evonne curran outbreak management norovirus. norovirus is the perfect pathogen it is important that...
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Evonne Curran
Outbreak ManagementNorovirus
Norovirus
• Norovirus is the perfect pathogen
• It is important that you are ready for norovirus
• Norovirus improvement in Scotland
‘The perfect human pathogen’(A. J. Hall 2012 J Infect Dis)
• ‘Highly contagious, rapidly and prolifically shed, constantly evolving, evoking limited immunity and only moderately virulent allowing most of those infected to fully recover, thereby maintaining a large susceptible pool of hosts.’ (A. J. Hall 2012 J Infect Dis)
Incubation period
12– 48 hrs (typical)
Infectious dose
Period of infectivityMainly whilst symptomatic
(1-3 days healthy but 4 – 6 days vulnerable)Peak shedding: 2 - 5days post onset
???
18
MMWR: Mch 4 2011(RR03); 1-15
Acute (D&V)Little warning
Low feverAches
Dispersion of infectious material
1 gram of faeces = 100 billion norovirus particles
(100,000,000,000 )= 5 billion infectious doses
Disposal of infectious material
3
3
Multiple routes of transmission
Touch something contaminated then eat
Eat or drink it
Survival of the virus in the environment and on food
28 days + freezing
Who has had norovirus?
How bad did you feel?
Imagine you are 80yrs old and you have co-
morbidities and you had norovirus
How bad do you think you would feel?
Epidemiology & Costs
• NHS Lothian– Sept 2007 – June 2009– 1732 patients– 599 HCWs– 192 unit outbreaks– 3768 bed days lost– £1.2m over 2 seasons
Daniel et al 2011 JHI
Mortality as a consequence of norovirus • 24mths cohort study• 308 nursing homes • 407 norovirus outbreaks• Significantly more hospitalisations• Significantly more deaths when
norovirus outbreaks ongoingTrivedi et al JAMA 2012
Average 442 ward closures per annum (Monday point prevalence)
Peak weeks 1-2
32E coli O157 Salmonella
Streptococcus pyogenesMTB
MRSA
MSSA
1
Norovirus
So why is it important to You?
You the person with norovirus
With the important job
Teaching people who work in care settings
Preparing food
Who work in multiple care settings
Who is going on holiday of a lifetime
With the elderly relative
In shared living accommodation
Receiving healthcare
Delayed surgery because wards
closed
Schools closedExams not possible
Can’t go to work because schools
closed
Businesses closedFinancial
implications
No holiday because cruise liner being disinfected and
stuck in wrong port
Acute gastroenteritis and video camera surveillance : a cruise ship care report: Diskin et al 2014. (International Maritime Health)
• A faecal incident outside a cabin
It is important to YOU because
• You can get it• You can start outbreaks• You can keep outbreaks going • You can help elderly people survive it • You can prevent outbreaks• You can teach others how to do likewise
•Nothing can be done•Nothing works•We just go through rituals•Should not bother
•No one comes into a care setting to get an infection•By being prepared we can reduce the impact of norovirus
If we fail to prepare, we prepare to fail
B Franklin
These outbreaks are people
• Vulnerable – elderly and very young
Hospitalised patients get it worseLopman et al 2004 CID
Improvement work to minimise norovirus in Scotland
Qualitative evaluation:
How was it for you?
= Evaluation Report
+
What should preparedness look like nationally and
locally?
Comms strategy about month to go
+ Season start Season tracker
Escalation planVisits to key areas
Training plans
Identified vulnerable areas
Guidance updates
Bay closures
Single web site
Front door notices
Stay at Home campaign
What can we do nationally to
make it happen?
+ =
Fire Prevention
Preparedness is the norm
What is new in the literature?
Does our guidance need to change?
Consultation+
Approval
What worked well – what additional
preparation?
Season Evaluation: how was it for you?
What do we want to know – Research
Questions?
Every system is perfectly designed to get the results it gets (Batalden)
• Healthcare and care facilities are designed to get norovirus outbreaks
• Because they happen• WINCL
Care home settings focus• Prepare
– Winter is coming so is norovirus....– Know about norovirus...– Know what to do if....– Get letters and posters ready– About a month to go 8 / 9 / 2014
• Prevent– No symptomatic patients staff / relatives
• Manage– Isolate in room– Temporary suspension of visiting– Infection prevention and control– CARE FOR THE RESIDENTS WITH NOROVIRUS
Hospital• Prepare – is guidance ready
– Does everyone know – teaching huddles– Weakest links – what and where are they– How are you going to work different
• Prevent – assessment on admission & patient placement– Early referral = bay closure (50%)
• Manage – close the area– Cleaning to disinfection – 1,000 ppm av cl.– Bide your time.... – Reopening is not outbreak over its outbreak
manageable
In addition
• Tweet.... – 50% attack rate– Vomit can travel 3 metres– Survive for 1 month– 7 touches from 1 hand...
HCW seasonal flu vaccine
• There was a small increase in the uptake of seasonal influenza in front-line health care workers (HCW) across the 2013-14 season (33.8%) compared with 2012-2013 (30.6%).
• The acting CMO is considering additional measures that could be deployed to boost vaccine uptake in the forthcoming season.
• Target remains 75% in front-line HCW.
Summary
• It is the perfect pathogen
• You can minimise its impact on you
• Together we can minimise norovirus on those receiving care in Scotland
• What are you going to do?
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