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Identifying the Probable Timing and Setting of Respiratory Virus Infections

  • Justin Lessler (a1), Ron Brookmeyer (a2), Nicholas G. Reich (a2), Kenrad E. Nelson (a1), Derek A. T. Cummings (a1) and Trish M. Perl (a3)...



Show how detailed incubation period estimates can be used to identify and investigate potential healthcare-associated infections and dangerous diseases.


We used the incubation period of 9 respiratory viruses to derive decision rules for distinguishing between community- and hospital-acquired infection. We developed a method, implemented in a simple spreadsheet, that can be used to investigate the exposure history of an individual patient and more specifically to identify the probable time and location of infection. Illustrative examples are used to explain and evaluate this technique.


If the risks of hospital and community infection are equal, 95% of patients who develop symptoms of adenovirus infection within 5 days of hospital admission will have been infected in the community, as will 95% of patients who develop symptoms within 3 days for human-coronavirus infection, 2.5 days for severe acute respiratory syndrome, 1 day for influenza A, 0.5 day for influenza B, 12 days for measles, 2 days for parainfluenza, 4 days for respiratory syncytial virus infection, and 1.5 days for rhinovirus infection. Sources of infection suggested by analysis of the symptom onset times of individual patients are consistent with those from detailed investigations.


This work shows how a detailed understanding of the incubation period can be an effective tool for identifying the source of infection, ultimately ensuring patient safety.


Corresponding author

Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, E6545, Baltimore, MD 21205 (


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1.Bridges, CB, Kuehnert, MJ. Transmission of influenza: implications for control in healthcare settings. Clin Infect Dis 2003;37:10941101.
2.Graman, PS, Hall, CB. Epidemiology and control of nosocomial viral infections. Infect Dis Clin North Am 1989;3:815841.
3.Hall, CB. Nosocomial respiratory syncytial virus infections: the “Cold War” has not ended. Clin Infect Dis 2000;31:590596.
4.Munoz, FM, Campbell, JR, Atmar, RL, et al.Influenza A virus outbreak in a neonatal intensive care unit. Pediatr Infect Dis J 1999;18:811815.
5.Salgado, CD, Farr, BM, Hall, KK, Hayden, FG. Influenza in the acute hospital setting. Lancet Infect Dis 2002;2:145155.
6.Lessler, J, Brookmeyer, B, Perl, TM. An evaluation of classification rules based on date of symptom onset to identify healthcare-associated infections. Am I Epidemiol 2007;166:12201229.
7.Lessler, J, Reich, NG, Brookmeyer, R, Perl, TM, Nelson, KE, Cummings, DAT. Incubation periods of acute respiratory viral infections: a systematic review. Lancet Infect Dis 2009;9:291300.
8.Karanfil, LV, Conlon, M, Lykens, K, et al.Reducing the rate of nosocomially transmitted respiratory syncytial virus. Am J Infect Control 1999;27:9196.
9.Sartwell, PE. The distribution of incubation periods of infectious disease. Am J Hyg 1950;51:310318.
10.World Health Organization. WHO immunization surveillance, assessment and monitoring, Updated 2010. Accessed June 15, 2009.
11.Filia, A, Barale, A, Malaspina, S, et al.A cluster of measles cases in northern Italy: a preliminary report. Euro Surveill 2007;12:E071129.1.
12.Dwosh, HA, Hong, HH, Austgarden, D, Herman, S, Schabas, R. Identification and containment of an outbreak of SARS in a community hospital. CMAJ 2003;168:14151420.

Identifying the Probable Timing and Setting of Respiratory Virus Infections

  • Justin Lessler (a1), Ron Brookmeyer (a2), Nicholas G. Reich (a2), Kenrad E. Nelson (a1), Derek A. T. Cummings (a1) and Trish M. Perl (a3)...


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