SC-ANFP Norovirus 10.9.13 HO - · PDF file– Updated Norovirus Outbreak Management and Disease Prevention Guidelines, 2011 ... Microsoft PowerPoint - SC-ANFP_Norovirus_10.9.13_HO

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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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


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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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


Confirmed Norovirus Outbreaks in the US, 2010-2011

http://www.cdc.gov/features/dsNorovirus/figure2.html

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• Fatal among vulnerable populations

• Y Young

• O Old

• P Pregnant

• I Immune compromised


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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• 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


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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Norovirus Classification

Hall 2011 MMWR


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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Transmission

CDC: Mode of Transmission in 20 US States, 2009


Transmission


Person-to-person

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Person-to-Person


Transmission


Food & Water

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Foodborne Outbreaks, U.S., 2006-2010

Norovirus, 49%

Bacteria, 40%

Chemicals, 6%

Other/Multiple, 4%

Parasites, 1%

Hall 2013 EID


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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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


Transmission


Surfaces

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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.


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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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


Transmission


Aerosolized particles

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Transmission by Air: 25 feet


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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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


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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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


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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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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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


Guideline Summary

• Green Light: Prevention Strategies

• Yellow Light: High-risk months & preparedness

• Red Light: Body fluid cleanup - outbreak management & recovery

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Prevention: Food Safety

Employee Healthy Policy

No Bare-Hand Contact with RTE Foods

Hand Hygiene

The “Three-Legged Stool” of Food Safety


Prevention: Policies & Education

• Hand washing – Direct care providers

– Indirect care providers

– Food handlers

– Volunteers

– Residents

– Visitors

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Seeing is Believing!

www.GloGerm.com or www.Glitterbug.com


How: Handwashing for Life!

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Ready? Go!

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Hand Antiseptics

• Hand Sanitizers• FDA Compliant EtOH based

• 60-95% EtOH

– Currently available products are relatively “ineffective against norovirus”



• 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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• 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:




• 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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Prevention: The “T” Zone


Preparedness

• Vomit and diarrhea cleanup ‘hit squads’

• “Go kits” for body fluid cleanup

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A Challenge….

The Body Fluid Cleanup Kit – “Go Kits”

– Which components are for Personal Protective Equipment (PPE)?

– Which components are for cleaning?


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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Assemble

Personal Protective Equipment

• Disposable, nonabsorbent, medical grade gloves

• Disposable facemask with face shield or goggles

• Disposable gown

• Disposable shoe covers


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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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


On Alert

• Peak activity during winter months – 80% of outbreaks between Nov-Apr

• Surveillance

• Cleaning Frequency

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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)


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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Body Fluid Cleanup or Outbreak


Dining/Group/Public Venues

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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)


Respond

Put on Personal Protective Equipment


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Respond

Cover/solidify the waste



Respond

Remove waste and clean area– Detergent and water

– Spiral-in (least to highest contamination)


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Respond

Re-glove

(NSFMI)


Respond

Mix, then spray fresh disinfectant to saturate the cleaned area & adjacent 25 foot area-– Include all food contact & shared contact surfaces

– Contact time


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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


Respond

Disinfect non-disposable tools

• Bag disposable tools


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Respond

• Remove Personal Protective Equipment

• Dispose of bagged waste



Respond

Change uniform– Hottest wash, hottest dry

– Longest cycles

Linens, privacy curtains – Minimize agitation

– Use PPE

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Total Cleanup

Resuming food operations

• Rinse disinfectant

• Wash

• Rinse

• Sanitize (routine)

• Air dry

• High-touch areas


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


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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



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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NFSMI Resource Kit

• Training video (18 minute)

• Trainer & participant manuals

• Mini posters & fact sheets

• Standard operating procedures

• Online courses

www.nfsmi.org/norovirus


www.cdc.gov/norovirus

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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


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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Contact Information

Jamie Stamey, MS, RD, LDN, CP-FSFood Safety, Training, Applied Nutrition

[email protected]

704.576.7302www.HealthyAndSafeFood.com

Documents

SC-ANFP Norovirus 10.9.13 HO - · PDF file– Updated Norovirus Outbreak Management and Disease Prevention Guidelines, 2011 ... Microsoft PowerPoint - SC-ANFP_Norovirus_10.9.13_HO