Health officials continue to investigate after seven people died and at least 11 others have been infected with an adenovirus at a New Jersey health care facility, the New Jersey Department of Health said Wednesday.
This is up from the six deaths announced Tuesday among medically fragile children at the Wanaque Center for Nursing and Rehabilitation in Haskell, New Jersey.
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"They range in age from toddlers to young adults," New Jersey Department of Health Commissioner Dr. Shereef Elnahal told reporters Wednesday. "The vast majority are under the age of 18. Some have been hospitalized, and some are being cared for at this facility."
The outbreak appears to be confined to the facility's respiratory unit, he added.
While the timing of the deaths remains unclear, the health department was notified of respiratory illness at the facility on October 9. The facility notified parents ten days later, on October 19, according to health department spokeswoman Nicole Kirgan.
"Health professionals and other people don't think of the common cold as being serious, but when you're a child, disabled, chronic disease, immunosuppressed, elderly, multiple medical conditions, the common cold can be life-threatening," said Dr. David Gifford, senior vice president of quality and regulatory affairs for the American Health Care Association.
The association -- whose member organizations represent nursing homes and other health care facilities across the country -- does not own or operate individual facilities. Though the Wanaque facility is a member of the national organization by default, Gifford said the association does not take positions to individually represent individual facilities.
Gifford said that the amount of time it takes to respond to a potential outbreak and notify families is variable. "There are so many nuances," he said, including how long health experts need to investigate a potential outbreak, culture a virus and confirm its identity.
"Generally, if you're seeing a number of people in an institutional setting who have an illness, you start to take some precautions about the spread," said Gifford, but that may not necessarily include notifying families of something that initially resembles a common cold.
In a statement Tuesday, the Wanaque facility said it "promptly notified all appropriate government agencies when the virus was initially identified." On Wednesday, an additional statement by the facility said the health department "continues to work very closely with the facility to ensure that all infection control measures are being followed."
The facility did not respond to multiple calls and emails for further comment. It has been "instructed not to admit any new patients until the outbreak ends and they are in full compliance," according to the state health department. According to Elnahal, the outbreak can only be declared over once four weeks pass without an additional case.
"Nursing homes don't call the health department that often," Gifford said, though there has been a push for nursing homes and health care facilities to get health departments involved in outbreak investigations earlier.
Adenoviruses are known to persist on unclean surfaces and medical instruments for long periods of time, may not be eliminated by common disinfectants, and rarely cause severe illness in healthy people. However, people with weakened immune systems have a higher risk for severe disease, and they may remain infectious long after they recover, according to the US Centers for Disease Control and Prevention.
"The strain of adenovirus seen in this outbreak is associated with communal living arrangements and known to cause severe illness," the state health department said.
"It can be difficult to impossible to know how the virus got to the facility, what its source was, or what its specific mechanism of spread is from person to person," Elnahal said. "But we are working with the CDC on this ongoing outbreak investigation."
The state health department said Tuesday that an inspection team at the facility on Sunday found minor handwashing deficiencies.
In a review by the Centers for Medicare and Medicaid Services, the Wanaque Center was awarded an above-average ranking in overall quality but a below-average health inspection rating.
Based on an inspection conducted in August, CMS reported that "it was determined that the facility failed to provide a clean and homelike physical environment for their residents." The review found carpeted areas that "smelled of old carpet and mildew."
On Wednesday, Elnahal described these as "low-level, self-limited deficiences" that were subsequently resolved when health inspectors rechecked.
A May 2017 inspection report "determined that the facility failed to ensure infection control practices were followed." Among the deficiencies cited were improperly stored syringes, which were used to measure liquid medication, and over-bed tables and medication trays that were not properly cleaned and disinfected. The deficiencies were listed as corrected a month later and were lower in number than the US average.
"It is rare that in any inspection a facility would come out with no citations," Elnahal said. "If it's a number of citations, all of which are low-level, we ask for a plan of correction. We make sure the facility follows through -- and that's what this facility did here."
"If the findings are severe enough to take further action, we will," he added.
Nurses at the facility had previously reported a shortage of nursing staff and supplies, according to a statement Tuesday from the union that represents the nursing staff. The Health Professionals and Allied Employees said the shortages may have led to "poor infection control practices."
The union said it represents the 70 nurses that work at the Wanaque Center for Nursing and Rehabilitation.
Adenoviruses can cause mild to severe illness, though serious illness is less common. People with weakened immune systems or existing respiratory or cardiac disease are at higher risk of developing severe illness from an adenovirus infection, according to the CDC.
This outbreak, caused by adenovirus type 7, "is affecting medically fragile children with severely compromised immune systems," the health department said Tuesday.
"Most of the time, adenoviruses produce influenza-like illness with cough and runny nose and feeling crummy, but you get better," Dr. William Schaffner, an infectious disease specialist at Vanderbilt University, previously told CNN. "But they can also cause conjunctivitis and, particularly in children, diarrhea."
In rare cases, among people with weakened immune systems, the viruses may cause pneumonia or inflammation of the brain and the tissues around it. In extremely unusual cases, an adenovirus infection could result in death.
That said, most adenovirus infections are mild, with symptoms usually lasting about 10 days, according to the CDC. And for most patients, home remedies and over-the-counter medicines to relieve the symptoms will be the only treatment necessary.
Adenoviruses, unlike the flu, are not seasonal and can cause illness throughout the year. And while an adenovirus vaccine exists, it's available only to military recruits.
The viruses themselves are also "resistant to many common disinfectants and can remain infectious for long periods on environmental surfaces and medical instruments," the CDC says. Adenoviruses tend to be spread by coughing and sneezing, direct contact with an infected person, or touching objects and surfaces, such as door handles and light switches, where adenoviruses can live and remain infectious for days or weeks.
Adenoviruses can "stay stable at room temperature for weeks" on unclean surfaces, according to Dr. Alex Valsamakis, director of Clinical Virology and Molecular Microbiology and a professor of pathology at the Johns Hopkins University School of Medicine.
She described this family of viruses as "environmentally hardy."
"Wash your hands frequently and avoid touching your face," she previously told CNN. "That's kind of the easiest way to prevent inadvertently transporting something from your fingers into your nose or mouth."
Adenovirus infections "usually occur sporadically -- here a case, there a case -- so outbreaks are pretty rare," Schaffner said.
From 2003 through 2016, the two most commonly reported adenovirus types in the US were types 2 and 3, though four additional types -- 1, 4, 7 and 14 -- also caused illness, according to a 2017 report from the National Center for Immunization and Respiratory Disease of the CDC. These six types accounted for 85.5% of 1,497 laboratory-confirmed specimens reported during the time period.
This small number of cases is believed to be an underrepresentation of the actual number of cases due to the fact that most people who become sick either do not go to a doctor, or their doctors do not test for this virus.
And adenoviruses are still difficult to diagnose since they're not typically included in a panel of tests used to identify specific viruses, according to Schaffner. He said this is changing, and for that reason, he believes the number of cases will rise.
Still, Schaffner doesn't think people need to be worried about adenoviruses. "They cause principally a whole bunch of minor troublesome infections spread by children, often from children to adults," he said.
"But they're not nearly as serious as influenza."