be impacted by cultural or ethnic differences. Whether this can be attributed
to physician or patient communication behaviors, perceptual biases, language barriers, or a combination of these
and other factors is somewhat unclear.74 Numerous studies
have been conducted to better understand how unique
cultural backgrounds of patients and their care providers
might affect communication with health care providers and
interpretation of medical information. In one study that
evaluated cultural variations in response to end-of-life care,
the authors suggest that health care providers consider
potential differences in values or beliefs based on culture
but maintain an individualized approach to care, avoiding
inferences and stereotyping.75 Several recommended guidelines that may be helpful in a variety of clinical settings
include assessing the language used to discuss the patient’s
illness; considering the relevance of religious beliefs; determining who makes the decisions on behalf of the patient
(e.g., a patriarch or larger social unit); taking into account
political or historical context including past discrimination and socioeconomic status; considering gender, age,
and power relationships within the patient’s family and
in interactions with the health care team; and making
use of available resources, such as community or religious
leaders or professional medical translators.75 A variety of
N E O N ATA L   N E T W O R K
VOL. 31, NO. 6, NOVEMBER/DECEMBER 2012 363
valuable resources, including culture-specific case studies,
an overview of “cultural competence,” and links to various
texts and references on cultural diversity in the clinic,
are available through the Transcultural Nursing website
(http://www.culturediversity.org/index.html). Although
it is acknowledged that developing a culturally competent
program is a constantly evolving process, five key elements
are emphasized: (a) value diversity, (b) have the capacity for
cultural self-assessment, (c) be conscious of the dynamics
inherent when cultures interact, (d) have institutionalized
cultural knowledge, and (e) have in place developed adaptations of service delivery reflecting an understanding of
cultural diversity.76
TREATMENT OPTIONS FOR RESPIRATORY
SYNCYTIAL VIRUS DISEASE
Many families with infants and young children are
unaware of the potentially serious consequences of RSV
infection. In addition to educating caregivers on simple
strategies to help reduce the risk of their child acquiring
RSV or other respiratory viruses, it is also important to
emphasize the potential acute and long-term clinical consequences of RSV infection and current means of treating children who develop an LRTI. Caregivers should be
made aware that the onset of severe symptoms, such as difficulty breathing, wheezing, hypoxia, or lethargy, necessitates immediate medical attention and will likely require
hospitalization with supportive care measures. According to
current evidence-based clinical practice guidelines and comprehensive reviews,77–81 supportive care remains the primary
means of treatment for bronchiolitis and routinely includes
administration of intravenous fluids for infants who have
difficulty feeding, clearance of nasal passages, and supplemental oxygen—mechanical ventilation may be required in
the case of severe RSV disease. Numerous treatment options
have been explored, including bronchodilators, systemic and
inhaled steroids, steam inhalation, and antibiotic regimens,
but none of these options have consistently demonstrated
clinical efficacy.77,79–86 Nebulized hypertonic saline with
or without epinephrine appears safe and may have benefit
as an initial intervention, but further large-scale trials of
this therapeutic strategy are needed.87–89 To date, there are
no curative medical therapies for RSV-related LRTIs. The
only antiviral therapy available in certain countries is ribavirin, but it is not routinely recommended because of the
low benefit–risk ratio for most patients.79,90,91 Experimental
studies involving small interfering RNAs (siRNAs), which
target mRNA of the RSV nucleocapsid protein, are being
explored for the active treatment of RSV infection. These
drugs appear promising,92–94 but safety and efficacy need to
be evaluated in large-scale randomized, controlled pediatric
clinical trials.
In many countries, including Canada, 95 the United
States,79,96 and European countries,97–100 prophylaxis with
palivizumab is the only current evidence-based medical
intervention recommended to help reduce the risk of serious
RSV disease in high-risk infants and young children. Health
care providers should discuss with caregivers the specific
eligibility criteria that are required for their child to receive
­palivizumab prophylaxis, means of administration, possible
adverse effects, and the importance of compliance.
SUMMARY: EMPIRICAL PRACTICE
RECOMMENDATIONS
We have emphasized in this article the important role of
nurses in providing education to both health care providers and caregivers to help reduce the risks of transmitting
RSV and other respiratory viruses and thus help protect all
infants and young children from developing serious respiratory disease. Despite the potential for significant morbidity
and mortality associated with RSV disease, very simple strategies can be employed to help reduce the spread of the virus.
However, risk reduction requires effective education and
year-round programs to ensure that both health care providers and caregivers understand and implement these strategies both consistently and effectively. In Canada, challenges
to implementing educational programs include population
disparities and large geographic distances between metropolitan areas and the many remote communities in northern
regions of the country. In addition, cultural differences and
language barriers hinder clear communication and understanding. Overcoming these challenges, which are certainly
not unique to Canada, has become a key focus of the health
care system.
It has been our experience that reducing rates of RSV
infection depends on three core practices: (a) educational
campaigns on RSV epidemiology, seasonality, and burden of
disease, and infection prevention measures targeted toward
health care providers that care for infants and young children (i.e., at hospitals, pediatricians’ offices, community
clinics, and/or remote outpost centers); (b) year-round
education of all caregivers with infants and young children; and (c) extensive networking among nurses or other
health care providers to ensure knowledge and sharing of
policies, procedures, best practice recommendations, and
ongoing research. In many provinces in Canada, RSV educational programs are generally located at larger tertiary or
Level II hospitals by a collaborative group consisting of a
medical director or physician(s), nurse(s), pharmacist(s),
and other health care staff. These programs serve as a focal
point for national, regional, and local efforts to reduce the
spread of RSV. In a companion article in this special issue,
Bracht and colleagues101 describe some of the objectives of
these programs, including the design and implementation
of educational campaigns within their own hospital/clinic;
overseeing the development of easy-to-read, culturally sensitive educational materials and their distribution to families
across Canada; educational outreach and networking with
N E O N ATA L   N E T W O R K
364 NOVEMBER/DECEMBER 2012, VOL. 31, NO. 6
other hospitals, physicians’ offices, community clinics, and/
or outpost centers, especially in rural and remote regions of
the country; and attendance at national, regional, and local
meetings/workshops and sharing of information garnered
from these meetings. In particular, networking and collaboration have been essential for broad understanding of the
impact of RSV infection and optimized care for infants and
young children across Canada.
ACKNOWLEDGMENTS
Abbott Laboratories funded the development of this
article by Complete Publication Solutions, LLC. Debbie
Basevitz, RN, is on the national advisory committee sponsored by Abbott Canada and received funding to attend an
advisory meeting.
Marianne Bracht, RN, RSCN, Marilyn Cranis, RN, and
Rose Paulley, BN, have received support from Abbott Canada
in the form of unrestricted educational grants in sponsorship of their respective institutional RSV programs. They
have received honoraria or travel support for presentations
at Abbott-sponsored professional meetings. They are on the
national advisory committee sponsored by Abbott Canada
and have received funding to attend advisory meetings.
Bosco Paes, MBBS, FRCPI, FRCPC, has received honoraria or research support from Abbott Laboratories for his
roles as consultant, coprincipal investigator, and on a speakers bureau.
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About the Author
Marianne Bracht has over 38 years of nursing experience in neonatology, both in the neonatal intensive care unit (NICU) and neonatal
follow-up clinic predominantly at Mount Sinai Hospital, Toronto. Since
1999 she has served as parent resource nurse, coordinating and leading
educational programs and providing support to NICU parents. She is
involved in research specifically related to family-integrated care and
has coordinated the NICU RSVP program at Mount Sinai since its
inception in 1999.
Rose Paulley has 25 years of pediatric and neonatal experience. She
has been Manitoba’s RSV Prophylaxis Program Coordinator for 8 years
at the Children’s Hospital in Winnipeg.
Marilyn Cranis has 33 years of nursing experience and 22 years
working in the cardiac program at the Hospital for Sick Children.
For the past 9 years she has served as Cardiac RSV Program
Coordinator.
Debbie Basevitz has worked in neonatology and pediatrics for
the past 49 years. She has been the nurse coordinator of the neonatal
­follow-up clinic at the Jewish General Hospital in Montreal since 1984
and has been the RSV Program Coordinator since 1998.
Dr. Bosco Paes is Professor Emeritus, Department of Pediatrics, at
McMaster Children’s Hospital, McMaster University, in Hamilton,
Ontario. He was the medical director and a pioneer of the neonatal
nurse practitioner program in neonatology in Canada. His current
research interests focus predominantly on RSV in infants and hematology in the neonatal population.
Creative Commons License
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For further information, please contact:
Marianne Bracht, RN, RSCN
Neonatal Intensive Care Unit
Mount Sinai Hospital
775 A-600 University Avenue
Toronto, Ontario
M5G 1X5, Canada
E-mail: mbracht@mtsinai.on.ca
N E O N ATA L   N E T W O R K
368 NOVEMBER/DECEMBER 2012, VOL. 31, NO. 6