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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 HealthKristen.Obbink@idph.iowa.gov515-281-6049

Eric Bradley, MPH, REHS, CP-FS, DAASEnvironmental Health SpecialistScott County Health DepartmentEric.Bradley@scottcountyiowa.com563-326-8618