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Health Alert Network 2009 <br>
<br>
HEALTH ADVISORY #141 <br>
Norovirus - General Recommendations for Prevention and Control <br>
<br>
DATE: January 21,2009 <br>
TO: Health Alert Network <br>
FROM:Everette James, Acting Secretary of Health<br>
<br>
COUNTIES AFFECTED:Statewide <br>
<br>
<br>
This transmission is a "Health Advisory," provides important
information for a specific incident or situation; may not require
immediate<br>
action. <br>
<br>
HOSPITALS: PLEASE SHARE WITH ALL MEDICAL, PEDIATRIC, INFECTION
CONTROL,<br>
NURSING, AND LABORATORY STAFF IN YOUR HOSPITAL<br>
<br>
FQHCs: PLEASE DISTRIBUTE AS APPROPRIATE<br>
<br>
LOCAL HEALTH JURISDICTIONS: PLEASE DISTRIBUTE TO ALL
PRIMARY CARE PHYSICIANS IN YOUR JURISDICTION AND AS APPROPRIATE<br>
<br>
PROFESSIONAL ORGANIZATIONS: PLEASE DISTRIBUTE TO YOUR MEMBERSHIP <br>
<br>
<br>
The Pennsylvania Department of Health (PADOH)<br>
is releasing the following advisory with the intention to<br>
alert clinicians to of an above-average Norovirus season and<br>
provide some guidance on infection control and prevention<br>
strategies that can be followed for any patient with<br>
gastrointestinal symptoms (nausea, diarrhea, vomiting, etc.)<br>
of unknown etiology.<br>
<br>
Pennsylvania, like other U.S. states as well as<br>
Canada and Europe, is experiencing particularly high<br>
Norovirus activity this winter. In recent weeks, many<br>
confirmed or likely cases of gastrointestinal illness due to<br>
Norovirus have been reported in community settings and in<br>
institutions (including hospitals and nursing homes) across<br>
the state. <br>
A person infected with norovirus sheds the<br>
virus in stool and vomitus, and it can then be easily spread<br>
by food, water, hands, and even air (when aerosolized in the<br>
process of vomiting.) The incubation period is typically 1-2<br>
days but can be as short as 12 hours. Virus may still be<br>
shed in stool for at least one week after symptoms resolve.<br>
Norovirus can survive 3 to 4 weeks on surfaces at room<br>
temperature, and many common disinfectants will not kill<br>
this virus.<br>
<br>
The lack of long term immunity, low infectious<br>
dose, prolonged shedding and duration of survival in the<br>
environment facilitate easy spread of this virus in<br>
institutions. Containing a single case is easier than<br>
containing 20 or 30, so routine preventive measures should<br>
be taken in all institutions prior to outbreaks. The<br>
following preventive measures may prevent outbreaks and will<br>
decrease the spread in facilities.<br>
<br>
1) Exclude individuals with vomiting or diarrhea from
patient care, child care and food preparation.<br>
<br>
<a href="http://www.pacode.com/secure/data/007/chapter46/s46.113.html">http://www.pacode.com/secure/data/007/chapter46/s46.113.html</a>,<br>
<a href="http://www.pacode.com/secure/data/028/chapter27/s27.72.html">http://www.pacode.com/secure/data/028/chapter27/s27.72.html</a>
<br>
and<br>
<a href="http://www.pacode.com/secure/data/028/chapter27/s27.155.html">http://www.pacode.com/secure/data/028/chapter27/s27.155.html</a><br>
<br>
2) Practice frequent hand washing and no bare<br>
hand contact with ready to eat food. <br>
<a href="http://www.pacode.com/secure/data/007/chapter46/s46.261.html">http://www.pacode.com/secure/data/007/chapter46/s46.261.html</a><br>
<br>
3) Promptly clean vomit and feces using a<br>
standard protocol. The protocol will need to vary because of<br>
individual circumstances; however protection of the<br>
employee, prompt remove of waste using absorbent material<br>
and disinfection with an effective agent such as a bleach<br>
solution should be part of every plan. The US National Park<br>
Service has an extensive protocol which is available at<br>
<a
href="http://www.nps.gov/public_health/inter/info/factsheets/fs_noro_r&c.htm">http://www.nps.gov/public_health/inter/info/factsheets/fs_noro_r&c.htm</a>.<br>
<br>
Outbreaks of nausea, vomiting, diarrhea and<br>
stomach cramps, sometimes with muscle aches and fever, are<br>
typical for norovirus infection (previously named<br>
"Norwalk" or "Norwalk-like" virus). Consistent illness are generally
described as "mild" with nausea and vomiting resolving in one<br>
to three days, and malaise continuing for several more days.<br>
Outbreaks of norovirus have higher rates of vomiting (greater than
50%) than outbreaks from other gastrointestinal organisms.<br>
<br>
A general norovirus fact sheet from the Centers for Disease
Control and Prevention is at:<br>
<a
href="http://www.cdc.gov/ncidod/dvrd/revb/gastro/norovirus-factsheet.htm">www.cdc.gov/ncidod/dvrd/revb/gastro/norovirus-factsheet.htm</a>.<br>
<br>
A detailed fact sheet relating to healthcare is at:<br>
<a href="http://www.cdc.gov/ncidod/dhqp/id_norovirusFS.html">http://www.cdc.gov/ncidod/dhqp/id_norovirusFS.html</a><br>
<br>
Norovirus can be a formidable on-going problem for
facilities even when food is not contaminated because:<br>
. Individuals (especially the elderly) may<br>
excrete norovirus for one week or after symptoms resolve. <br>
. Individuals can become infected multiple<br>
times during a lifetime. <br>
. Vomiting in public areas can contribute to<br>
further transmission by providing an opportunity for<br>
widespread fomite and food contamination. <br>
. Not all standard disinfecting methods<br>
commonly used in facilities will kill norovirus.<br>
Disinfection should be performed using a commercial product<br>
specifically listed as capable of killing norovirus, or with<br>
a bleach solution equal to or stronger than a 1:50 dilution<br>
of household bleach (1/2 cup bleach to 1 gallon water).<br>
Carpets may need to be steam-cleaned.<br>
<br>
. In the absence of disinfection, norovirus can<br>
survive on surfaces for 3 to 4 weeks at room temperature. <br>
. Hand washing and hand sanitizer both decrease<br>
the amount of norovirus but neither is absolutely effective.<br>
Frequent, vigorous hand washing with hot water and soap or<br>
hand sanitizer is important. <br>
. Residents of long term care facilities in<br>
particular may have medical problems such as incontinence<br>
and dementia that have the potential to lead to widespread<br>
contamination. <br>
<br>
Facilities are reminded to notify their local<br>
health department or State Health Center of all possible<br>
outbreaks (call 877-PA-HEALTH). When indicated by symptoms,<br>
your local health department or State Health Center can<br>
facilitate testing for norovirus at the Pennsylvania<br>
Department of Health Bureau of Laboratories. New cases<br>
should be recorded daily using a case log, which will help<br>
with the investigation of the outbreak (name, age, room # if<br>
applicable, onset date, symptoms, and duration of illness).<br>
<br>
In addition to the CDC fact sheets listed<br>
above, the Pennsylvania Department of Health offers the<br>
following recommendations (adapted from Los Angeles<br>
guidelines at:<br>
<br>
<a
href="http://www.lapublichealth.org/acd/docs/Norovirus/NorovirusControlMeasures_12_1_06.pdf">http://www.lapublichealth.org/acd/docs/Norovirus/NorovirusControlMeasures_12_1_06.pdf</a>).<br>
<br>
These suggested control measures should be implemented for
all suspected norovirus outbreaks pending results of laboratory
testing: <br>
<br>
CLEANING<br>
. Frequently wash hands vigorously with soap and water,
especially:<br>
After: <br>
<br>
toilet visits <br>
<br>
cleaning up vomitus or diarrhea <br>
<br>
changing diapers <br>
<br>
handling soiled clothes or linens <br>
<br>
contact with a symptomatic person <br>
<br>
Before: <br>
<br>
eating <br>
<br>
preparing food <br>
<br>
serving food to patients <br>
<br>
(augment hand washing with hand sanitizer for those instances where
soap and water is not immediately available prior to eating) <br>
<br>
<br>
. Clean up vomit and fecal spillages promptly.<br>
Consider wearing a mask, gown and gloves.<br>
. Flush any vomitus and/or stool in the toilet<br>
and disinfect the surrounding area.<br>
. Use an Environmental Protection Agency<br>
approved disinfectant with specific activity for norovirus<br>
or a freshly prepared sodium hypochlorate solution (e.g., a<br>
minimum of 1 part household bleach to 50 parts water<br>
solution) to clean environmental surfaces.<br>
. Increase frequency of routine ward, bathroom<br>
and toilet cleaning. Give special attention to frequently<br>
touched objects such as doorknobs, faucets, toilet rails and<br>
bath rails. <br>
. Immediately wash clothing or linens that may<br>
be contaminated with the virus, especially after an episode<br>
of illness. Handle them as little as possible and with<br>
minimal agitation. Launder with hot water and detergent on<br>
the maximum cycle length and machine dry.<br>
. Clean soiled carpets and soft furnishings<br>
with hot water and detergent or steam clean. Dry vacuuming<br>
is not recommended since the virus may become airborne.<br>
. Wear gloves when entering the room of a sick<br>
resident (keep gloves available in rooms).<br>
. Remove gloves and wash hands after contact<br>
with an ill resident and before contact with an unaffected<br>
resident.<br>
. Dispose of any food that may have been<br>
contaminated by an ill kitchen employee.<br>
<br>
<br>
PATIENT CARE / STAFF PRECAUTIONS<br>
. Educate staff, residents and visitors about<br>
methods of transmission.<br>
. Confine symptomatic residents to their rooms<br>
(cohort ill patients together if possible) and minimize<br>
movement of all residents.<br>
. Require all symptomatic staff (including<br>
kitchen staff), visitors and volunteers to stay home until<br>
symptom free for 48 hours.<br>
. Limit staff from moving between affected and<br>
unaffected units, and exclude any nonessential personnel<br>
from affected units.<br>
. Maintain the same staff-to-resident<br>
assignments.<br>
. Cancel group activities until ill individuals<br>
are asymptomatic for at least 48 hours.<br>
. Limit new admissions until the incidence of<br>
new cases has reached zero.<br>
. Consider use of antiemetics for patients with<br>
vomiting and maintain hydration.<br>
. Discontinue self-service in the cafeteria/dining room to
minimize food handling by residents.
<pre class="moz-signature" cols="72">--
The problem with socialism is that you eventually run out of other people's money.
- Margaret Thatcher
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