Norovirus Outbreak on Campus

1. Norovirus Outbreak on Campus Mary Crabtree, Workplace Safety Manager Peter A. Reinhardt, Director Department of Environment, Health & Safety University of North Carolina at Chapel Hill Presented at the 50th Anniversary International Conference of the Campus Safety, Health and Environmental Management Association, July 5th, 2004

2. Presentation Objectives • General Information • Review of UNC’s Norovirus Outbreak • Actions taken within UNC • Debriefing within UNC • Attendance at NCSU’s Debriefing • Lessons Learned • Recommendations for Other Institutions

3. General Information • In January 2004, EHS implemented a Hand Washing Campaign with Orange County Health Dept. • Goal: To reduce overall risk to infectious diseases and food-borne illnesses

4. Carolina Dining Services • Two full dining facilities • Four snack facilities • ARAMARK: Contractor for food services • Serve 7,000 meals/day in full dining halls

5. Review of UNC’s Norovirus Outbreak • On January 21, 2004, sixty-six students reported to Student Health Services • Symptoms: nausea, vomiting, diarrhea, acute gastroenteritis

6. Review of UNC’s Norovirus Outbreak

7. About Norovirus Norovirus Infection Symptoms • Vomiting • Diarrhea • Nausea • Abdominal cramps • Headache, muscle aches • Fever (minority) • Dehydration • Up to 30% may be asymptomatic Adapted from Strategies for Norovirus Infection Control Aboard Cruise Ships, Robert E. Wheeler, MD, 2003.

8. About Norovirus Norovirus-Public Health Aspects • 23-25 million cases in 2002 • About 8% of the U.S. population • Restaurants, schools, dormitories at risk Adapted from Strategies for Norovirus Infection Control Aboard Cruise Ships, Robert E. Wheeler, MD, 2003.

9. About Norovirus Norovirus Infection • Infectious dose of 10-100 virus particles • 24-48 hour incubation period • 12-60 hour duration of illness • A “mild” and short-lived illness • Treatment may indicate IV fluids • Viral shedding of 3 weeks or more Adapted from Strategies for Norovirus Infection Control Aboard Cruise Ships, Robert E. Wheeler, MD, 2003.

10. About Norovirus Transmission • “Oral-fecal” route • Food (39%) • Hands, person-to-person (12%) • Water (3%) • Also environmental surfaces: carpets, toilets, etc. Adapted from Strategies for Norovirus Infection Control Aboard Cruise Ships, Robert E. Wheeler, MD, 2003.

11. About Norovirus Modes of Transmission by Food • Food sources (i.e., food arrives contaminated) • Preparation • Food handlers • Customers • Most at risk: ready-to-eat foods that require handling but no subsequent cooking (e.g., salads) Adapted from Strategies for Norovirus Infection Control Aboard Cruise Ships, Robert E. Wheeler, MD, 2003.

12. About Norovirus Norovirus Characteristics • Highly contagious • Multiple modes of transmission • Stable in the environment • Resistant to routine disinfection methods • Carriers may not be symptomatic Adapted from Strategies for Norovirus Infection Control Aboard Cruise Ships, Robert E. Wheeler, MD, 2003.

13. Review of UNC’s Norovirus Outbreak

14. UNC Student Health Service Epicurve

15. Action Taken by Student Health Services • Immediately notified Orange County Health Department, who began an investigation. • Enacted Disaster Plan and notified EHS • Assisted with Incident Communications Plan • Posted “Student Illness Update” on websites

16. Initial Health Department Findings Based on calls to students who came to SHS, their roommates and other contacts.

17. Environment, Health & Safety • Established contact with entities that would be involved (i.e., Housekeeping, UEOHC, Athletics, Housing & Residential Education) • Coordinated Incident Communications Plan • Prepared clean-up packets for Residence Halls • Discussed clean-up procedures with Athletics (Men’s Basketball Game, January 24) • Advice to student dining operations to deal with rumors, business impact, etc.

18. Action Taken Within UNC

19. Cleaning Guidelines for Housekeepers

20. Housekeeping Department • EHS met with Housekeeping Zone Managers • Review Clean-up procedures • Identification of areas which students exhibit illness • Verify that available cleaners are sufficient • Required cleaning may exceed staff capabilities • Need feedback from housekeepers as to extent of cleaning needs

21. Housing and Residential Education • Distributed EHS clean-up kits to residence halls • Assisted with Incident Communications Plan • Prepared & distributed illness survey (for students who did not go to SHS for treatment)

22. Carolina Dining and ARAMARK • Placed “Hand Wash” tents on dining tables • Placed additional hand washing stations throughout dining halls • Reviewed staff absenteeism records • Fully assisted health investigators • ARAMARK’s SOP is to save food samples • ARAMARK offered corporate investigation and communication resources

23. Calendar of Outbreak Events

24. County Health Department’s Finding Final Results, February 2, 2004: • Overall, about 250 students became ill during this outbreak • Outbreak from a single source • Time limited • Common environmental exposure • Five times more likely in one location of dining hall • Four times more likely if the student ate salad bar • No point to a specific salad item • No procedural problems found with the Dining Services

25. Debriefing Within UNC • UNC’s Debriefing was conducted on March 2 • Parties involved: • Environment, Health & Safety • Student Health Services • Carolina Dining Services (including ARAMARK) • Housing & Residential Education • Housekeeping Services

26. Debriefing Within UNC • Reviewed Orange County Health Department Findings • Effectiveness of Communications • Involvement of key groups for decision making • What if any other potential resources were needed? • Further analysis by the UNC School of Public Health • What other action can be taken to prevent/ mitigate reoccurrence?

27. Attendance at NCSU’s Debriefing • Compare experiences and share best practices. • NCSU conducted a highly visible handwashing campaign

28. Attendance at NCSU’s Debriefing • Paralleled UNC’s case • After 6th case at SHS, implemented survey—a best practice UNC could adopt. • Saw 410 students from February 9 to March 4—longer duration. • No source identified.

29. Lessons Learned • Delay in Health Department investigation results limited University’s response, so—to compliment the Health Department—we plan to initiate medical survey at the time of complaint. • Immediately review geographic data–who ate where and when. • Consider using epidemiology resources from UNC’s School of Public Health. • Continue contingency planning with outside parties.

30. Other Plans of Action • Presentation to the North Carolina Public Health Training and Information Network • Plans for a more aggressive hand washing campaign for winter of 2004-05, including additional hand cleaners in dining halls in strategic locations. • Consider arrangements to purchase and acquire effective cleaners overnight. • If UNC staff cannot manage cleaning, consider hiring cleaning contractor.

31. Recommendations for Other Institutions • Establish emergency communication procedures • Openly discuss contingency plans and responsibilities internally and with public health officials • Conduct drills (i.e. table top) to identify needs • Review contracts of food service and establish a working partnership • Implement stronger health campaigns • Share information

32. Chancellor’s SARS Task Force—Fall 2003 Promote handwashing Housing workshop on response to communicable disease outbreak Strengthened internal and external relationships, communication and decision making. Everyone better understands resources available at the University, County and the State. However, we would rather not make an “outbreak” presentation at the 2005 CSHEMA conference. How Our 2003 SARS Experience Helped Mark Stinson, an auto mechanic from Chatham County NC, has survived four lightning strikes—in 1985, 1993, 2000 and 2002. Although his resulting disabilities are “a never-ending nightmare,” he says, “I’m still fascinated by lightning.”