Nosocomial Respiratory Syncytial Virus Infections: The Cost-Effectiveness
and Cost-Benefit of Infection Control
Kristine K. Macartney, MBBS, BMedSci*; Marc H. Gorelick, MD, MSCE‡;
Mary Lou Manning, RN, PhD, CPNP§; Richard L. Hodinka, PhD储; and Louis M. Bell, MD¶
ABSTRACT. Objective. To determine the cost-effec-
tiveness and cost-benefit of an infection control program
to reduce nosocomial respiratory syncytial virus (RSV)
transmission in a large pediatric hospital.
Design. RSV nosocomial infection (NI) was studied
for 8 years, before and after intervention with a targeted
infection control program. The cost-effectiveness of the
intervention was calculated, and cost-benefit was esti-
mated by a case– control comparison.
Setting. Children’s Hospital of Philadelphia, a 304-
bed pediatric hospital.
Patients. All inpatients with RSV infection, both
community- and hospital-acquired.
Intervention. Consisted of early recognition of pa-
tients with respiratory symptoms, confirmation of RSV
infection by laboratory testing, establishing cohorts of
patients and nursing staff, gown and glove barrier pre-
cautions, and monitoring and education of staff.
Outcome Measures. The incidence density of RSV NI
before and after the intervention was calculated as the
rate per 1000 patient days-at-risk for infection. Interven-
tion costs included laboratory testing, isolation, and ad-
ministration of the program. The cost of RSV NI was
estimated by comparing hospital charges for 30 cases and
matched uninfected controls.
Results. A total of 148 patients acquired NI (88 before
and 60 after the intervention). The Mantel-Haenszel strat-
ified relative risk for NI in the period before the infec-
tion control program, compared with the postinterven-
tion period, was .61 (95% confidence interval: .53–.69). By
applying the preintervention stratum-specific rates of in-
fection to the days-at-risk in the postintervention period,
an estimated 100 NIs would have been expected, which
in comparison to the 60 NIs observed, yielded an esti-
mated program effectiveness of 10 RSV NIs prevented
per season. The total cost of the program per season was
$15 627 or $1563/NI prevented. In comparison, the mean
From the *Division of Immunologic and Infectious Diseases, Children’s
Hospital of Philadelphia, and University of Pennsylvania School of Medi-
cine; ‡Department of Emergency Medicine, Alfred I. du Pont Hospital for
Children, Department of Pediatrics, Jefferson Medical College, and Center
for Clinical Epidemiology and Biostatistics, University of Pennsylvania;
§Departments of Infection Control and Occupational Health, Children’s
Hospital of Philadelphia, and University of Pennsylvania School of Nurs-
ing; 储Department of Clinical Virology, Children’s Hospital of Philadelphia,
Department of Pediatrics, University of Pennsylvania School of Medicine;
and ¶Department of Infection Control, Children’s Hospital of Philadelphia,
Department of Pediatrics, University of Pennsylvania School of Medicine,
Philadelphia, Pennsylvania.
Received for publication Nov 23, 1999; accepted Feb 1, 2000.
Reprint requests to (K.K.M.) Division of Immunologic and Infectious Dis-
eases, Abramson Bldg, 12th Floor, 34th St and Civic Center Blvd, Philadel-
phia, PA 19104. E-mail: macartney@email.chop.edu
PEDIATRICS (ISSN 0031 4005). Copyright © by the American Academy of
Pediatrics.
520 PEDIATRICS Vol. 106
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cost to the hospital was $9419/case of RSV NI, resulting
in a cost-benefit ratio of 1:6.
Conclusions. A targeted infection control interven-
tion was cost-effective in reducing the rate of RSV NI.
For every dollar spent on the program, approximately
$6 was saved. Pediatrics 2000;106:520 –526; respiratory
syncytial virus, nosocomial infection, infection control,
cost-effectiveness, cost-benefit.
ABBREVIATIONS. RSV, respiratory syncytial virus; NI, nosoco-
mial infection; EIA, enzyme immunoassay; ICD-9-CM, Interna-
tional Classification of Diseases, Ninth Revision, Clinical Modification;
LOS, length of stay.
R
espiratory syncytial virus (RSV) infection, the
most important cause of bronchiolitis and vi-
ral pneumonia in young children, causes an
estimated 90 000 hospitalizations and 4500 deaths
each year from lower respiratory tract disease.1 Nu-
merous RSV-infected children occupy pediatric hos-
pitals during the winter peak months of infection,
when RSV is the leading cause of nosocomial respi-
ratory illness. Transmission rates approach at least
45% of contacts in the absence of infection control
measures.2 Because RSV infection does not induce
long-term immunity, repeated symptomatic and
asymptomatic infections may be acquired in both
adults and children.3 The virus is spread directly by
large-particle droplets or by contaminated secretions
carried on infected patients, health care workers, or
fomites.3,4 Transmission by aerosolized droplets is
minimal. Infection control interventions suggested to
reduce nosocomial RSV have included isolation of
patients in single-bed rooms5; assigning cohorts of
patients to the same rooms6 – 8 or assigning cohorts of
nursing staff to care for infected patients8 –10; contact
isolation techniques such as gowns,8 –13 gloves,8,9,11,13
eye–nose goggles,14 and masks15; admission screen-
ing7,13; and visitor restrictions.8,9 However, it is un-
clear which combination of these interventions is
most effective, and hospital infection control prac-
tices vary widely.11 The broad elements of a success-
ful infection control program are likely to be early
recognition of patients with RSV infection, contact
isolation precautions, and compliance with these
precautions by health care workers.5
In the United States, bloodstream nosocomial in-
fections (NIs), urinary tract infections, and pneumo-
nia are monitored by the National Nosocomial Infec-
tion Surveillance program. A national program to
monitor the incidence of nosocomial RSV infection
does not exist. Efficacy and cost analyses of NI con-
trol practices in adult patients have been per-
formed,16 –21 including the original nationwide Study
on the Efficacy of Nosocomial Infection Control,
which established the basis for understanding the
economic impact of NI.16 However, the economic
impact of reducing nosocomial RSV infection has not
previously been assessed. Although reducing NIs
may be one of the only proven methods for reducing
resource utilization while improving patient care, it
is increasingly important to demonstrate that such
interventions accomplish protection of the patient
and health care worker in a cost-effective man-
ner.22,23
This study was undertaken as a quality improve-
ment initiative of Children’s Hospital of Philadel-
phia, with the goal of reducing the hospital-wide
incidence of RSV NI. A targeted infection control
program that utilized multiple strategies to reduce
RSV transmission was implemented simultaneously
throughout the hospital, and its impact was assessed
over the subsequent four RSV seasons. The success of
the intervention allowed us to estimate both the cost-
effectiveness and the cost-benefit of preventing nos-
ocomial RSV in this setting.
METHODS
Study Population and Setting
All patients admitted to Children’s Hospital of Philadelphia, a
304-bed pediatric hospital, for 8 consecutive RSV seasons from
1988 –1989 to 1995–1996 were included in the study. During this
time, the hospital consisted of general medical and surgical wards,
and neonatal, cardiothoracic, and general intensive care units. In
most wards the rooms had 4 to 6 patients per room; few single-bed
rooms existed. The only changes to the hospital wards during this
time consisted of the merger of 2 neonatal units and the separation
of the cardiothoracic from the general intensive care unit in the
final year of the study. The characteristics of patients admitted to
the hospital remained consistent throughout the study period.
Specifically, the percentage of medical versus surgical admissions
did not change significantly (medical:surgical ratio was 1.8 in the
preintervention period and 2.2 in the later period), the percentage
of patients with medical assistance remained constant (18.5% vs
19.4%), and the percentage of patients transferred to the hospital
remained the same. In addition, the percentage occupancy of
hospital beds did not differ significantly throughout the study
period (83% occupancy in the preintervention period, compared
with 78% in the later period).
The RSV season was defined as the time from the first hospi-
talized case of laboratory-confirmed RSV infection, usually early
November, through the end of April (⬃6 months). Patients with
RSV infection were prospectively identified throughout the study
period by tracking laboratory specimens. Nasopharyngeal aspi-
rate specimens were collected from all patients who had symp-
toms of a viral upper or lower respiratory tract infection (includ-
ing rhinorrhea, cough, wheeze, tachypnea, or apnea)3 either on
admission or during the course of their hospital stay.5 Testing for
RSV was performed by enzyme immunoassay (EIA [Abbott Lab-
oratories, Abbott Park, IL]) in the hospital’s Clinical Virology
Laboratory with a same-day turnover time, 7 days per week. For
the purposes of the infection control intervention, EIA for RSV
was performed as the screening test for identification of RSV cases
and had a sensitivity of ⬎90%.24 Conventional viral culture of
nasopharyngeal aspirate specimens was also performed occasion-
ally; however, ⬍10% of all RSV infections were diagnosed by this
method. Testing for RSV infection by viral culture was not man-
dated by the intervention because the longer test turnaround time
(5–14 days) rarely impacted decisions regarding isolation and
cohorting. Children of any age who had symptoms compatible
with RSV infection and a positive RSV test result were considered
as RSV cases and were included in the study. Because the average
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incubation period for RSV is 5 days, community-acquired RSV
infection was defined as the development of symptoms within the
first 5 days of admission.3 RSV infection was considered nosoco-
mial when symptoms developed on or after the sixth hospital day.
Patients were also considered to have RSV NI if they were read-
mitted with RSV within 5 days after discharge from the hospital
(when the first admission was for an unrelated illness). Postdis-
charge surveillance was not performed.
RSV Infection Control Intervention
At the beginning of the 1992–1993 RSV season, a quality im-
provement intervention was launched with the aim of decreasing
the incidence of hospital-acquired RSV infection. Before the inter-
vention, methods used for prevention of RSV NI varied among
patient care units. Screening of patients for RSV infection oc-
curred; however, the use of barrier methods for isolation and
cohorting of patients and nursing staff was inconsistent.
The interdisciplinary intervention consisted of the following
components:
1. Formal education of nursing, medical, and paramedical staff on
the epidemiology and control of RSV infection, before and
throughout each RSV season.
2. High index of suspicion in suspected cases of RSV infection,
with laboratory confirmation of infection in all patients with
respiratory symptoms.
3. Contact precautions for all patients with symptoms of viral
respiratory tract infection, consisting of handwashing before
and after contact and the use of gloves and cotton cover gown
by all staff for any physical interaction with a patient or their
environment. Neither masks nor eye–nose goggles were used.
Gown and glove use for visitors was not required.
4. Maintenance of contact precautions for 2 weeks for all patients
with confirmed RSV infection (or for the duration of respiratory
symptoms if RSV testing was negative and no other cause for
their respiratory illness was found).
5. Placement of patients in single-bed rooms, when available, or
cohorting of patients on RSV contact precautions to the same
rooms.
6. Cohorting nursing staff to care for isolated patients.
7. Discouraging staff with symptoms of an acute viral respiratory
tract infection from caring for intensive care unit and immuno-
compromised patients and encouraging them to wear a mask
only to prevent nose/mouth contact when caring for other
patients. RSV testing was not performed on staff members.5,25
8. Restriction of visits by family members with acute respiratory
symptoms.
9. Regular surveillance by infection control staff to monitor com-
pliance, verbal feedback to nursing unit managers in the event
of a nosocomial RSV case, and monthly written performance
reports to all wards.
Epidemiologic Analysis
The risk of acquiring RSV NI is related to the intensity of
exposure of susceptible patients to all hospitalized patients shed-
ding RSV.13 Because both children and adults may repeatedly
acquire RSV infections, all uninfected children hospitalized during
the RSV season were considered susceptible to RSV NI.3,13 Because
all infected hospitalized patients can act as reservoirs for trans-
mission of the virus, and because our objective was to decrease the
incidence of RSV NI throughout the hospital, we implemented
and assessed the intervention simultaneously in all patient care
areas.
To account for variations in intensity of exposure to the virus,
5 exposure strata were calculated, based on the proportion of all
patient hospital days in each month of the study period that were
accounted for by patients shedding RSV (using the total number of
patients with a diagnosis of RSV infection, International Classifica-
tion of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM]
466.1 or 480.1, and the estimate that each patient shed virus for 7
days). The total number of patient days-at-risk in each month was
calculated from records of hospital admissions. Because RSV NI
acquired in the last 4 days of hospitalization would not have been
symptomatic during that stay (and thus not detected by our
in-hospital surveillance system), all but the last 4 days of the
admission of uninfected patients were counted in the number of
days-at-risk. For patients who acquired RSV NI, hospital days
ARTICLES 521
occurring subsequent to acquiring the infection were excluded
from the days-at-risk. All study months were then grouped into 1
of the 5 exposure strata, and incidence density rates of RSV NI
were calculated for each exposure stratum as the rate of NI per
1000 patient days-at-risk.
Incidence rates of nosocomial RSV infection were compared
before and after the intervention using crude relative risk and
Mantel-Haenszel stratified relative risk. To estimate the number of
RSV NI prevented, preintervention stratum-specific rates of infec-
tion were applied to the number of days-at-risk in the postinter-
vention period.
Economic Analysis
The cost of the infection control intervention per season was
calculated from the perspective of the hospital, and all costs were
estimated in US dollars based on the currency value in 1996. The
3 major cost components of the infection control intervention were
gown and gloves for contact isolation, additional RSV testing
performed because of the intervention, and administrative costs.
The cost of each use of a reusable cotton gown included the
purchase price and laundering cost. The mean number of gowns
and gloves used per RSV patient day was obtained after observa-
tion of 10 isolated patients over a 24-hour period in various wards,
and was multiplied by the number of isolated patient days per
season. These observations were made during a season in the
postintervention period (1996), when the intervention and com-
pliance with gown and glove use was well established. However,
because some utilization of gowns and gloves was made in the
preintervention period, only a proportion of the observed gown
and glove use was attributed to the intervention. In a study by
Leclair et al,13 compliance by staff with wearing gowns and gloves
increased from 38.5% of patient contacts to 95% of patient contacts
after an intervention comparable to ours. We assumed that a
similar 60% increase in gown and glove utilization occurred in our
study setting and adjusted the cost accordingly. In addition, esti-
mates that assumed either 40% or 80% increase in utilization of
gloves and gowns were evaluated for sensitivity analysis.
The total number of RSV EIAs performed was recorded per
season, and the cost of each test calculated from the purchase price
of the test kit, labor costs for laboratory personnel, and hospital
overheads. Because the intervention mandated RSV testing for all
symptomatic patients, additional RSV tests may have been per-
formed in the postintervention period because of the infection
control program. To estimate the number of intervention-related
RSV tests, we assumed that ordering of RSV tests by physicians
was proportional to the number of patients with the clinical diag-
nosis of bronchiolitis. The number of tests ordered in the pre- and
postintervention periods was compared with the number of cases
of bronchiolitis (by ICD-9 coding). RSV tests performed in the
postintervention period that exceeded the number of tests per-
formed in the preintervention period (per diagnosis of bronchioli-
tis) were attributed to the infection control program. Sensitivity
analysis was performed using 2 additional assumptions regarding
test utilization. The first analysis assumed that physician ordering
of RSV tests was proportional to the number of patients with a
positive test (that is, the rate of positive tests remained constant
over time). Thus, only additional tests beyond the number ex-
pected after adjusting for the observed increase in the rate of test
positivity were attributed to the intervention. The second analysis
assumed that the absolute number of RSV tests would otherwise
have remained constant, so that all additional tests in the post-
intervention period were attributed to the program. The cost of
testing for RSV by viral culture was not included in the economic
analysis because viral culture was not mandated by the infection
control intervention and had minimal impact on decisions to
isolate and cohort patients.
The administrative costs of the program consisted of the cost of
salaried time dedicated by infection control and nursing staff and
the cost of administrative supplies (which were estimated direct-
ly). The estimated increase in time directed toward the interven-
tion, compared with the staff’s preintervention activity, was mul-
tiplied by each participant’s full-time salary with benefits and
adjusted to 1996 dollars.
The financial burden of a RSV NI was estimated by comparing
the hospital charges of 30 randomly selected RSV NI cases with 30
matched inpatients who did not have RSV infection (controls).
Controls were chosen from computer-generated lists of patients
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who were admitted during the same RSV season as the patients
with RSV NI, had the same principal discharge diagnosis by
ICD-9-CM coding, had the same number of secondary diagnoses
(where possible), and were the same approximate age as the case
patients. To account for the risk of acquiring RSV NI, a control was
selected only if he or she was hospitalized for at least as many
days as it took the corresponding case patient to develop their RSV
NI. When multiple controls existed, the patient with a length of
stay (LOS) closest to the median LOS for the group was selected.
RSV NI and control patients were excluded if their hospital stay
was ⬎180 days (ie, spanning 2 RSV seasons). Hospital charges
were adjusted to 1996 dollars using the hospital and related ser-
vices price index of the Health Care Financing Administration.
The mean difference in hospital charges between the 2 groups was
attributed to RSV NI. The difference in hospital charges was
divided by the hospital charge to cost ratio in 1996, to obtain an
estimate of the cost of a RSV NI. Cost-effectiveness was calculated
by dividing the estimated number of RSV NIs prevented by the
estimated cost of the infection control intervention. Comparing the
cost per RSV NI to the estimated cost of preventing an infection
derived the cost-benefit ratio of the intervention.
RESULTS
Rates of RSV NI Before and After the Intervention
Overall, in the 4 RSV seasons before the interven-
tion, 88 RSV NIs occurred in a total of 90 174 patient
days-at-risk. In the 4 seasons after the intervention,
60 RSV NIs occurred in a total of 82 196 patient
days-at-risk. The total number of patients hospital-
ized with community-acquired RSV was 1604 in the
preintervention period, compared with 2065 patients
in the later period. The median age of the patients
who acquired RSV NI was 1 year. Fifty-two percent
of the RSV NI patients had preexisting illnesses that
predispose to greater morbidity from RSV infection
(20%, congenital heart disease; 17%, chronic lung
disease; 10%, immunodeficiency; and 5%, prema-
turity). The number of patients with underlying
illnesses did not differ significantly between the pre-
and postintervention periods (51% vs 54%, respec-
tively).
The number of RSV NIs that occurred in each of
the 5 risk strata is shown in Fig 1. The stratum-
specific rate of RSV NI increased nearly linearly as
the RSV infection risk increased, in both the pre- and
postintervention periods. This is consistent with the
assumption that the incidence of RSV NI depends on
the number of hospitalized patients shedding virus
at a given time. Comparison of rates of infection
before and after the intervention showed a decrease
in the incidence of RSV NI across all 5 risk strata. The
nosocomial RSV infection rate in the preintervention
period was .098 (or .98 cases per 1000 hospital days-
at-risk) compared with .073 (or .73 cases per 1000
hospital days at risk) in the postintervention period.
The crude relative risk of acquiring a RSV NI in the
postintervention period compared with the earlier
period was .75 (95% confidence interval: .54 –1.04).
The Mantel-Haenszel stratified relative risk was .61
(95% confidence interval: .53–.69). This represents a
statistically significant reduction of 39% in the rate of
RSV NI in the post- compared with the preinterven-
tion period. By applying the preintervention rates of
infection to the number of days-at-risk in the postin-
tervention period, 40 cases of RSV NI, or 10 infec-
tions per season, were estimated to have been pre-
vented by the program (Table 1).
RSV INFECTIONS
 Fig 1. RSV NI rates before and after the intervention according to level of exposure.

TABLE 1. RSV NIs Expected and Observed After the Infection Control Intervention
Stratum* Number of Days Rate of RSV NI in the Number of Number of
at Risk in the Preintervention Infections Infections
Postintervention Period Period† Expected‡ Observed‡
⬍2.5 27 778 .275 8 5
2.5–4.9 14 967 .702 11 8
5.0–7.4 15 168 1.809 27 10
7.5–9.9 11 544 2.117 24 15
ⱖ10 12 739 2.348 30 22
Total 100 60
* Defined by percentage of hospital days with patients shedding RSV (calculated for each month of the
study).
† Per 1000 patient days-at-risk.
‡ In the postintervention period.

Cost of RSV Infection Control Intervention
The costs of the components of the RSV infection
control intervention are shown in Table 2. Each use
of a cotton cover gown was estimated to cost $.39,
based on a purchase price of $3.83 per gown, assum-
ing each gown was laundered 65 times (at a cost of
$.25 per laundering). The cost of 1 glove was $.038.
The total estimated cost of contact isolation was
$11 094 per season (sensitivity analysis range: $7396 –
$14 791).
The mean increase in personnel and administra-
tive costs attributed to the intervention was $2022/
RSV season (Table 2). In the preintervention period,
the salary with benefits of the infection control nurse
was $21.42/hour ($1996), and the time dedicated to
RSV infection control was ⬃8 hours per week for
each of the 4 seasons (assuming 24 weeks/season).
The infection control intervention was implemented
and maintained by a registered nurse and the med-
ical director of the infection control department,
whose salaries with benefits were $22/hour and
$60/hour ($1996), respectively. In the first 2 seasons,
⬃16 hours/week of infection control nursing time
and 1 hour/week of medical director time were di-
rected toward the intervention. In the subsequent 2
seasons, the time required by the infection control
nurse for the RSV program activities was decreased
to 4 hours/week. The infrastructure had been well
established, allowing the nurse’s time to focus on
program support and maintenance. During this pe-
riod, medical director time was negligible. No addi-
tional nursing staff was required for cohorting pa-
tients, and additional salaried nursing time was not
required for education or other activities (which
were incorporated into routine nursing meetings).
The cost of a RSV EIA test was $19.17, which
included the test-kit cost of $9.14 per test, and labor
and overhead costs. The number of RSV tests per-
formed increased from a mean of 2850 tests per
season in the first 4 seasons to 3255 tests per season
in the postintervention period, and the number of
positive EIA tests increased by 19%, from a mean of
368 per season to 432 per season. There was a 9.6%
increase in the number of patients admitted with

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TABLE 2. Cost of the RSV Infection Control Intervention
Intervention Determination Mean Cost per Cost Sensitivity Analysis
Component of Estimate RSV Season per RSV Season (1996 Dollars)
(1996 Dollars)
Best Case Worst Case
Contact isolation
Gloves $1.99/pt d (52 gloves/pt d) 3335* 2223† 4446‡
Gowns $4.63/pt d (15 gowns/pt d) 7759* 5173† 10 345‡
Administrative costs§
Personnel $6000 (mean/season postint) 1887 1887 1887
⫺ $4113 (mean/season preint)
Materials Estimated directly 135 135 135
Laboratory testing
RSV EIA tests See text 2511 0 7764
Total intervention 15 627 9418 24 577
Post-int, postintervention period; preint, preintervention period; pt, patient.
* Multiplied by 2793 pt days/season and an estimated .6 adjustment for compliance.
† Multiplied by 2793 pt days/season and an estimated .4 adjustment for compliance.
‡ Multiplied by 2793 pt days/season and an estimated .8 adjustment for compliance.
§ Administrative costs were estimated directly and not subjected to sensitivity analysis.
¶ See text for explanation of methods.

bronchiolitis in the postintervention period. After
adjusting for the increase in bronchiolitis, 131 addi-
tional RSV EIA tests per season were attributed to
the intervention at a cost of $2511 per season. When
the assumption was made that the rate of RSV tests
ordered should remain the same, compared with
the number of positive tests, the resulting cost esti-
mate was $0 per season. Alternatively, if all the extra
RSV tests in the postintervention period were attrib-
uted to the program, the cost was $7764 per season
(Table 2).
The total cost of the intervention was $15 627 per
season (sensitivity analysis range: $9418 –$24 577).
Because 10 RSV infections were prevented by the
intervention per season, the cost of preventing a
single RSV NI was estimated at $1563.
Cost of Nosocomial RSV Infection by Case–Control
Comparison
Thirty RSV NI patients were randomly selected
from all 8 RSV seasons in the study and matched
with 30 control patients (Table 3). The mean time to
acquire RSV NI was 14.9 days. The mean age of the
30 RSV NI patients was 1.8 years, compared with 2.0
years for control patients (and 2.1 years for all RSV
NI patients throughout the study period). The mean
excess in hospital charges between the RSV NI pa-
tients and controls was $45 335 per patient, after
adjustment for inflation. The mean difference in LOS
was an additional 10.7 days per RSV NI patient.
However, 2 of the patient– control pairs had differ-
ences in LOS (50 and 54 days, respectively) that
exceeded 39 days, the longest median duration of
stay for high-risk patients in a study of community-
acquired RSV.26 This may have overestimated the
differences in hospital charges. After excluding these
2 patients, the mean difference in hospital charges for
the remaining 28 case– control pairs was $20 721,
with a mean difference in LOS of 7.8 days. Further
elimination of patients based on differences in LOS
did not alter the results of cost comparison between
the 2 groups but reduced the mean difference in LOS
(Table 3).
Using the 1996 hospital charge to cost ratio, and
the conservative estimate that the excess hospital
charge for a nosocomial RSV infection was $20 721
per patient, the cost to the hospital was estimated to
be $9419 per infection. Because the estimated cost of
preventing a RSV NI was $1563, the cost-benefit ratio
of the infection control intervention was 1:6. For
every dollar spent on this RSV infection control mea-
sure, an estimated $6.00 was saved.
DISCUSSION
The incidence of RSV NI throughout our hospital
was reduced 39% by a targeted infection control
intervention. This outcome is comparable to the 37%
reduction in RSV NI achieved in a study by Leclair et
al,13 in an infant ward over a shorter period. Accu-
rate comparison of RSV NI rates in this study was

TABLE 3. Comparison of Hospital Charges of Patients With RSV NI and Matched Uninfected Control Patients
Pairs of Mean/Median Mean LOS Mean of Mean of Differences
Cases and Age (Years) (Days) Differences in in Hospital Charges
Controls LOS (Days)* (1996 Dollars)†
Pts Ctrls Pts Ctrls
n ⫽ 30 1.8/.5 2.0/.6 31.9 22.5 10.7 45 335
n ⫽ 28‡ 1.8/.5 2.0/.6 29 21.5 7.8 20 721
n ⫽ 26§ 1.9/.5 2.0/.6 25.8 20.2 3.5 20 347
Pts indicates RSV NI patients; Ctrls, control patients.
* Calculated as the mean of all the differences in LOS between RSV NI patients and matched controls.
† Hospital charges were adjusted to 1996 dollars using the hospital and related services price index of the Health Care Financing
Administration.
‡ Two patient/control pairs were eliminated for LOS differences exceeding 39 days.26
§ Four patient/control pairs were eliminated for LOS differences exceeding 30 days.

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achieved by calculating the incidence density of NI,
using risk strata that accounted for the number of
patients excreting RSV and the number of days of
exposure of susceptible patients. This method is pref-
erable to other techniques, such as the RSV nosoco-
mial ratio, to determine rates of NI for external re-
porting.11,13 Other studies have analyzed various
measures to decrease nosocomial RSV and have
shown statistically significant reductions in trans-
mission rates; however, differences in study methods
preclude direct comparison.6 –9,14,15
To our knowledge, this study is the first to deter-
mine the cost-effectiveness of a hospital-based infec-
tion control program to reduce nosocomial RSV
transmission. An estimated 10 RSV infections were
prevented per RSV season, resulting in a cost-effec-
tiveness of $1563 per infection prevented (sensitivity
analysis range: $942–$2458). There are limited data
available on the cost of infection control programs in
general, and no published values for comparison of
the cost of RSV prevention programs. However, in
an analysis of the economics of hospital infections,
Wenzel21 liberally estimated the cost of preventing a
NI in an adult hospital to be $2100 per infection, an
estimate comparable to that found in this study. We
did not address the relative cost-effectiveness of in-
dividual components of the intervention. The most
recent Centers for Disease Control and Prevention
guidelines for the prevention of RSV NI recommend
handwashing and wearing gloves and a gown for
patient contact, with the additional measures of iso-
lation of patients and cohorting of staff and patients
suggested as prudent.5 Guidelines in place until 1994
suggested the use of gowns (but not gloves) and
single-room isolation, which is often impractical in
hospitals with multibed rooms. Because our hospital
had very few single-bed rooms over the entire study
period, it seems that a significant reduction in RSV
transmission rates can occur without isolating pa-
tients to single rooms.
Using a case– control comparison, we determined
the LOS attributed to RSV NI to be 7.8 days (sensi-
tivity analysis: 3.5–10.7 days). In a study of RSV NI
in Canadian pediatric hospitals, the median LOS at-
tributable to RSV NI was double that for community-
acquired illness (10 vs 5 days, respectively).11 Chil-
dren with RSV NI were significantly more likely
than patients with community-acquired RSV to have
preexisting factors for severe disease (66% vs 17%,
respectively).11 Similarly, we found that 52% of pa-
tients who acquired RSV NI had preexisting con-
ditions for severe RSV infection (congenital heart
disease, chronic lung disease, prematurity, or immu-
nocompromise). Such patients are known to have
increased morbidity and mortality from RSV infec-
tion, with LOS for community-acquired illness rang-
ing from 5 to 39 days.26
The mean cost of a RSV NI was estimated by our
analysis to be $9419 (range: $9249 –$20 721), resulting
in a cost-benefit ratio of 1:6 for the intervention. In an
analysis of the cost-effectiveness of RSV prophylactic
agents in preterm infants, the mean cost of hospital-
ization for RSV infection was $8502 (range: $5207–
$13 518).27 Our analysis was limited to determining
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direct medical costs.22,23,28 We did not account for
additional monetary factors, such as delayed return
to work of caregivers, long-term disability, loss of
life, or nonmonetary outcomes such as quality of life
savings, patient satisfaction, legal considerations,
and negative publicity.22,28 Such factors would have
likely enhanced the cost-benefit ratio of 1:6.
Use of a case– control comparison is considered a
valid method to determine the cost of NIs; however,
it is subject to limitations.22 Matching patients by
first diagnosis alone greatly overestimates costs. In
this analysis we accounted for differences in severity
of illness by matching, using the number of patient
discharge diagnoses.22 We also sought to control for
the risk of acquiring RSV NI, by selecting uninfected
patients who were hospitalized for at least as long as
the case patients took to acquire their infection. Con-
troversy exists over whether to divide charges by
departmental charge-cost ratios or the overall hospi-
tal ratio (because patient’s utilization of different
services and departmental charge-cost ratios may
vary widely).20,22 In this study, we chose to use the
overall hospital charge-cost ratio because the pa-
tients studied were drawn from throughout the hos-
pital, we had a moderately large sample size, and a
prospective study comparing the 2 methods yielded
little difference in outcome.20 However, it is impor-
tant to note that dividing by the charge-cost ratio
estimates total costs (both fixed and marginal costs),
which may inflate the estimated cost of a RSV NI,
because the fixed costs of care may not be affected by
extended hospital stays.21,22
This analysis was limited to assessing the impact
of the infection control intervention across the entire
hospital inpatient population, consistent with our
goal of decreasing hospital-wide rates of RSV NI. It is
likely that there was a variability of effect of the
intervention, not reflected in the overall risk reduc-
tion estimate provided. Because RSV infection causes
more serious illness in infants and patients with pre-
existing conditions such as chronic lung disease,
heart disease, and prematurity, analysis of the inter-
vention’s impact based on patient age or underlying
diagnosis would likely have enhanced the results of
this study. In addition, it would have been preferable
to examine the changes in rates of RSV NI over time
by a time-series analysis. This was problematic be-
cause of the great deal of variability in RSV disease
activity and the relatively small number of NIs, mak-
ing year-to-year fluctuations difficult to interpret.
Data from a reliable time-series analysis may have
added to establishing a causal relationship between
the intervention and the reduction in rates of RSV NI.
Despite our attempts to control for numerous factors
affecting fluctuations in nosocomial transmission
rates of RSV infection, factors other than the inter-
vention itself may have been responsible for the re-
duction in RSV NI seen in this study.
From the perspective of a hospital, it has been
estimated that only between 1% and 5% of the costs
of treating NIs are reimbursed under a prospective
payment system based on diagnostic-related groups.17
In this study at least 95% of the estimated $7856
savings per RSV NI prevented may have represented
ARTICLES 525
a financial gain to the hospital. Studies of the eco-
nomic impact of preventing RSV NI should continue
as newly available RSV prophylactic agents are in-
creasingly used in high-risk patients.27
ACKNOWLEDGMENTS
We gratefully thank Michael J. Barbella and the staff of Health
Information Management, and the Admissions Department of
Children’s Hospital of Philadelphia for providing assistance with
medical records and hospital admission information.
We also thank all infection control personnel who collected
data during the study years, and the staff of the Clinical Virology
Laboratory for their technical contributions.
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Submitted by Student
RSV INFECTIONS
Nosocomial Respiratory Syncytial Virus Infections: The Cost-Effectiveness and
Cost-Benefit of Infection Control
Kristine K. Macartney, Marc H. Gorelick, Mary Lou Manning, Richard L. Hodinka
and Louis M. Bell
Pediatrics 2000;106;520
DOI: 10.1542/peds.106.3.520

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Nosocomial Respiratory Syncytial Virus Infections: The Cost-Effectiveness and
Cost-Benefit of Infection Control
Kristine K. Macartney, Marc H. Gorelick, Mary Lou Manning, Richard L. Hodinka
and Louis M. Bell
Pediatrics 2000;106;520
DOI: 10.1542/peds.106.3.520

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/106/3/520

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