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we reviewed respiratory infection outbreaks registered with the public health laboratory ( phl ) , ontario agency for health protection and promotion dating back to october 2007 ( table 1 ) .
molecular detection methods were used for a subset of outbreaks registered during october 1 , 2008april 19 , 2009 .
after emergence of severe respiratory illness clusters in mexico in early april , intensified tracking of respiratory infection outbreaks in ontario was undertaken .
consequently , more information was available on outbreaks registered during the spring ( april 20 to june 12 , 2009 ) ; these data comprise the bulk of the study .
* influenza season is delineated as october 1april 19 ; spring season is delineated as april 20june 12 . 
greater toronto area includes submissions by peel , york , and toronto public health units . 
 specimens from 78 of the 101 outbreaks were tested by the luminex xtag respiratory viral panel ( luminex molecular diagnostics , toronto , ontario , canada ) .
respiratory infection outbreaks in ltcfs were defined as any of the following : 2 cases of acute respiratory tract illness , 1 of which was laboratory - confirmed ; 3 cases of acute respiratory tract illness within 48 hours in a geographic area ( e.g. , unit , floor ) ; and > 2 units having a case of acute respiratory illness within a 48-hour period .
influenza - like - illness was defined as acute onset of respiratory illness with fever and cough with > 1 of the following : sore throat , arthralgia , myalgia , or prostration . from april
20 through june 12 , 2009 , a total of 112 respiratory infection outbreaks were registered .
molecular testing was not used in 29 outbreaks ( e.g. , insufficient / inappropriate sample ) .
most of the remaining 83 outbreaks submitted for molecular testing originated from ltcfs ( 91% ) ; hospitals ( 2% ) , child care centers ( 2% ) , and psychiatric care facilities ( 1% ) comprised the remainder .
mean age of persons tested as part of an outbreak investigation was 82 years ( sd 13.96 years ) and median age was 85 years ; 95% were > 57 years of age .
testing on the 589 specimens received from 161 outbreaks registered from october 1 , 2008 through june 12 , 2009 was performed by real - time reverse transcription 
pcr ( rt - pcr ) for the influenza a virus matrix gene and the luminex respiratory viral panel ( rvp ) ( luminex molecular diagnostics , toronto , ontario , canada ) for other respiratory viruses .
an etiologic agent was identified in 89% of the 161 outbreaks tested by molecular methods .
two and 3 different pathogens were identified in 24 ( 15% ) and 6 ( 4% ) outbreaks , respectively .
no etiologic agent was identified in 18 ( 11% ) of the outbreaks tested by molecular methods , which includes 1 specimen in which the result was indeterminate for coronavirus oc43 .
a wide range of causative etiologic agents were detected for outbreaks by the rvp assay ( table 2 ) .
specimens from most patients were positive for enterovirus / rhinovirus ( 114 patients ) followed by metapneumovirus ( 85 ) , parainfluenza virus type 3 ( 55 ) , and human influenza virus a ( h3 ) ( 41 ) . no virus was identified in 186 patients . * luminex molecular diagnostics , toronto , ontario , canada . 
spring season is delineated as april 20june 12 ; influenza season is delineated as october 1april 19 . 
 seven of the 15 outbreaks were confirmed as rhinovirus by the seeplex rv12 detection kit ( seegene , inc . ,
co - infections were noted in 22 of the patients tested by the rvp assay . in 1 ltcf outbreak ,
2 patients had co - infection of an untypeable influenza a and enterovirus / rhinovirus on testing by rvp .
an influenza a real - time rt - pcr result was negative in both patients ; 1 patient had a co - infection with respiratory syncytial virus b and enterovirus / rhinovirus .
co - infections with coronavirus subtypes 229e and nl63 were the most common , observed in 10 of the 22 patients ( 45% ) infected with multiple pathogens .
isolates from 1 patient were positive for 3 viruses ( coronavirus subtypes 229e and nl63 and enterovirus / rhinovirus ) .
one of the 2 outbreaks identified as caused by pandemic ( h1n1 ) 2009 originated from a ltcf was not observed until june 3 , 2009 , six weeks into the evolving pandemic , despite widespread community prevalence . the second pandemic ( h1n1 ) 2009 outbreak , registered on june 11 , 2009 , originated from a hospital treating patients with influenza - like illness .
seasonal influenza ( h1n1 and h3n2 ) or pandemic ( h1n1 2009 ) was detected in 2,966 ( 25.5% ) , and pandemic ( h1n1 ) 2009 in 2,203 ( 19% ) of 11,612 persons tested at phl for influenza a by real - time rt - pcr during april 20june 12 , 2009 . seasonal influenza a ( h3n2 )
was only identified in 273 specimens ( 11.0% ) of the 2,476 influenza a positive samples subtyped . however , it was the strain responsible for 15 ( 88% ) of the typeable influenza a outbreaks at the same time .
seasonal influenza a ( h1n1 ) was absent from institutional outbreaks and only detected in 41 ( 2% ) of subtyped influenza a  positive samples from the general population .
persons with laboratory - confirmed pandemic ( h1n1 ) 2009 infection tested at the phl , ontario agency for health protection and promotion , were younger than those tested as part of outbreak investigations .
mean and median ages were 21.5 and 16 years , respectively ; only 10% were > 46 years of age .
the number of respiratory infection outbreaks in institutions submitted to phl may reflect disease impact caused by respiratory viruses during the influenza season .
respiratory viruses during the 200708 season may have been more active than those of the 200809 season because the number of outbreaks registered with phl decreased from 1 year to the next .
declaration of pandemic status for the novel ( h1n1 ) virus has not influenced the reporting of respiratory infection outbreaks from institutions in ontario because submission rates for the corresponding period in 200708 and 200809 are similar .
variation would not be expected because reporting is required by ontario law ( 4 ) .
respiratory viruses detected in outbreaks in institutions reflect those known to be major causes of acute respiratory disease in the community ; prevalence varies based on geographic location , season , and detection methods ( 57 ) .
free access to such institutions by members of the community ( staff or visitors ) , in conjunction with communal close quarters of residents , creates an ideal environment for propagation of viral respiratory outbreaks ( 8) .
current guidelines for isolation during viral respiratory outbreaks are not tailored for the specific virus . as shown in this study ,
multiplex molecular testing makes it possible to identify the virus causing most ltcf respiratory infection outbreaks .
infection control guidelines for a specific outbreak could be modified based on the incubation period and duration of viral shedding for the identified virus ( 9 ) .
clinicians should be reminded that rhinovirus can cause severe lower respiratory tract infection , including death , as documented in several ltcf outbreaks ( 10,11 ) .
these data highlight the need for molecular capacity to diagnose rhinovirus infection because detection is otherwise limited to less sensitive viral culture systems .
this review of outbreaks predominantly involving elderly persons in ltcfs highlights the sparing of older persons by pandemic ( h1n1 ) 2009 .
possible explanations include cross - protective antibodies from previous exposure to influenza a ( h1n1 ) strains circulating before the antigenic shift of influenza a to subtype h2n2 in 1957 or minimal contact with those most likely to have imported the pandemic strain into canada ( young travelers ) ( 12 ) .
in addition , older persons may have less contact with the age group ( children 1019 years of age ) , with most cases being in ontario .
our findings support centers for disease control and prevention guidelines for vaccination with monovalent pandemic ( h1n1 ) 2009 virus vaccine .
these guidelines have not placed older persons in a high priority group for vaccination because increased rates of hospitalization and severe disease caused by pandemic ( h1n1 ) 2009 have not been observed ( 13,14 ) .
investment in multiplex technologies to investigate respiratory outbreaks in ltcfs shortens time for pathogen detection , helps guide infection control and vaccination policies , and can potentially save resources spent on other investigations .
outbreaks of respiratory infection in institutions in ontario , canada were studied from april 20 to june 12 , 2009 , during the early stages of the emergence of influenza a pandemic ( h1n1 ) 2009 . despite widespread presence of influenza in the general population , 
 only 2 of 83 outbreaks evaluated by molecular methods were associated with pandemic ( h1n1 ) 2009 .