The Poop Stops Here Norovirus outbreak in LTC

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The Poop Stops Here (Norovirus outbreak in
LTC)

• Candi Shearen R.N., C
• Clinical Nurse Consultant
• Golden Living

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Objectives

• Explain Norovirus transmission routes
• Define the components of an outbreak
• Describe infection prevention measures for
  outbreak management.

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Norovirus

• RNA virus from the Calciviridae family Formerly
  known as Norwalk
• Most common cause of enteric illness in LTC
• Human reservoir

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Incidence of Infections LTC facilities
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• Norovirus is a MOST DIFFICULT bug to get rid of
  during an outbreak situation. In fact, it is
  nearly impossible.
• Dr. Lindsay E. Nicolle University of Manitoba
  Winnipeg Canada September 2007

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What Makes Norovirus So Contagious?
Source CDC
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Potential Transmission Level of Norovirus

• NoV is shed in the feces at levels up to
  10,000,000 viral particles per gram
• One projectile vomiting incident can include up
  to 30,000,000 viral particles

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Factors to Consider in Control of Norovirus
Outbreaks

• 25 of cases shed virus 3 weeks post recovery
• Resistant to common disinfectants?
• Widespread and persistent environmental
  contamination
• Very low infectious dose (10 viral particles?)
• Staff infected and contagious
• Up to 30 asymptomatic infections - contagious?
• Constant introduction

Rockx, CID, 2003
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Transmission

• Food
• Contamination at source
• Foodhandlers
• Person to Person
• Fecal Oral Route
• Emesis Airborne
• Indirect via fomites / contaminated environment
• Water
• Drinking water wells

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Estimated Cases of Selected Known Enteric
Pathogens, United
States
Agent Cases
Food-Related

• Norovirus 23,000,000
  40
• Rotavirus 3,900,000
  1
• Campylobacter 2,453,926 80
• Giardia 2,000,000 10
• Salmonella 1,412,498 95
• Shigella 448,240 20
• Cryptosporidium 300,000 10
• C. perfringens 248,520 100
• S. aureus 185,060
  100
• Hepatitis A Virus 83,391 5
• E. coli O157H7 73,450 85

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Person-to-Person Studies

• Vomiting and airborne spread
• UK restaurant
• Sudden vomiting
• gt50 sick
• Table-specific attack rates
• Environmental contamination
• Hotel in UK cases occurring over 4 months
• Swabs of carpet, light fittings, toilet Positive
• Spread on airplane
• Associated with contaminated but unsoiled toilets

Marks et al Epidemiol Infect 2000 Cheesbrough
et al Epidemiol Infect 1998 Widdowson et al
JAMA, 2005
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Duration of Symptoms and Shedding of Norovirus

• Community-based cohort study of 99 cases in the
  Netherlands
• all age groups represented
• Median duration of symptoms 5 days
• Shedding (virus detected in stool)
• Day 1 78
• Day 8 45
• Day 15 35
• Day 22 26

Rockx et al., 2002
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Non-foodborne Norovirus Outbreaks in
Institutional Settings, Minnesota, 2000-2006
Number of outbreaks
Year
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Duration of Norovirus Illness among Staff,
Patients and Residents of Hospitals and Resident
Homes
Lopman et al CID 2005
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Clinical Disease

• Incubation period 12-48 hours median, 33 hours
• Mild and short-lived
• Acute onset diarrhea, nausea, vomiting, cramps
• Acute phase lasts 12-72 hours
• No long-lasting immunity all ages affected

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Clinical Disease

• Diarrhea (non-bloody)
• Nausea
• Vomiting
• More likely in children
• Can be primary complaint
• Abdominal pain
• Myalgia
• Headache
• Low-grade fever (or none)

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Treatment for Norovirus

• Self-limiting illness
• May require oral or intravenous rehydration
• 10 cases seek health care
• 1 hospitalized
• hospitalizations rare in healthy children and
  adults
• More debilitating in elderly or immunocompromised

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Norovirus in Long-Term Care Facilities (LTCF)

• Majority of gastroenteritis outbreaks in LTCF are
  due to norovirus
• Usually person-to-person spread
• Some food-related outbreaks have been traced to
  ill food service employees
• Spread may be amplified by ill employees, e.g.,
  aides passing medications
• Winter seasonality

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You Can Help Prevent These Outbreaks!

• The key to implementing a solid employee health
  program is communication.
• Talk to foodworkers about the hazards of vomiting
  and diarrhea.
• Work as a team to find innovative ways to keep
  ill foodworkers out of the kitchen and care
  givers away from the care of the residents tell
  them NOT to report to work ill
• Proper Barrier use when caring for ill residents
• HANDWASHING is the key component of your health
  program!

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Handwashing

• Every step of handwashing is important!
• Scrubbing with soap 1 log virus reduction
• Rinsing under strong velocity and volume of water
  increased effect in physically removing virus
• Drying hands with paper towels 1 log virus
  reduction

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• Norovirus
• Outbreak Management

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Key Concepts

• Cooperation between facility, Medical Director,
  corporate staff and public health experts is
  necessary to effectively manage outbreak
  situations
• Ultimate goal is to ID probable contributing
  factors and stop or reduce risk of transmission
  and ultimately control/eliminate the outbreak
• APIC Text 2005

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Key Concepts (cont)

• Suspect outbreak when GI symptoms occur above the
  endemic/background/normal facility rate of
  infections rule of thumb is 10. (Candis rule
  of thumb has always been cautious start the
  outbreak measures if you see a couple cases.
  Better to be safe than sorry!!!!!!!!)

APIC Text 2005
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Key Concepts (cont.)

• Focus of an outbreak may be associated with
  specific groups of residents, locations,
  treatment modalities, contaminated products or
  devices, healthcare providers, and/or healthcare
  practices
• All residents who ate at a picnic
• All dietary employees
• All residents on East wing
• One employee who floats and several residents on
  different floors
• ETC..
• Investigation of an outbreak must be conducted to
  assess the contributing factors source,
  pathogen, host, and mode of transmission

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Recognize Outbreak

• On-going Surveillance
• Endemic is usual level of disease within LTC
  facility
• May fluctuate slightly from month to month but
  does not differ significantly
• Outbreak/epidemic
• Excess over the expected level of disease
• One case of an unusual disease

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Recognize Outbreak (cont)

• Notification of health dept varies state by
  state, BUT most require outbreaks be reported.
• Will assist in providing epidemiologic and
  laboratory support
• Guide you through outbreak and other resources
  available to you

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Conducting Investigation

• Steps are not especially in order some done at
  same time all are important
• Prepare for investigation
• Medical Director/District Staff if in
  corporation/Health Department
• Commitment of staff Administrator to NA/Rs
• Designated person to lead the charge to put
  necessary pieces in place Infection
  Preventionalist

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Conducting Investigation (cont)

• Confirm outbreak exists
• Compare current incidence with baseline incidence
• Establish or verify DX/ID agent- determine
  treatment
• Characterize the symptoms
• Sudden onset of high fever, non-productive cough,
  malaise, body aches what do you suspect?
• Confirm DX
• Laboratory

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Conducting Investigation (cont.)

• Collect data line list ill residents/employees
  collect specimens Cont. surveillance until
  return to endemic/normal level
• Help you determine and evaluate how well your
  outbreak management measures worked
• Calculate the rates seen during the entire
  outbreak

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Conducting Investigation (cont.)

• Initiate immediate control and prevention
  measures
• Environmental controls cleaning
• Hand hygiene and barriers
• Educate staff - document
• Inform residents/families signs on entrances to
  building
• AUDIT to ensure staff is doing what you have
  taught them
• Develop timeline and communicate findings to
  Health Dept, Med Director, District staff and QA

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• Dawn Kaehler
• Health Program Representative
• Acute Disease Investigation and Control Section
• Minnesota Department of Health
• 651-201-5228
• Checklist for LTC
• Staff List
• Line List
• Food handler info

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Refer to outline and attachments in folder
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Acknowledgement
Kirk Smith, DVM, MS, PhD Supervisor,
Foodborne, Vectorborne, and Zoonotic Diseases
Acute Disease Investigation and
Control Section Minnesota Department of Health