Viral Gastroenteritis: Prevention and Control in Long-Term Care Facilities

1. Viral Gastroenteritis:Prevention and Control in Long-Term Care Facilities Daniel Golson, MPHEpidemiologistdaniel.golson@nashville.gov615-340-5651

2. Practical Guidance for LTCFs www.health.nashville.gov/healthdata

3. Development of Document • early 2009 – 4 confirmed norovirus outbreaks • LTCF, retirement community, restaurant, social gathering • only one was determined to be foodborne • internal work group formed • internal communication, outbreak response, guidance for public facilities (e.g. hotels and LTCFs) • CDIs, environmentalists, & epidemiologists • Food Division, Public Facilities, Epidemiology

4. And Then.... • Swine flu!

5. Next Thing You Know...Fall 2009 Viral Gastroenteritis Outbreaks in Davidson County • 5* Assisted Living facilities • 2** Retirement communities • 2 Social gatherings • wedding (confirmed norovirus G2 etiology) • work environment (confirmed norovirus G2 etiology) *1 confirmed etiology – norovirus G2 **1 confirmed etiology – norovirus G2

6. Lessons Learned • Some large institutions have very clear control protocols • Many do not • Many HCWs lackadasical about viral gastroenteritis – “it’s going around” • Closed communities must be prepared

7. Guidance Needed for LTCFs • Prepare for eventuality of a viral gastroenteritis outbreak • When to suspect an outbreak • Control measures • Info to collect for CDIs, epi’s • Notification the LHD • Examples of info to hand out to residents & signs to discourage visitors

8. Guidance Needed for LTCFs • Isolation practices • Dining facilities & community activities • Ill staff • Home-health workers • Transfers, EMS transports • New admissions • Environmental cleaning & disinfection • Flexible step by step guide

9. Outbreaks • ≥2 residents or staff with new onset of V and/or D w/n 48 hrs of each other  suspect norovirus • early recognition critical to control • aggressive implementation of control measures

10. Preparation is Critical! • Review guidance & share with staff • Think about what info your audience will want during an outbreak – be transparent in your communications • Prepare for specific audiences: • residents • residents’ families/friends • staff (food, maintenance, volunteers, home-health workers, etc) • the media?

11. You suspect an outbreak, now what? Notification– Everyone plays a role • Residents, Staff – Report SxS to Mgmt • Mgmt or ICP • Consult with MPHD (615-340-5632) • Log cases daily using line list • Alert “sister” facilities, hospitals, hospice, EMS • Provide staff, residents, family, visitors with fact sheet on norovirus

13. Isolation and Case Management • 48 hrs rule • isolate those with SxS until 48 hrs SxS-free • send ill staff home until 48 hrs SxS-free • discontinue communal activities until 48 hrs after last case ID’d • close dining facility until 48 hrs after last case • Limit staff to one area of assignment • Postpone transfers & new admissions • Discourage visitors

14. Managing the Environment • Norovirus resistant to most disinfectants • Clean & disinfect (C&D) contaminated areas promptly • Step up C&D and continue enhanced C&D ≥72 hrs after last case ID’d • Chlorine bleach is best Lysol® 409® Pinesol®

15. Managing the Environment • Do Not bring non-essential equip into contaminated areas • Do Not vacuum until after steam cleaning (carpets, rugs, furnishings) • Segregate clean & soiled linens/laundry • Wear PPE when handling soiled laundry

16. Viral Gastroenteritis Outbreaks in Davidson County since Fall 2009 • Over 175 illnesses in total • At least 8 hospitalizations, many ED visits • No fatalities • Attack rates among residents ranged from 16% to 73%

17. Propagated Outbreak in 3 phases?

18. Questions? www.health.nashville.gov/healthdata