Don’t Gamble with Norovirus

1. Don’t Gamble with Norovirus Kristen Obbink, DVM, MPH Eric Bradley, MPH, REHS, CP-FS, DAAS 2014 NEHA AEC - Las Vegas, NV

2. What it is, What it isn’t • Caliciviruswith 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

3. 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

4. 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

5. How does it spread? (Cont…) • Aerosol • Being near someone who is vomiting

6. True or False Questions • You can only get Norovirus once in your life and then you are immune

7. 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

8. True or False Questions • You can spread Norovirus even after your diarrhea stops

9. True or False Questions • You can spread Norovirus even after your diarrhea stops • True, see the next slide

10. 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

11. 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

13. Top pathogens contributing to foodborne illnesses, hospitalizations and deaths in US (2011)

16. Cruise Ships…Schools…Gatherings…Long Term Care Facilities • Transmits easily when people are in close contact • Very low infectious dose

17. Infectious Dose • Norovirus: 10-100 • Shigella: 10-100 • Salmonella: 105 - 108 • Campylobacter: 104 – 106 • E. coli: 108

20. Investigating Norovirus Outbreaks • Collect illness information • Get a diagnosis – COLLECT STOOL SPECIMENS • Focus on prevention, educate everyone

21. 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

22. Get a Diagnosis Collect 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

23. 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

24. Prevention is KEY!! • Noro Cleaning Guidance • In the home • In restaurants/facilities • Stay home when sick!! • If you are out and about, you are spreading norovirus • Good hand hygiene • Don’t cook for others… • Don’t cook for others until at least 48 hours after symptoms cease

26. 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

27. Guidance documents available for many situations… • Long term care guidance • School /childcare guidance • Healthcare setting guidance • Food handlers

28. 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: • Excludeuntil 48 hrsafter diarrhea & vomiting cease • Most staff members in child care programs are considered food handlers • Educate staff, parents& children on proper hand washing technique

29. 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

30. 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

31. General Guidance for Schools • Students and staff with diarrhea and/or vomiting: • Exclude until 24 hrsafter diarrhea & vomiting cease • Any staff/student who handles food &has diarrhea and/or vomiting: • Exclude from food handling activities until 48 hrsafter diarrhea &vomiting cease • Educate staff members, parents, &students on proper hand washing technique

32. 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

33. 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 hrsafter vomiting and diarrhea cease

34. 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 hrsafter vomiting or diarrhea cease • Educate staff members, residents, and visitors on proper hand washing technique

35. 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

36. 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

37. General Guidance for Hospital & Long-term Care Facilities (cont…) • Staff with diarrhea and/or vomiting: • Exclude until 24 hrs after diarrhea & vomiting cease • Educate 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

38. 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 hrsafter vomiting & diarrhea cease

39. 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 OR • Thoroughly disinfect when removed from patient’s room • Select appropriate cleaning agent based on equipment manufacturer’s recommendation for compatibility

40. 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 both • Limit staff from moving between affected & unaffected areas of facility & limit any non-essential personnel from affected areas

41. 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

43. IDPH Norovirus Outbreaks - 2012 • Only outbreaks are reportable • 30 suspected or confirmed Norovirus outbreaks investigated in 2012 • 9 long-term-care or assisted living • 7 restaurant • 6 child care/school/college • 4 private gathering • 2 hospital • 2 other • Over 660 people ill

44. Activity Ongoing in 2013-14 • Activity slowing but ongoing • Investigated several in the last few weeks • Long term care • Private gatherings • Restaurants

45. Outbreaks • Restaurant • Hotel • Casino • Hotel / Conference Center / buffet

46. Restaurant Outbreak

47. Restaurant Outbreak

48. Restaurant Outbreak

49. Restaurant Outbreak • EH coordinator and Deputy Director • DIA Foodborne Illness Complaint Form • Staff

50. Complaint Inspection