Download - Don’t Gamble with Norovirus
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Don’t Gamble with Norovirus
Kristen Obbink, DVM, MPHEric Bradley, MPH, REHS, CP-FS, DAAS2014 NEHA AEC - Las Vegas, NV
What it is, What it isn’t Calicivirus with 6 Genogroups
Genogroups I, II, and IV cause human illness
Environmentally stable Resists heating to 60o C & able to
survive freezing AKA - “Food Poisoning” or “Stomach
Flu” Not related to the influenza virus
What does it do to you? Commonly causes diarrhea,
vomiting, nausea, stomach cramps Other symptoms include fever,
headache, body aches Usually no long-term health impacts Dehydration most common
complication
How does it spread?Fecal/Oral
○Eating or drinking contaminated food items
○Touching contaminated surfaces or objects and then putting your fingers in your mouth, or
○Having contact with someone who is infected
How does it spread? (Cont…)Aerosol
○Being near someone who is vomiting
True or False Questions You can only get Norovirus once in your
life and then you are immune
True or False Questions You can only get Norovirus once in your
life and then you are immune. False
○Many different types of noroviruses○Immunity is short-lived
True or False Questions
You can spread Norovirus even after your diarrhea stops
True or False Questions You can spread Norovirus even after
your diarrhea stopsTrue, see the next slide
When can you spread it? Virus is in stool before symptoms
start Virus can stay in stool for 2 weeks or
more after symptoms stop Most contagious when sick with
symptoms and during the first three days after recovery
Norovirus Trivia 1929 - First recognized outbreaks of
viral gastroenteritis termed “winter vomiting disease”
1940 - Demonstrated that pooled stool filtrates obtained from patients in an institutional outbreak could infect volunteers
1968-CDC investigated vomiting disease in an elementary school in Norwalk, OH
Top pathogens contributing to foodborne illnesses, hospitalizations and deaths in US (2011)
Pathogen Est. number of cases
Est. number of
hospitalizations
Est. number of deaths
Norovirus 5,461,731 (#1) 14,663 (#2) 149 (#4)
Salmonella(non-typhoidal)
1,027,561 19,336 378
Campylobacter spp. 845,024 8,463 76
C. perfringens 970,000 4,400 26
E.coli (STEC) O157 63,000 2,138 21
Toxoplasma gondii 87,000 4,428 327
Cruise Ships…Schools…Gatherings…Long Term Care Facilities Transmits easily when people are in
close contact Very low infectious dose
Infectious Dose Norovirus: 10-100 Shigella: 10-100 Salmonella: 105 - 108
Campylobacter: 104 – 106
E. coli: 108
Investigating Norovirus Outbreaks Collect illness information Get a diagnosis – COLLECT STOOL
SPECIMENS Focus on prevention, educate everyone
Collect illness information Onset of symptoms
Incubation typically 24-48 hours Symptoms
Diarrhea, vomiting, nausea, stomach cramps
Vomiting more common in children Duration of illness
Usually 24-48 hours Usually see high attack rate & 2° spread
Get a DiagnosisCollect stool specimens Offer to drop off and pick up stool kits, if
possible Send to appropriate laboratory (some
labs are unable to test for Norovirus) Label vials and fill out appropriate
paperwork
Diagnosing Norovirus Polymerase chain reaction (PCR) Takes ~4 hours to complete High sensitivity
Detects concentrations as low as 10 viral particles
Cannot detect all small round viruses, so negative test is not always conclusive
Prevention is KEY!! Noro Cleaning Guidance
In the homeIn restaurants/facilities
Stay home when sick!!If you are out and about, you are
spreading norovirusGood hand hygiene
Don’t cook for others…Don’t cook for others until at least 48
hours after symptoms cease
Hand Gels and Norovirus• Scientific uncertainty over
effectiveness of alcohol-based hand gels against norovirus
• Always wash hands with soap and warm water when able
• Alcohol-based hand gels should only be used in situations where soap and warm water are not available
Guidance documents available for many situations… Long term care guidance School /childcare guidance Healthcare setting guidance Food handlers
General Guidance for Childcare Facilities
Children or staff with diarrhea and/or vomiting:Exclude until 24 hrs after diarrhea & vomiting
cease Staff who handle food and have diarrhea and/or
vomiting:Exclude until 48 hrs after diarrhea & vomiting
ceaseMost staff members in child care programs are
considered food handlers Educate staff, parents & children on proper
hand washing technique
Outbreak Guidance for Childcare Facilities
Consider providing guidance on prevention of norovirus to parents, staff & children
Increase frequency of routine cleaning Focus on disinfection of commonly
touched areas: doorknobs, phones, etc. Toys should be cleaned & disinfected
daily
Outbreak Guidance for Childcare Facilities (cont…)
Ensure restrooms are adequately stocked with soap, paper towels, & warm running water
Request stool specimens from 3-5 of the ill individuals to confirm cause of the outbreak
General Guidance for Schools Students and staff with diarrhea and/or
vomiting:Exclude until 24 hrs after diarrhea &
vomiting cease Any staff/student who handles food & has
diarrhea and/or vomiting:Exclude from food handling activities until
48 hrs after diarrhea & vomiting cease Educate staff members, parents, & students
on proper hand washing technique
Outbreak Guidance for Schools Consider providing guidance on prevention of
norovirus to parents, staff & children Increase frequency of routine cleaning Temporarily stop using self-service foods for
school breakfast/lunch Ensure restrooms are adequately stocked
with soap, paper towels, and warm running water
Request stool specimens from 3-5 of the ill individuals to confirm the cause of the outbreak
Guidance forCommunity Residential Programs Actions taken will depend on the type of
program and the level of functioning of the residents
General recommendations include: Residents with suspected or confirmed
norovirus:○ Place on Enteric precautions until
symptoms subside Staff members with suspected or confirmed
norovirus:○ Exclude until 24 hrs after vomiting and
diarrhea cease
Guidance for Community Residential Programs (cont…)
Staff and clients with suspected or confirmed norovirus:
Refrain from handling or preparing food for other residents until 48 hrs after vomiting or diarrhea cease
Educate staff members, residents, and visitors on proper hand washing technique
General Guidance for Hospital & Long-term Care Facilities
Place ill patients in private rooms or cohort ill patients in the same room
Consider grouping ill patients in same area or wing of facility
Minimize un-necessary movement of residents
Consider temporarily discontinuing group activities until outbreak has resolved
General Guidance for Hospital & Long-term Care Facilities (cont…)
Consider serving meals in resident rooms instead of dining hall
Educate staff members, residents, and visitors on proper hand washing techniques
Send all ill staff home immediately
General Guidance for Hospital & Long-term Care Facilities (cont…)
Staff with diarrhea and/or vomiting:Exclude until 24 hrs after diarrhea &
vomiting ceaseEducate on proper hand hygiene upon
returning to work Patients with suspected norovirus infection:
Manage with standard & contact precautions with careful attention to hand hygiene practices
General Guidance for Hospital & Long-term Care Facilities (cont…)
Contact precautions should be used when caring for diapered or incontinent persons, during outbreaks in a facility, and when a splash could occur
Persons cleaning areas heavily contaminated with vomitus or feces should wear surgical masks
Food handlers with diarrhea and/or vomiting:Exclude until 48 hrs after vomiting &
diarrhea cease
General Guidance for Hospital & Long-term Care Facilities
(cont…) Medical equipment used for care of
norovirus-infected patients:Dedicate to that patient for duration of
patient’s isolation ORThoroughly disinfect when removed
from patient’s room Select appropriate cleaning agent based
on equipment manufacturer’s recommendation for compatibility
Outbreak Guidance for Hospital & Long-term Care Facilities
Collect stool specimens from 3-5 patients to confirm cause of outbreak
Assign staff to work with well residents or sick residents, not bothLimit staff from moving between
affected & unaffected areas of facility & limit any non-essential personnel from affected areas
Outbreak Guidance for Hospital & Long-term Care Facilities (cont…)
Consider limiting new admissions to affected areas until all patients are well and no new cases are occurring
Inform visitors about a possible disease outbreak in your facility
Consider limiting or stopping visitation to facility until there have been no new cases for at least 48 hrs
Post extra hand washing signs in various visible areas in the facility
IDPH Norovirus Outbreaks - 2012 Only outbreaks are reportable 30 suspected or confirmed Norovirus
outbreaks investigated in 20129 long-term-care or assisted living7 restaurant6 child care/school/college4 private gathering2 hospital2 other
Over 660 people ill
Activity Ongoing in 2013-14 Activity slowing but ongoing Investigated several in the last few
weeksLong term carePrivate gatheringsRestaurants
Outbreaks Restaurant
Hotel Casino
Hotel / Conference Center / buffet
Restaurant Outbreak
• Phone callMarch 20,
2012
Restaurant Outbreak
• Phone call• Suspected foodborneMarch 20,
2012
Restaurant Outbreak
• Phone call• Suspected foodborne
• DIA Foodborne illness form
March 20, 2012
Restaurant Outbreak EH coordinator and Deputy
Director DIA Foodborne Illness
Complaint Form Staff
Complaint Inspection
• ManagementOn-site
Visit
Complaint Inspection
• Management• FacilityOn-site
Visit
Complaint Inspection
• Management• Facility• EmployeesOn-site
Visit
Customer Interviews
• Identifying information
EPI2000 Outbreak
Form
Customer Interviews
• Identifying information
• Sick?
EPI2000 Outbreak
Form
Customer Interviews
• Identifying information
• Sick?• Symptoms
EPI2000 Outbreak
Form
Customer Interviews
• Identifying information
• Sick?• Symptoms• Food eaten
EPI2000 Outbreak
Form
Investigation
• 33 individuals called
March 20, 2012 PM
Investigation
• 33 individuals called
• 21 illMarch 20, 2012 PM
Investigation
• 33 individuals called
• 21 ill• Incubation period
March 20, 2012 PM
Investigation March 20, 2012
Stool kitsData entry
Investigation
• Person 1BMarch 21, 2012
Investigation
• Person 1B• Norovirus Y/N
March 21, 2012
Investigation
• Person 1B• Norovirus Y/N• Closed for cleaning• Bleach
March 21, 2012
Investigation
• EmployeesMarch 21, 2012
Investigation
• Employees• Informed facility
March 21, 2012
Investigation
• Employees• Informed facility• Stool kits
March 21, 2012
Employee Interviews
• 17 EmployeesEPI2000 Outbreak
Form
Employee Interviews
• 17 Employees• 11 ill
EPI2000 Outbreak
Form
Conference Call SCHD Staff IDPH DIA
EPI2000
• 2-tailed pData
EPI2000
• 2-tailed p• Tossed saladData
Employee Interviews
• Employee CEPI2000 Outbreak
Form
Investigation March 21, 2012
Stool kits
Investigation March 22, 2012
Facility reopenedNoro confirmedEmployee CConference call
Restaurant OutbreaK
• Phone callMarch 23,
2012
Restaurant Outbreak
• Phone call• Interviews
March 23, 2012
Restaurant Outbreak
• Phone call• Interviews• Noro confirmedMarch 23,
2012
Review Conference call 2 groups – 67 total 40 ill
Attack rate: 60% Stool kits Employee C Noro cleaning Case closed
Restaurant Outbreak
• Phone callMarch 26, 2012
Restaurant Outbreak
• Phone call• Thursday, March 22
March 26, 2012
Restaurant OutbreaK
• Phone call• Thursday, March 22
• Interview
March 26, 2012
Restaurant Outbreak
• Phone call• Thursday, March 22
• Interview• Noro Cleaning
March 26, 2012
Casino Outbreak
• ReportOctober 18, 2006
Casino Outbreak
• Report• Facility
October 18, 2006
Casino Outbreak
• Report• Facility• ER’s notified
October 18, 2006
Casino Outbreak
• Incident command
October 19, 2006
Casino Outbreak
• Incident command
• On-site visitOctober 19, 2006
Casino Outbreak
• SymptomsOn-site Visit
Casino Outbreak
• Symptoms• InspectionOn-Site
Visit
Casino Outbreak
• Symptoms• Inspection• Record review
On-Site Visit
Casino Outbreak
• Stool kitsOctober 20, 2006
Casino Outbreak
• InterviewsOctober 23, 2006
Casino Outbreak
• ResultsOctober 24, 2006
Casino Outbreak
• Illinois CasinoOctober 27, 2006
Casino Outbreak
• Illinois Casino• Conference CallOctober
27, 2006
Conference Call• End outbreak quickly
• Prevent spread• Avoid closing• Interventions
Objectives
Interventions
• Signage/Handouts
Public Notice
Health Department
• InterviewsOctober 28, 2006
Food Service
• ShutdownOctober 28, 2006
Conference Call
• Additional action plansOctober
31, 2006
Action Plan
• Continue current plan
• Handwashing procedures”
• Stay home
Employees
Action Plan• Chips• Counters and tables
• Slot machines• Widespread area
Frequent cleanings
Continued Surveillance• Case definition• Interviews• Monitor absenteeism
• Stool samples• Decrease of interventions
November 1, 2006
10/12/2006
10/17/2006
10/22/2006
10/27/2006
11/1/2006
11/6/2006
11/11/2006
11/16/2006
11/21/2006
11/26/2006
12/1/2006
12/6/2006
12/11/2006
0369
1215182124273033363942454851545760
Number of Cases (non-employee) by
Date of Illness Onset
Date of Illness Onset
Num
ber o
f Cas
es
Questions?
Kristen Obbink, DVM, MPHFoodborne Illness EpidemiologistIowa Department of Public [email protected]
Eric Bradley, MPH, REHS, CP-FS, DAASEnvironmental Health SpecialistScott County Health [email protected]