Preventing Norovirus Outbreaks in Hospitality

1. NorovirusHotels and Restaurants Georgina Fox - Health Protection Practitioner South West Public Health England Centre. May 2019

2. About PHEa SW Health Protection Team: 0300 303 8162: option 2, then option 1 Including out of hours Norovirus: Hotels and Restaurants. May 2019

3. Why control Norovirus • Major discomfort • Occasionally severe • Disrupt holiday/wedding • Disruption to business • Financial risk • Reputational risk Presentation title - edit in Header and Footer

4. What is Norovirus • Aka “Gastric flu”, “ Winter Vomiting”, “Norwalk”- the most common cause of viral gastroenteritis • Symptoms are short lived ( 12-60 hours): • Sudden onset • Vomiting ( often projectile) and/or diarrhoea (releasing millions of virus particles each episode) • Nausea & Abdominal pain • Sometimes: Headache, Muscle aches, Low grade fever Norovirus: Hotels and Restaurants. May 2019

5. Norovirus: Hotels and Restaurants. May 2019

6. How it is spread • Humans are only known source • Passed from person to person by faecal-oral route: • Direct contact with infected faeces or vomit • Touching contaminated surface/object • Eating food contaminated by an infected food handler • Consuming contaminated food or water e.g. shellfish, Norovirus: Hotels and Restaurants. May 2019

7. Norovirus circulates in the community all year round- regular hand washing is best way to reduce the risk • Before commencing work/after leaving work area • Before preparing or eating food • After using the toilet • After smoking • After handling contaminated laundry & waste and • After cleaning equipment or the environment • Even if gloves were worn

8. Staff need to know how to wash their hands and the need to be “Bare Below the Elbow” for some activities http://www.who.int/gpsc/5may/How_To_HandWash_Poster.pdf?ua=1 Norovirus: Hotels and Restaurants. May 2019

9. Hand wash basins- staff areas • Used only for hand washing • Kept clean and clutter free • No disposal of used environmental cleaning fluids • No storing of used equipment awaiting decontamination • Well stocked with liquid soap and paper towels • Foot operated bin nearby • Provide moisturising hand creams Norovirus: Hotels and Restaurants. May 2019

10. Cleaning- general principles • Cleaning: general removal of debris (dirt, food, body fluids) • • Disinfection: reduces microorganisms to a safe level • You cannot disinfect anything that is not clean • It’s not clean until it’s dry • Staff need to know what to clean, when and how

11. Cleaning room/area affected by Norovirus • Dispose of consumables e.g. tea and coffee, biscuits, toilet rolls and toiletries • Clean all horizontal and hand touch surfaces and fixtures and fittings with detergent and hot water • Then disinfect with 1000 ppm ( 0.1%) sodium hypochlorite solution • Soft furnishings and curtains laundered/ steam cleaned • Vacuuming can increase spread • Use disposable cloths • Ideally- disposable mop heads ( otherwise launder 70°C). Buckets must be cleaned, disinfected and dried • Crockery and cutlery removed and washed in hot dishwash (at least 70 °C) • Consider keeping bedroom empty for 72 hours • ? “fogging” Norovirus: Hotels and Restaurants. May 2019

12. Disinfectants- Sodium hypochlorite is gold standard for norovirus • A Log10 reduction of 4 (99.99%) or greater is considered adequate for FCV/Norovirus disinfection. • Safe to use • Have reasonable contact time • Staff training needed Norovirus: Hotels and Restaurants. May 2019

13. Dealing with body fluid spillage- PPE • Gloves should be worn for any activity with potential for contact with blood or body fluids • Disposable and single use • They should be of sufficiently good quality and carry CE mark • Removed with care- Training • Plastic apron -disposable and single use • Staff area for changing/washing http://www.hse.gov.uk/skin/posters/singleusegloves.pdf Norovirus: Hotels and Restaurants. May 2019

14. Cleaning body fluid spillages • Wear PPE • Remove gross contamination ( paper towels, granules) • Clean with detergent and hot water • Disinfect with 10, 000 ppm ( 1%) sodium hypochlorite solution • Use disposable cloths • Dispose of waste appropriately- ( check with waste contractor) Staff require training in correct use of chemicals Norovirus: Hotels and Restaurants. May 2019

15. Contaminated linen and waste • PPE and hand hygiene • Alginate bags • Ensure laundry capable of temperature greater than 60 C i.e. 70OC • Tumble dry • Dirty laundry must not come into contact with clean linen • Store waste appropriately http://www.hse.gov.uk/pubns/waste22.pdf Norovirus: Hotels and Restaurants. May 2019

16. Preparation for Norovirus outbreaks- recognition and management Norovirus: Hotels and Restaurants. May 2019

17. Marks et al. 2000. Evidence for airborne transmission of Norwalk-like virus (NLV) in a hotel restaurant. Epidemiology and Infection 124 (3), 481-487 Presentation title - edit in Header and Footer

18. Outbreak definition • Two or more linked cases describing the same illness • OR • A number of observed cases exceeds the expected number The key is to consider how you would recognise an outbreak and be prepared to respond Norovirus: Hotels and Restaurants. May 2019

19. Organisational preparedness Norovirus: Hotels and Restaurants. May 2019

20. February. Approx 100 guests. Restaurant Norovirus: Hotels and Restaurants. May 2019

21. Wednesday 1pm Mr and Mrs Smith are checking out. Mrs Smith had been violently ill through the night. They say that they had arrived the previous afternoon feeling completely well and ate in the hotel restaurant that evening. Mrs Smith started being sick at 10 pm, vomited through the night (including on the bed linen and carpet) They blame the ‘food poisoning’ on the steak and chips that they ate in the restaurant which was not hot enough and although she is feeling a bit better now they have had such a horrible time that they are now leaving for home Presentation title - edit in Header and Footer

22. Actions • Clean and disinfect room • ? Food poisoning Norovirus: Hotels and Restaurants. May 2019

23. Wednesday 4pm • A member of cleaning staff informs you that the ladies toilet in reception/lobby is in a terrible mess- someone has clearly had an upset stomach. He has cleaned the cubicle and placed a wet floor warning cone there. Norovirus: Hotels and Restaurants. May 2019

24. Actions • Cordon off whole bathroom • Clean and disinfect as described earlier- at least 3 metres from affected cubicle • Wait until surfaces are dry before re-opening to public • Consider- will all staff flag this up? Would staff flag up evidence of D&V in bedrooms • ? How often are toilets checked • NB- you don’t know it- but this was a parting gift from affected guest before leaving earlier that day…. Norovirus: Hotels and Restaurants. May 2019

25. Thursday 7 am • Mr Jones telephones reception- he is complaining of a dodgy stomach and is feeling weak. He is alone in the room and is too ill to travel home. Norovirus: Hotels and Restaurants. May 2019

26. Actions • Persuade symptomatic guests to remain in their rooms • Keep them stocked up- consumables, food, drinking water • Daily hand towels- consider use of paper towels • Do you have an outbreak? Norovirus: Hotels and Restaurants. May 2019

27. Thursday 3 pm • A member of cleaning staff phones in sick- they have been vomiting at home. • He was the cleaner that dealt with the contaminated toilet cubicle the day before • Another member of staff hears of this and wonders if she should go home as she helped with the cleaning Norovirus: Hotels and Restaurants. May 2019

28. Staff illness • 48 hour rule for staff exclusion- i.e. can return to work once free of symptoms for 48 hours • Return to work interview • Norovirus can remain in faeces for up to three weeks-hand hygiene is key • Exposed staff to remain vigilant for symptoms and leave work asap if unwell • Exposed staff to be excluded from food handling • Affected staff may get short term immunity ( ? 6 months) but only to that strain • Possibility of an outbreak to be considered. Be vigilant for further cases, ensure staff aware, increase toilet checks and cleaning of communal areas, remove nibbles from communal areas, refresh hand hygiene posters Norovirus: Hotels and Restaurants. May 2019

29. Thursday 7pm • 4 further guests are reporting a sudden illness with diarrhoea and/or vomiting • You find out that one had vomited suddenly in a restaurant area which was promptly cleaned at the time. • One guest is diabetic, has become very unwell and you have phoned for an ambulance Norovirus: Hotels and Restaurants. May 2019

30. What to do when outbreak occurs Norovirus: Hotels and Restaurants. May 2019

31. Norovirus: Hotels and Restaurants. May 2019

32. Norovirus: Hotels and Restaurants. May 2019

33. Summary sheet Norovirus: Hotels and restaurants. May 2019

34. Friday 1pm • A number of guests are due to be taken home by coach today • Ill guests to travel independently • Ensure coach operator aware of the outbreak Norovirus: Hotels and Restaurants. May 2019

35. Friday 9pm • The outbreak is on-going and a large number of guests who were eating at the time of the restaurant incident yesterday are now ill. • You learn that a member of kitchen staff vomited in a kitchen sink this evening. They cleaned the sink straight away and, after finishing sorting the bread rolls, were sent home Norovirus: Hotels and Restaurants. May 2019

36. Cleaning food prep areas • The entire kitchen should be considered as being contaminated with norovirus • Any exposed food is not fit for consumption and must be disposed of. • A ‘deep clean’ of the kitchen is required prior to re-use • Consider alternative sources of food for guests • Consider suspending use of kitchen for 72 hours after cleaning • Any further illness within this time will necessitate a second deep clean Norovirus: Hotels and Restaurants. May 2019

37. End of the outbreak • The environmental health/PHE outbreak control team will advise when the outbreak is considered to be over • Usually after 72 hours from the last symptom experienced within the hotel • The hotel and other shared facilities should undergo a thorough deep clean prior to re-opening • Consider contracting an external company to carry this out Norovirus: Hotels and Restaurants. May 2019

38. Conclusion- Be prepared https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/362998/2007_guideline_norovirus_cruiseships.pdf Norovirus: Hotels and Restaurants. May 2019