Surviving Norovirus Not Just a Cruise Ship Issue Maria Wellisch, RN, LFNA Vice President of Corporate Education Morningside Ministries

How Prevalent is Norovirus

•  21 million cases

•  71,000 individuals hospitalized

•  91,000 emergency visits

•  800 deaths

Foodborne Illness Outbreaks in the US

Norovirus is responsible for more than 50% of all outbreaks

What is the cost of this virus?

The cost for healthcare and lost productivity is…

• $2 billion per year

• $1 billion per year

• $20 million per year

$2 Billion Dollars

•  This is healthcare and lost productivity •  This does not measure the impact on the public

perception of your facility if you have an out break.

Where is the most common setting for outbreaks?

•  Healthcare facilities

•  Cruise Ships

•  Schools

Why are long term care facilities so susceptible?

1.  Communal / Social Activities

2.  Congregate Meals

3.  Dementia / hand washing

Clinical Symptoms

1.  Short incubation usually 12:48 hours after exposure

2.  Common symptoms – acute onset of vomiting, watery, non-bloody diarrhea, abdominal cramping and nausea

3.  Low-grade fever, headache and myalgia

Asymptomology

30% of infected individuals do not develop any symptoms

How long do symptoms last?

Usually 24-72 hours with most individuals recovering completely.

Most Serious Outcomes

•  Seen in children under 2 •  Elderly

•  Immunocompromised patients/residents »  Severe Dehydration

»  Hospitalization »  Death

Treatment

•  No specific treatment for norovirus gastoenteritis •  Dehydration is the most common complication

that requires treatment

•  Antimotility agents and antiemetics are generally not recommended

•  Antibiotics have NO value… …this is a virus

Shedding •  This virus is shed primarily in the stool •  Vomitus is infectious

•  Shedding peaks 4 days after exposure but can last up to 2-3 weeks

•  Shedding can occur in non-symptomatic individuals

Transmission •  Person to person

»  Fecal-oral

»  Aerosolized Vomitus »  Indirect – contaminated items / the environment

Food

•  Food handlers

•  Contaminated Food (raspberries, oysters)

Contaminated drinking or recreational water A well contaminated by a septic tank

Inadequate chlorination

Transmission in Healthcare

•  Direct contact with infected persons •  Contaminated equipment

Highly Infectious

When do we start to think about

an outbreak?

Immediate Response •  As soon as you see the 1st case (s) begin your

investigation and implement precautions

•  Collect data on both ill and exposed residents / patients and staff. »  Date of Onset

»  Location

»  Work Assignment »  Test Results

»  Outcomes

Prior to lab results

Kaplan Criteria may be used to detect an outbreak

Kaplan Criteria

•  Vomiting in more than ½ of the symptomatic cases

•  Mean incubation period of 24-48 hours

•  Mean duration of illness is 12-60 hours

•  No bacterial pathogen isolated in stool culture

Lab Testing

•  Check with your reference laboratory to determine what are the specimen requirements

•  The (RT-PCR), reverse transciptase polymerase chain reaction

•  The optimal specimen is a stool specimen while someone is acutely ill.

REMEMBER There are many causes

for Gastroenteritis

What to do if you have an outbreak

Notify health dept/public health – know your states requirements and jurisdictions

Hand Washing

Staff

•  Exclude ill staff until at least 48 hours after diarrhea and vomiting have stopped

•  No floating

•  Non-essential staff excluded from affected areas

•  Hand washing instructions

•  Review contact precautions

Residents

1.  Start record for all symptomatic residents 2.  Ill residents on contact precautions

3.  No group activities

4.  Do NOT move residents from affected to non-infected areas

Residents

•  Maintain the same staff-to-resident assignments •  If resident transferred to hospital notify receiving

site of the outbreak

Facility •  Consider halting new admissions until outbreak is

over

•  Review disinfectants and be sure you are using appropriate agents – Quaternary ammonium compounds are NOT effective against noroviruses

•  Clean and disinfect more frequently

•  Review cleaning and disinfection with housekeeping and all staff

Facility (continued)

•  Change mop heads •  Do not share common medical equipment unless

disinfected between residents

•  Change privacy curtains if soiled or after resident discharge

•  Carpets and upholstery

Facility (continued) •  Soiled linens – maximum cycle length, appropriate

detergent

•  Discontinue self-service or communal food/beverages until outbreak over

•  Disposable dishes/utensils NOT required

•  Post signs facility is experiencing increase in gastrointestinal illness

Facility (continued)

•  Be ready to discuss with media •  Be prepared to explain what you are doing with

your family members

Visitors/Volunteers

•  Encourage hand washing •  Postpone visits from children and elderly persons

•  Ill family members and friends should be asked to avoid visitation

•  Monitor Volunteers

Lesson Learned