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Section 3. Summaries of Infectious Diseases
Respiratory Syncytial Virus
Clinical ManifestationsEtiology
Epidemiology
Diagnostic Tests
Treatment
Isolation of the Hospitalized Patient
Control Measures
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CLINICAL MANIFESTATIONS
Respiratory syncytial virus (RSV) causes acute upper respiratory tract infection in patients of all ages and is one of the most common diseases of childhood. Most infants are infected during the first year of life, with virtually all having been infected at least once by the second birthday. Most RSV-infected infants experience upper respiratory tract symptoms, and 20% to 30% develop lower respiratory tract disease with their first infection. During the first few weeks of life, particularly among preterm infants, infection with RSV may produce minimal respiratory tract signs. Lethargy, irritability, and poor feeding, sometimes accompanied by apneic episodes, may be the presenting manifestations in these infants. Most previously healthy infants who develop RSV bronchiolitis do not require hospitalization, and most who are hospitalized improve with supportive care and are discharged in fewer than 5 days. Characteristics that increase the risk of severe RSV lower respiratory tract illness are preterm birth; cyanotic or complicated congenital heart disease, especially conditions causing pulmonary hypertension; chronic lung disease of prematurity; and immunodeficiency disease or therapy causing immunosuppression at any age. The association between RSV bronchiolitis early in life and subsequent reactive airway disease remains poorly understood. RSV bronchiolitis may be associated with short-term or long-term complications that include recurrent wheezing, reactive airway disease, and abnormalities in pulmonary function. This association may reflect an underlying predisposition to reactive airway disease rather than a direct consequence of RSV infection.
Reinfection with RSV throughout life is common. RSV infection in older children and adults usually manifests as upper respiratory tract illness. More serious disease involving the lower respiratory tract may develop in older children and adults especially in immunocompromised patients, the elderly, and in people with cardiopulmonary disease.
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ETIOLOGY
RSV is an enveloped, nonsegmented, negative strand RNA virus of the family Paramyxoviridae. The virus uses attachment (G) and fusion (F) surface glycoproteins that lack neuraminidase and hemagglutinin activities. Two major strains (groups A and B), each with numerous genotypes, have been identified, and strains of both groups often circulate concurrently. The clinical and epidemiologic significance of strain variation has not been determined, but evidence suggests that antigenic differences may affect susceptibility to infection and that some strains may be more virulent than others.
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EPIDEMIOLOGY
Humans are the only source of infection. Transmission usually is by direct or close contact with contaminated secretions, which may occur from exposure to large-particle droplets at short distances (<3 feet) or fomites. RSV can persist on environmental surfaces for several hours and for a half-hour or more on hands. Infection among hospital personnel and others may occur by hand to eye or hand to nasal epithelium self-inoculation with contaminated secretions. Enforcement of infection-control policies is important to decrease the risk of health care-related transmission of RSV. Health care-related spread of RSV to bone marrow or solid organ transplant recipients or patients with cardiopulmonary abnormalities or immunocompromised conditions has been associated with severe and fatal disease in children and adults.
RSV usually occurs in annual epidemics during winter and early spring in temperate climates. Spread among household and child care contacts, including adults, is common. The period of viral shedding usually is 3 to 8 days, but shedding may last longer, especially in young infants and in immunosuppressed people, in whom shedding may continue for as long as 3 to 4 weeks.
The incubation period ranges from 2 to 8 days; 4 to 6 days is most common.
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DIAGNOSTIC TESTS
Rapid diagnostic assays, including immunofluorescent and enzyme immunoassay techniques for detection of viral antigen in nasopharyngeal specimens, are available commercially and generally are reliable in infants and young children. In children, the sensitivity of these assays in comparison with culture varies between 53% and 96%, with most in the 80% to 90% range. The sensitivity may be lower in older children. As with all antigen detection assays, false-positive test results are more likely to occur when the incidence of disease is low. Therefore, antigen detection assays should not be the only basis on which the beginning and end of monthly prophylaxis is determined.
Viral isolation from nasopharyngeal secretions in cell culture requires 1 to 5 days (shell vial techniques can produce results within 24 to 48 hours), but results and sensitivity vary among laboratories. Experienced viral laboratory personnel should be consulted for optimal methods of collection and transport of specimens. Conventional serologic testing of acute and convalescent serum specimens cannot be relied on to confirm infection in young infants in whom sensitivity may be low. In some studies, polymerase chain reaction assays have increased RSV detection rates as much as twofold over viral isolation or antigen detection, but these assays are not widely available.
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TREATMENT
Primary treatment is supportive and should include hydration, careful clinical assessment of respiratory status, including measurement of oxygen saturation, use of supplemental oxygen, suction of the upper airway, and if necessary, intubation and mechanical ventilation. 199 Ribavirin has in vitro antiviral activity against RSV, and aerosolized ribavirin therapy has been associated with a small but statistically significant increase in oxygen saturation during the acute infection in several small studies. However, a consistent decrease in need for mechanical ventilation, decrease in length of stay in the pediatric intensive care unit, or reduction in days of hospitalization among ribavirin recipients has not been demonstrated. The aerosol route of administration, concern about potential toxic effects among exposed health care professionals, and conflicting results of efficacy trials have led to decreasing use of this drug. Ribavirin is not recommended for routine use but may be considered for use in select patients with documented, potentially life-threatening RSV infection.
Beta-adrenergic Agents Beta-adrenergic agents are not recommended for routine care of first-time wheezing associated with RSV bronchiolitis. Some physicians elect to use bronchodilator therapy because of concern that reactive airway disease may be misdiagnosed as bronchiolitis. Repeat doses of an inhaled bronchodilator may be continued in a minority of infants with well-documented improvement in respiratory function soon after the first dose, but its use is unlikely to alter the clinical course of RSV disease or to permit earlier hospital discharge.
Corticosteroid Therapy In most randomized clinical trials of hospitalized infants as well as outpatients with RSV bronchiolitis, corticosteroid therapy has been found to have no effect on disease severity or length of stay and is not recommended.
Antimicrobial Therapy Intravenous antimicrobial therapy is not indicated in infants hospitalized with RSV bronchiolitis or pneumonia unless there is evidence of secondary bacterial infection. Bacterial lung infections and bacteremia are uncommon in this setting. Otitis media occurs in infants with RSV bronchiolitis, but oral antimicrobial agents can be used if therapy for otitis media is necessary.
Prevention of RSV Infections Respiratory Syncytial Virus Immune Globulin Intravenous (RSV-IGIV), a hyperimmune, polyclonal globulin prepared from donors selected for high serum titers of RSV neutralizing antibody, no longer is available. Palivizumab, a humanized mouse monoclonal antibody, is licensed for prevention of RSV lower respiratory tract disease in certain infants and children with chronic lung disease of prematurity (CLD [formerly called bronchopulmonary dysplasia]), or with a history of preterm birth (less than 35 weeks’ gestation), or with congenital heart disease. Palivizumab is administered intramuscularly at a dose of 15 mg/kg once every 30 days. An attempt should be made to maintain compliance with monthly administration. In some reports, palivizumab administration in a home-based program has been shown to improve compliance and to reduce exposure to microbial pathogens compared with administration in office- or clinic-based settings. Additional doses of palivizumab should not be given to any patient with a history of a severe allergic reaction following a previous dose. Palivizumab is not effective in treatment of RSV disease and is not approved or recommended for this indication.
Cost Considerations Immunoprophylaxis with 5 monthly doses of palivizumab is an effective, though costly, intervention that reduces hospitalization rates by 39% to 82% among high-risk infants. Optimal cost benefit from immunoprophylaxis is achieved during peak outbreak months when most RSV hospitalizations occur. If prophylaxis is initiated after widespread RSV circulation has begun, high-risk infants may not receive the full benefit of protection. Conversely, early initiation or continuation of monthly immunoprophylaxis during months when RSV is not circulating widely is not cost-effective and provides little benefit to recipients.
The primary benefit of immunoprophylaxis is a decrease in the rate of RSV-associated hospitalization. No prospective, randomized clinical trial has demonstrated a significant decrease in the rate of mortality attributable to RSV or in the rate of recurrent wheezing following RSV infection among infants who receive prophylaxis. Economic analyses fail to demonstrate overall savings in health care dollars because of the high cost if all at risk infants receive prophylaxis.
Initiation and Termination of Immunoprophylaxis In the temperate climates of North America, peak RSV activity typically occurs between November and March, whereas in equatorial countries, RSV seasonality patterns vary and may occur throughout the year. The inevitability of the RSV season is predictable, but the severity of the season, the time of onset, the peak of activity, and the end of the season cannot be predicted precisely. Substantial variation in timing of community outbreaks of RSV disease from year to year exists in the same community and between communities in the same year, even in the same region. These variations occur within the overall pattern of RSV outbreaks, usually beginning in November or December, peaking in January or February, and ending by the end of March or sometime in April. Communities in the southern United States, particularly some communities in the state of Florida, tend to experience the earliest onset of RSV activity. In recent years, the national median duration of the RSV season has been 17 weeks or less. Results from clinical trials indicate that palivizumab trough serum concentrations more than 30 days after the fifth dose will be well above the protective concentration for most infants. Five monthly doses of palivizumab will provide more than 20 weeks of protective serum antibody concentration. In the continental United States, a total of 5 monthly doses for infants and young children with congenital heart disease or chronic lung disease of prematurity or preterm birth before 32 weeks’ gestation (31 weeks, 6 days) will provide an optimal balance of benefit and cost, even with variation in season onset and end.
For infants who qualify for 5 doses, initiation of immunoprophylaxis in November and continuation for a total of 5 monthly doses will provide protection into April and is recommended for most areas of the United States. If prophylaxis is initiated in October, the fifth and final dose should be administered in February.
Data from the Centers for Disease Control and Prevention (CDC) have identified variations in the onset and offset of the RSV season in the state of Florida that should affect the timing of palivizumab administration. Northwest Florida has an onset in mid-November, which is consistent with other areas of the United States. In north central and southwest Florida, the onset of RSV season typically is late September to early October. The RSV season in southeast Florida (Miami-Dade County) typically has its onset in July. Despite varied onsets, the RSV season is of equal duration in the different regions of Florida. Children who qualify for palivizumab prophylaxis for the entire RSV season (infants and children with chronic lung disease of prematurity or congenital heart disease or preterm infants born before 32 weeks’ gestation) should receive palivizumab only during the 5 months following the onset of RSV season in their region (maximum of 5 doses), which should provide coverage during the peak of the season, when prophylaxis is most effective (Table 3.59, p 565).
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View this table: [in a new window] | Table 3.59. Palivizumab Prophylaxis for Infants and Young Children With Chronic Lung Disease of Prematurity or Congenital Heart Disease |
Specific groups of American Indian/Alaska Native children in certain geographic regions may experience more severe RSV disease and a longer RSV season. RSV hospitalizations for Navajo and White Mountain Apache infants and young children may be 2 to 3 times those of children of similar ages in the United States population. However, the timing and duration of the RSV season is similar to the remainder of the United States (November through March), so standard recommendations for children with congenital heart disease, chronic lung disease of prematurity, or preterm birth (before 32 weeks’ gestation) still are appropriate. Alaska Native infants in the Yukon Kuskokwim (YK) Delta experience not only higher RSV hospitalization rates but also a longer RSV season. Pediatricians from the YK Delta may wish to use CDC-generated RSV hospitalization data from the YK Delta region to assist in determining the onset and offset of RSV season for the appropriate timing of palivizumab administration.
Infants and children with congenital heart disease or chronic lung disease or preterm infants less than 32 weeks’ gestation who initiate palivizumab prophylaxis after start of the RSV season will not require all 5 doses (see Table 3.60, p 565).
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View this table: [in a new window] | Table 3.60. Maximum Number of Monthly Doses of Palivizumab for Respiratory Syncytial Virus Prophylaxis |
Eligibility Criteria for Prophylaxis of High-Risk Infants and Young Children
Infants with CLD. Palivizumab prophylaxis may be considered for infants and children younger than 24 months of age who receive medical therapy (supplemental oxygen, bronchodilator, diuretic or chronic corticosteroid therapy) for CLD within 6 months before the start of the RSV season. These infants and young children should receive a maximum of 5 doses. Patients with the most severe CLD who continue to require medical therapy may benefit from prophylaxis during a second RSV season. Data are limited regarding the effectiveness of palivizumab during the second year of life. Individual patients may benefit from decisions made in consultation with neonatologists, pediatric intensivists, pulmonologists, or infectious disease specialists. A maximum of 5 monthly doses is recommended for patients in this category.
Infants born before 32 weeks’ gestation (31 weeks, 6 days or less). (See Table 3.61.) Infants in this category may benefit from RSV prophylaxis, even if they do not have CLD. For these infants, major risk factors to consider include gestational age and chronologic age at the start of the RSV season. Infants born at 28 weeks of gestation or earlier may benefit from prophylaxis during the RSV season, whenever that occurs during the first 12 months of life. Infants born at 29 to 32 weeks of gestation may benefit most from prophylaxis if younger than 6 months of age at the start of the RSV season. In this setting, 32 weeks’ gestation refers to an infant born before the 32nd week of gestation (31 weeks, 6 days or less). Once an infant qualifies for initiation of prophylaxis at the start of the RSV season, administration should continue throughout the season and not stop at the point an infant reaches either 6 months or 12 months of age. A maximum of 5 monthly doses is recommended for infants in this category.
Infants born at 32 to less than 35 weeks’ gestation (defined as 32 weeks, 0 days through 34 weeks, 6 days). (See Table 3.61.) Available data do not enable definition of a subgroup of infants at risk of prolonged hospitalization and admission to the intensive care unit. Therefore, current recommendations are intended to reduce the risk of RSV hospitalization during the period of greatest risk (the first 3 months of life) among infants with consistently identified risk factors for hospitalization. Palivizumab prophylaxis should be limited to infants in this group at greatest risk of hospitalization due to RSV, namely infants younger than 3 months of age at the start of the RSV season or who are born during the RSV season and who are likely to have an increased risk of exposure to RSV. Epidemiologic data suggest that RSV infection is more likely to occur and more likely to lead to hospitalization for infants in this gestational age group when at least one of the following two risk factors is present:
infant attends child care, defined as a home or facility where care is provided for any number of infants or young toddlers in the child care facility; or
infant has a sibling younger than 5 years of age.
Prophylaxis may be considered for infants from 32 through less than 35 weeks’ gestation (defined as 32 weeks, 0 days through 34 weeks, 6 days) who are born less than 3 months before the onset or during the RSV season and for whom at least 1 of the 2 risk factors is present. Infants in this gestational age category should receive prophylaxis only until they reach 3 months of age and should receive a maximum of 3 monthly doses; many will receive only 1 or 2 doses until they reach 3 months of age. Once an infant has passed 3 months of age (90 days of age), the risk of hospitalization attributable to RSV lower respiratory tract disease is reduced. Administration of palivizumab is not recommended after 3 months of age.
Infants, especially high-risk infants, never should be exposed to tobacco smoke. In published studies, passive household exposure to tobacco smoke has not been associated with an increased risk of RSV hospitalization on a consistent basis. However, exposure to tobacco smoke is a known risk factor for many adverse health related outcomes. Exposure to tobacco smoke can be controlled by the family of an infant at increased risk of RSV disease, and preventive measures will be less costly than palivizumab prophylaxis.
In contrast to the well-documented beneficial effect of breastfeeding against many viral illnesses, existing data are conflicting regarding the specific protective effect of breastfeeding against RSV infection. Breastfeeding should be encouraged for all infants in accordance with recommendations of the American Academy of Pediatrics. High-risk infants should be kept away from crowds and from situations in which exposure to infected people cannot be controlled. Participation in group child care should be restricted during the RSV season for high-risk infants whenever feasible. Parents should be instructed on the importance of careful hand hygiene. In addition, all high-risk infants 6 months of age and older and their contacts should receive influenza vaccine as well as other recommended age-appropriate immunizations.
Infants with congenital abnormalities of the airway or neuromuscular disease. Immunoprophylaxis may be considered for infants born before 35 weeks of gestation who have either congenital abnormalities of the airway or a neuromuscular condition that compromises handling of respiratory secretions. Infants and young children in this category should receive a maximum of 5 doses of palivizumab during the first year of life.
Infants and children with congenital heart disease. Children who are 24 months of age or younger with hemodynamically significant cyanotic or acyanotic congenital heart disease may benefit from palivizumab prophylaxis. Decisions regarding prophylaxis with palivizumab in children with congenital heart disease should be made on the basis of the degree of physiologic cardiovascular compromise. Children younger than 24 months of age with congenital heart disease who are most likely to benefit from immunoprophylaxis include:
Infants who are receiving medication to control congestive heart failure
Infants with moderate to severe pulmonary hypertension
Infants with cyanotic heart disease
Because a mean decrease in palivizumab serum concentration of 58% was observed after surgical procedures that use cardiopulmonary bypass, for children who still require prophylaxis, a postoperative dose of palivizumab (15 mg/kg) should be considered as soon as the patient is medically stable.
The following groups of infants are not at increased risk of RSV and generally should not receive immunoprophylaxis:
Infants and children with hemodynamically insignificant heart disease (eg, secundum atrial septal defect, small ventricular septal defect, pulmonic stenosis, uncomplicated aortic stenosis, mild coarctation of the aorta, and patent ductus arteriosus)
Infants with lesions adequately corrected by surgery, unless they continue to require medication for congestive heart failure
Infants with mild cardiomyopathy who are not receiving medical therapy for the condition
Dates for initiation and termination of prophylaxis should be based on the same considerations as for high-risk infants with CLD.
Immunocompromised children. Palivizumab prophylaxis has not been evaluated in randomized trials in immunocompromised children. Although specific recommendations for immunocompromised patients cannot be made, infants and young children with severe immunodeficiencies (eg, severe combined immunodeficiency or advanced acquired immunodeficiency syndrome) may benefit from prophylaxis.
Patients with cystic fibrosis. Limited studies suggest that some patients with cystic fibrosis may be at increased risk of RSV infection. Whether RSV infection exacerbates the chronic lung disease of cystic fibrosis is not known. In addition, insufficient data exist to determine the effectiveness of palivizumab use in this patient population. Therefore, a recommendation for routine prophylaxis in patients with cystic fibrosis cannot be made.
Other considerations.
Hospitalized infants who qualify for prophylaxis during the RSV season should receive the first dose of palivizumab 48 to 72 hours before discharge or promptly after discharge.
If an infant or child who is receiving palivizumab immunoprophylaxis experiences a breakthrough RSV infection, monthly prophylaxis should continue until a maximum of 3 doses have been administered to infants in the 32 to less than 35 weeks’ gestation group (defined as 32 weeks, 0 days through 34 weeks, 6 days) or until a maximum of 5 doses for infants with congenital heart disease, CLD, or preterm birth before 32 weeks’ gestation. This recommendation is based on the observation that high-risk infants may be hospitalized more than once in the same season with RSV lower respiratory tract disease and the fact that more than one RSV strain often cocirculates in a community.
RSV is known to be transmitted in the hospital setting and to cause serious disease in high-risk infants. Among hospitalized infants, the major means to reduce RSV transmission is strict observance of infection control practices, including prompt initiation of precautions for RSV-infected infants. If an RSV outbreak occurs in a high-risk unit (eg, pediatric or neonatal intensive care unit or stem cell transplantation unit), primary emphasis should be placed on proper infection control practices, especially hand hygiene. No data exist to support palivizumab use in controlling outbreaks of health care-associated disease, and palivizumab use is not recommended for this purpose.
Palivizumab does not interfere with response to vaccines.
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View this table: [in a new window] | Table 3.61. Maximum Number of Palivizumab Doses for RSV Prophylaxis of Preterm Infants Without Chronic Lung Disease, on the Basis of Birth Date, Gestational Age, and Presence of Risk Factors (Shown for Geographic Areas Beginning Prophylaxis on November 1)a |
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ISOLATION OF THE HOSPITALIZED PATIENT
In addition to standard precautions, contact precautions are recommended for the duration of RSV-associated illness among infants and young children, including patients treated with ribavirin. The effectiveness of these precautions depends on compliance and necessitates scrupulous adherence to appropriate hand hygiene practices. Patients with RSV infection should be cared for in single rooms or placed in a cohort.
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CONTROL MEASURES
The control of health care-associated RSV transmission is complicated by the continuing chance of introduction through infected patients, staff, and visitors. Because the major source of spread is through direct contact, hand hygiene or, preferably, routine utilization of gloves during inpatient and outpatient contact appears to be the most effective means of preventing health care-associated spread. During the peak of the RSV season, many infants and children hospitalized with respiratory tract symptoms will be infected with RSV and should be cared for with contact precautions (see Isolation of the Hospitalized Patient, above). Early identification of RSV-infected patients (see Diagnostic Tests, p 561) is important so that appropriate precautions can be instituted promptly. During community outbreaks of RSV, a variety of measures have been demonstrated to reduce the risk of health care-associated transmission, including the following: (1) laboratory screening of symptomatic patients for RSV infection; (2) cohorting of infected patients and staff; (3) excluding visitors with current or recent respiratory tract infections; (4) excluding staff with respiratory tract illness or RSV infection from caring for susceptible infants; (5) using gowns and gloves and, possibly, goggles or masks for protection of health care workers’ eyes; (6) emphasizing hand hygiene before and after direct contact with patients, after contact with inanimate objects in the direct vicinity of patients, and after glove removal; and (7) limiting young sibling visitation during the RSV season.
A critical aspect of RSV prevention among high-risk infants is education of parents and other caregivers about the importance of decreasing exposure to and transmission of RSV. Preventive measures include limiting, where feasible, exposure to contagious settings (eg, child care centers) and emphasis on hand hygiene in all settings, including the home, especially during periods when contacts of high-risk children have respiratory tract infections.
Respiratory Syncytial Virus Images
Clinical Manifestations Images See Text View larger version (130K): [in a new window] [Download PPT slide] | Image 109_07. Respiratory Syncytial Virus Chest radiography reveals hyperinflation and right upper lobe atelectasia in an infant with respiratory syncytial virus infection. |
 View larger version (127K): [in a new window] [Download PPT slide] | Image 109_05. Respiratory Syncytial Virus Respiratory syncytial virus bronchiolitis and pneumonia. Note the bilateral infiltrates and striking hyperaeration. |
 View larger version (185K): [in a new window] [Download PPT slide] | Image 109_03. Respiratory Syncytial Virus Green fluorescence indicates the presence of respiratory syncytial virus antigen in nasopharyngeal secretions. |
 View larger version (129K): [in a new window] [Download PPT slide] | Image 109_15. Respiratory Syncytial Virus An anterior-posterior radiograph of a 2 month old female with respiratory syncytial virus bronchiolitis. Note the wide intercostal spaces, hyperaeration of the lung fields, and flattening of the diaphragm. |
 View larger version (120K): [in a new window] [Download PPT slide] | Image 109_16. Respiratory Syncytial Virus Respiratory syncytial virus pneumonia shown in this anterior-posterior radiograph of a 6 month old male hospitalized in severe respiratory distress. |
 View larger version (124K): [in a new window] [Download PPT slide] | Image 109_14. Respiratory Syncytial Virus Respiratory syncytial virus bronchiolitis in the 2 month old female in the previous image. |
 View larger version (106K): [in a new window] [Download PPT slide] | Image 109_08. Respiratory Syncytial Virus Typical epidemiologic curve for respiratory syncytial virus - 1989-1990. |
 View larger version (97K): [in a new window] [Download PPT slide] | Image 109_02. Respiratory Syncytial Virus Direct fluorescent antibody staining of respiratory syncytial virus. |
 View larger version (137K): [in a new window] [Download PPT slide] | Image 109_10. Respiratory Syncytial Virus This is the photomicrographic detection of respiratory syncytial virus (RSV) using indirect immunofluorescence technique- 40x. RSV is the most common cause of bronchiolitis and pneumonia among infants and children under 1 year of age. The majority of children hospitalized for RSV infection are under 6 months of age. |
 View larger version (157K): [in a new window] [Download PPT slide] | Image 109_04. Respiratory Syncytial Virus The characteristic cytopathic effect of respiratory syncytial virus in tissue culture includes the formation of large multinucleated syncytial cells. |
 View larger version (116K): [in a new window] [Download PPT slide] | Image 109_01. Respiratory Syncytial Virus Electron micrograph of a respiratory syncytial virus. The virion is variable in shape and size (average diameter of between 120-300 nm). Respiratory syncytial virus is the most common cause of bronchiolitis and pneumonia among infants and children younger than 1 year. |
 View larger version (122K): [in a new window] [Download PPT slide] | Image 109_12. Respiratory Syncytial Virus This electron micrograph depicts the Respiratory Syncytial Virus (RSV) pathogen. RSV is a negative-sense, enveloped RNA virus. The virion is variable in shape and size, with a diameter ranging between 120 and 300 nm, and is unstable in the environment surviving only a few hours on environmental surfaces. |
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| 199 | American Academy of Pediatrics, Subcommittee on Diagnosis and Management of Bronchiolitis. Diagnosis and management of bronchiolitis. Pediatrics. 2006;118. (4): 1774–1793 |
Related text in Red Book:
- Summary of Major Changes in the 2009 Red Book
Red Book 2009: XXIX.[Extract] [Full Version] - Preterm and Low Birth Weight Infants
Red Book 2009: 68-70.[Extract] [Full Version] - American Indian/Alaska Native Children
Red Book 2009: 88-90.[Extract] [Full Version]
This topic has been referenced by these articles:
- Bloemers, B., van Furth, M., Weijerman, M., Bont, L.
(2008). Severe Respiratory Syncytial Virus Infection in Term Infants With Genetic or Other Underlying Disorders: In Reply. Pediatrics
121: 868-869
[Full Version] - Afghani, B., Ngo, T.
(2008). Severe Respiratory Syncytial Virus Infection in Term Infants With Genetic or Other Underlying Disorders. Pediatrics
121: 868-868
[Full Version] - El Saleeby, C. M., Somes, G. W., DeVincenzo, J. P., Gaur, A. H.
(2008). Risk Factors for Severe Respiratory Syncytial Virus Disease in Children With Cancer: The Importance of Lymphopenia and Young Age. Pediatrics
121: 235-243
[Abstract] [Full Version] - Thomsen, S. F., Stensballe, L. G., Skytthe, A., Kyvik, K. O., Backer, V., Bisgaard, H.
(2008). Increased Concordance of Severe Respiratory Syncytial Virus Infection in Identical Twins. Pediatrics
121: 493-496
[Abstract] [Full Version] - Bloemers, B. L.P., van Furth, A. M., Weijerman, M. E., Gemke, R. J.B.J., Broers, C. J.M., van den Ende, K., Kimpen, J. L.L., Strengers, J. L.M., Bont, L. J.
(2007). Down Syndrome: A Novel Risk Factor for Respiratory Syncytial Virus Bronchiolitis A Prospective Birth-Cohort Study. Pediatrics
120: e1076-e1081
[Abstract] [Full Version] - Subcommittee on Diagnosis and Management of Bronch,
(2006). Diagnosis and Management of Bronchiolitis. Pediatrics
118: 1774-1793
[Abstract] [Full Version] - American Academy of Pediatrics,
(2007). AAP Publications Retired or Reaffirmed, October 2006. Pediatrics
119: 405-405
[Full Version] - Van Waardenburg, D., De Betue, C., Joosten, K.
(2008). A DOUBLE-BLIND RANDOMIZED, CONTROLLED TRIAL OF PROTEIN ENERGY ENRICHED FORMULA ADMINISTERED TO CRITICALLY ILL INFANTS. Pediatrics
121: S99-S100
[Abstract]
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