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10/14/2013
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Norovirus
Jamie Stamey, MS, RD, LDN, CP-FS
Too Tough to Tame?
2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Buzz Groups
How is your LTC Facility similar to a Cruise ship ?
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2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Buzz GroupsLTC Facility vs Cruise Ship
Populations served
Elderly and at-risk, immune compromised
All ages including older, at-risk groups
Vomit & feces are common; A side effect of many med/dz/tx
“EtOH flu, sea sickness & NoV outbreaks
Facility venues &
Multi-use rooms (e.g. diningactivity room)
Multi-use rooms (e.g. loungebingolectures)
high-touch surfaces
Rails, med. equipment, door handles, elevator buttons
Rails, utensils/buffets, door handles, elevator buttons
Increased opportunity for person-to-person interaction and contact
Increased opportunity for person-to-person interaction and contact
Repeatedly exposed to the infected source over several weeks/months
Repeatedly exposed to the infected source over several days/weeks
Food: Large volume, large batch, high distribution; some unregulated
Food: Large volume, large batch, high distribution; off-ship food venues
Personnel & People
Staff (direct/indirect care), volunteers, residents,
visitors/community
Staff (direct/indirect contact), guests, excursion/port interaction
2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Why is Norovirus a Concern?
• Leading cause of epidemic gastroenteritis
• Fatal among vulnerable populations
• Highly contagious
• Survives many weeks on surfaces
• Very resistant to routine cleaning and sanitizers
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2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Norovirus Disease in the United States
56,000-71,000 Hospitalizations
400,000 Emergency Department Visits (1-9)
1.7-1.9 million Outpatient Visits (1-2)
19-21 million Total Illnesses (~5)
Hall 2013 EID
570-800 Deaths
2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Confirmed Norovirus Outbreaks in the US, 2010-2011
http://www.cdc.gov/features/dsNorovirus/figure2.html
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2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Why is Norovirus a Concern?
• Fatal among vulnerable populations
• Y Young
• O Old
• P Pregnant
• I Immune compromised
2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Gastroenteritis Deaths Among ≥65 year-olds, US, 1999-2007
Modeled Attribution of Cause-Unspecified Gastroenteritis Deaths Among ≥65 year-olds, US, 1999-2007; Hall 2012 CID
Novel strain* *
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2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Why is Norovirus a Concern?
• Staff sick leave and overtime
• Need for additional healthcare supplies
• Additional cleaning expenses
• Inability to manage infected residents
• Temporary closures of affected facilities
Patient Safety Advisory 2010
Significant Financial & Operational Burden
2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Goals for Today
Describe why norovirus is a concern in healthcare settings◦ Epidemiology, symptoms, transmission
Develop & implement guidelines for norovirus prevention & control◦ Facility policies and training◦ Continuous controls for prevention◦ Heightened vigilance in at-risk months◦ Outbreaks response
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2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Norovirus Classification
Hall 2011 MMWR
2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Poll Question
Norovirus transmitted in many ways. What is the leading mode of transmission?
A. Airborne particles
B. Environmental surfaces
C. Food
D. Person-to-person
E. Water
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2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Transmission
CDC: Mode of Transmission in 20 US States, 2009
2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Transmission
CDC: Mode of Transmission in 20 US States, 2009
Person-to-person
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2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Person-to-Person
2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Transmission
CDC: Mode of Transmission in 20 US States, 2009
Food & Water
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2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Foodborne Outbreaks, U.S., 2006-2010
Norovirus, 49%
Bacteria, 40%
Chemicals, 6%
Other/Multiple, 4%
Parasites, 1%
Hall 2013 EID
2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Foods Implicated* in Norovirus Outbreaks Reported to CDC, 2001-2008
0
20
40
60
80
100
120
140
No.
of O
utbr
eaks Production & Processing
Preparation & ServiceUnknown**
*Limited to outbreaks with a simple food (consisting of a single commodity) implicated.**Insufficient or conflicting information provided in outbreak report.
49% produce
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2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Sources of Food & Food Handlers
• Internal– Foodservice staff
– Direct care staff
– Allied health staff
– Family, visitors & volunteers
• Foodservice department
• Activities
• External– Family & visitors
– Dining out of facility
2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Transmission
CDC: Mode of Transmission in 20 US States, 2009
Surfaces
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2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Healthcare – Post Cleaning Reservoirs
• Trolleys/carts
• Computer key boards
• Soap & alcohol dispensers
• Blood pressure equipment
• Pulse oximeters
• Tympanic thermometers
• Bedside furniture
• Toilet & shower fixturesNorovirus in the Hospital Setting. J Hosp Infect. 2011 Feb; 77(2):106-12.
2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Environmental Persistence & Transfer
20% Norovirus-positive stool suspension
Ceramic Formica Stainless Steel
• Infectious in room temperature water stored in the dark for at least 61 days
• Gradually declines over time on common surfaces over 28 days.
• Still detected on surfaces after 4 weeks
• Persist longer at cooler temperatures
Journal of Medical Virology 80:8, 1468–1476, August 2008
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2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Disinfectants
• EPA-registered as effective against norovirus– http://www.epa.gov/oppad001/list_g_norovirus.pdf
• Chlorine bleach
(5.25% concentration)– 5000 parts per million =
– 1 2/3 cups bleach per 1 gallon of water
Resistant to Commonly Used Disinfectants
2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Transmission
CDC: Mode of Transmission in 20 US States, 2009
Aerosolized particles
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2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Transmission by Air: 25 feet
2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Viral Shedding
Highly Contagious• About 1 Trillion viral particles per gram of feces
(often explosive)
• About 300 thousand virus particles in one projectile vomiting incident (often explosive)
• About 10-18 viral particles to make you sick
2011 Supplement to the 2009 FDA Food Code
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2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Clinical Disease
• Incubation period: 12-48 hours
• Acute-onset vomiting and/or diarrhea
• Most recover after 12-72 hours
• 30% of infections are asymptomatic
Hall 2011 EID Phillips 2010 Am J Epid de Wit 2001 Am J Epid
2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Viral Shedding
• Primarily in stool, but also vomitus
• Peaks 4 days after exposure
• May persist for at least 2-3 weeks
Atmar 2008 EID ; Aoki 2010 J Hosp Infect ; Teunis 2008 J Med Virol
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2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Summary of Findings
• Greatest burden and highest rates of severe disease and death – Immune compromised– Elderly (≥65 years)
• Pronounced winter seasonality
• High shed rates & low infective dose
• Easy to spread & hard to kill
2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Goals for Today
Describe why norovirus is a concern in healthcare settings◦ Epidemiology, symptoms, transmission
Develop & implement guidelines for norovirus prevention & control◦ Facility policies and training◦ Continuous controls for prevention◦ Heightened vigilance in at-risk months◦ Outbreaks response
10/14/2013
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2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
A Case of Norovirus - Video
What mistakes are made?
2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FSFull video available: http://www.nfsmi.org/norovirus
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2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Guidelines
• FDA – 2009 Food Code & 2011 Supplement
• CFP - Emergency Action Plan for Retail Food Establishments
• CDC –– Updated Norovirus Outbreak Management and Disease
Prevention Guidelines, 2011
– Guideline for the Prevention and Control of Norovirus Gastroenteritis Outbreaks in Healthcare Settings, 2011
• NEAHIN - The Stomach Bug Book
2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Guideline Summary
• Green Light: Prevention Strategies
• Yellow Light: High-risk months & preparedness
• Red Light: Body fluid cleanup - outbreak management & recovery
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2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Prevention: Food Safety
Employee Healthy Policy
No Bare-Hand Contact with RTE Foods
Hand Hygiene
The “Three-Legged Stool” of Food Safety
2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Prevention: Policies & Education
• Hand washing – Direct care providers
– Indirect care providers
– Food handlers
– Volunteers
– Residents
– Visitors
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2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Seeing is Believing!
www.GloGerm.com or www.Glitterbug.com
2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
How: Handwashing for Life!
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Ready? Go!
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2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Hand Antiseptics
• Hand Sanitizers• FDA Compliant EtOH based
• 60-95% EtOH
– Currently available products are relatively “ineffective against norovirus”
2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Prevention: Policies & Education
• No Bare-hand contact with RTE foods or food contact surfaces (FDA Food Code-Priority)
• Direct/indirect care providers
• Food handlers
• Volunteers
• Family/Visitors
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2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
• Vomiting
• Diarrhea
• Jaundice (yellowing)
• Sore throat with fever
• Cuts & infected wounds on the hands, wrists, or exposed portions of the arms.
• A current, recent or exposure to a foodborne illness
Report symptoms:
Prevention: Policies & Education
2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Prevention: Policies & Education
• Employee health & sick leave – Direct/indirect/foodhandlers
• Illnesses symptoms & reporting (FDA)
• Exclusion – At least 48 hours after symptoms resolve
– Retrain: frequent handwashing
• Surveillance– Employee illness and absenteeism rates
– Resident case finding/reports
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2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Prevention: The “T” Zone
2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Preparedness
• Vomit and diarrhea cleanup ‘hit squads’
• “Go kits” for body fluid cleanup
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2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
A Challenge….
The Body Fluid Cleanup Kit – “Go Kits”
– Which components are for Personal Protective Equipment (PPE)?
– Which components are for cleaning?
2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Items PPE Cleaning
Bucket and/or spray bottle
Disposable gown
Effective disinfectant
Facemask with face/eye shield
Gloves
Paper towels
Plastic garbage bag
Sand, cat litter or commercial absorbent powder
Scoop, small shovel or dustpan
Shoe covers
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2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Assemble
Personal Protective Equipment
• Disposable, nonabsorbent, medical grade gloves
• Disposable facemask with face shield or goggles
• Disposable gown
• Disposable shoe covers
2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Cleaning Supplies
Sand, or liquid spill absorbent material
Disposable flat-edge scoop, shovel, or dustpan
Bucket and spray bottle
Disposable paper towels
Liquid soap
Designated, disposable mop head
Plastic garbage bag & twist-ties
Assemble
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2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Assemble
Disinfectants
• EPA-registered as effective against norovirus– http://www.epa.gov/oppad001/list_g_norovirus.pdf
• Chlorine bleach
(5.25% concentration)– 5000 parts per million =
– 1 2/3 cups bleach per 1 gallon of water
2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
On Alert
• Peak activity during winter months – 80% of outbreaks between Nov-Apr
• Surveillance
• Cleaning Frequency
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2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Prevention: Implement Policies
Increase Environmental Disinfecting
• Ward cleaning: twice daily
• High-touch areas: three times daily
• Shared venues (dining/activity room)
• Shared equipment
• Light switches, railing, tray tables, door handles, elevator buttons, key boards, faucets, telephones, fixtures, bathrooms (public & staff)
• Ice machines (NC advisory)
2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Prevention: Implement Policies
• Surveillance– Employee illness reporting, absenteeism rates
– Resident cases/illness reports
– Visitor check-in, symptom screening, exclusion
• Employee health & sick leave • Exclusion
– At least 48 hours after symptoms resolve
– Retrain: frequent handwashing
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2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Body Fluid Cleanup or Outbreak
2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Dining/Group/Public Venues
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2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Respond
In dining/group/public venues– Stop all food service/group activities
– Remove individuals within 25 feet
– Require handwashing
• Change of soiled clothes/uniform
– Dispose of ALL food & single-use items within 25 feet
(CDC, CFP, FMI, NSFMI)
2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Respond
Put on Personal Protective Equipment
(CDC, CFP, FMI, NSFMI)
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2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Respond
Cover/solidify the waste
(CDC, CFP, FMI, NSFMI)
2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Respond
Remove waste and clean area– Detergent and water
– Spiral-in (least to highest contamination)
(CDC, CFP, FMI, NSFMI)
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2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Respond
Re-glove
(NSFMI)
2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Respond
Mix, then spray fresh disinfectant to saturate the cleaned area & adjacent 25 foot area-– Include all food contact & shared contact surfaces
– Contact time
(CDC, CFP, FMI, NSFMI)
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2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Respond
• Upholstered/cloth items and carpet– Avoid using if possible
– To clean
• Remove soilage
• Use disinfectant if possible
• Steam clean – >5 minutes at >170 degrees Fahrenheit
CDC, Norovirus Gastroenteritis Management of Outbreaks in Healthcare Settings
2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Respond
Disinfect non-disposable tools
• Bag disposable tools
(CDC, CFP, FMI, NSFMI)
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2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Respond
• Remove Personal Protective Equipment
• Dispose of bagged waste
(CDC, CFP, FMI, NSFMI)
2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Respond
Change uniform– Hottest wash, hottest dry
– Longest cycles
Linens, privacy curtains – Minimize agitation
– Use PPE
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2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Total Cleanup
Resuming food operations
• Rinse disinfectant
• Wash
• Rinse
• Sanitize (routine)
• Air dry
• High-touch areas
2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
External Reporting
• Report norovirus outbreaks to your local, county, or state health department – In most states, all outbreaks of public health
significance are reportable to the state health department
• Implement your internal & media communication plan
CDC, Norovirus Gastroenteritis Management of Outbreaks in Healthcare Settings
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2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Summary
• Awareness & prevention through education, training & policies
• Detect and confirm suspected norovirus cases rapidly • Exclude ill staff/isolate residents for a minimum of 48 hrs after
symptom resolution
• During body fluid cleanup & outbreaks– Contact Precautions– Use enhanced hand hygiene– Deploy environmental infection control measures– Use surveillance for new and resolving cases
• Develop a communication plan during outbreaks to include key departments and services
• Consult with and report outbreak to local/state health departments
CDC, Norovirus Gastroenteritis Management of Outbreaks in Healthcare Settings
2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Resources
Food & Drug Administration
Employee Health & Hygiene Handbook, Interactive DVD, Satellite Broadcast
FDA Food Code – Annex 3 – 2-201.11 Reporting of Symptoms
– Annex 3 – 2-201.12 Exclusions & Restrictions
– Annex 3 - 2-201.13 Removal of Exclusions & Restrictions
– Annex 3 – 2-3 Hands and Arms (Cleaning)
– Annex 3 – 3-301.11 Preventing Contamination from Hands
– Annex 3 – 2-501.11 Clean-up of Vomiting & Diarrheal Events
Food Marketing Institute Norovirus Information Guide
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2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
NFSMI Resource Kit
• Training video (18 minute)
• Trainer & participant manuals
• Mini posters & fact sheets
• Standard operating procedures
• Online courses
www.nfsmi.org/norovirus
2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
www.cdc.gov/norovirus
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2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
The Stomach Bug Book
• Available online at http://www.fns.usda.gov/fns/safety/pdf/stomach_bug_book.pdf
• Hardcopies available from NEA http://www.neahin.org/HINPrograms/order.html
2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Summary
Norovirus is a concern in healthcare settings More deadly for elderly
Develop & implement guidelines for norovirus prevention & control◦ Continuous controls for prevention◦ Heightened vigilance in at-risk months◦ Outbreaks response & resolution
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2013 © HealthyAndSafeFood.com Jamie Stamey, MS, RD, LDN, CP-FS
Contact Information
Jamie Stamey, MS, RD, LDN, CP-FSFood Safety, Training, Applied Nutrition
704.576.7302www.HealthyAndSafeFood.com