Florida Department of Health Recommendations and Guidelines for the Control of Norovirus Outbreaks in Nursing Homes and Health Care Facilities

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1 Flrida Department f Health Recmmendatins and Guidelines fr the Cntrl f Nrvirus Outbreaks in Nursing Hmes and Health Care Facilities Fast Facts abut Nrvirus Outbreaks f gastrenteritis in nursing hmes and ther residential facilities are nt uncmmn. Nrvirus, which is highly cntagius, is mst ften the cause and requires immediate actin t prevent further spread f the virus t residents and staff. A Nrvirus utbreak shuld be suspected if vmiting and diarrhea are abut equally cmmn symptms amng peple with gastrenteritis (staff and residents). Nrvirus-assciated gastrenteritis utbreaks may be detected early by recgnizing the typical symptms f illness, and cntrlled by taking specific infectin cntrl steps t prevent the virus frm being transmitted frm persn t persn. While Nrvirus utbreaks may ccur any time f the year they are mre frequent in the winter and spring mnths. Fr mre detailed infrmatin abut Nrvirus see the links and references belw. Signs and Symptms f Nrvirus-assciated Gastrenteritis The symptms f nrvirus illness usually include nausea, vmiting, diarrhea, and stmach cramping. Smetimes peple experience a lw-grade fever, chills, headache, muscle aches, and a general sense f tiredness. The illness ften begins suddenly. In mst peple the illness is self-limiting, with symptms lasting fr ne r tw days. In general, vmiting is mre cmmn in children and diarrhea is mre cmmn in adults. Dehydratin is a ptential life-threatening prblem that is usually nly seen amng the very yung, the elderly, and peple with underlying medical cnditins. Incubatin Perid Illness begins between ne and tw days fllwing expsure t the virus. Transmissin f Nrvirus Nrvirus is very cntagius and can spread easily frm persn t persn. Bth stl and vmit are infectius. Peple wh have direct cntact with a persn wh is infected with the virus can becme infected. Peple can als becme infected by eating fd r drinking liquids cntaminated with the virus, r by cntacting surfaces r bjects cntaminated with the virus and then placing their hands in their muth. Persns wrking in nursing hmes r ther residential healthcare facilities, such as assisted living facilities, shuld pay special attentin t residents wh have symptms suggestive f a 5/19/2010 Page 1 f 6

2 nrvirus infectin. This virus is very cntagius and can spread rapidly thrughut such settings. Outbreak Detectin The ability t detect an utbreak early will allw fr mre timely interventins t cntrl and prevent the spread f Nrvirus. Diarrheal illnesses are cmmn within nursing hmes, making early detectin f a Nrvirus utbreak mre difficult. Cnducting surveillance fr illness thrughut the facility and mnitring the results fr increases may reveal an utbreak. Surveillance shuld include mnitring fr new nset f diarrheal illnesses amng bth patients and emplyees. Diarrheal illness assciated with vmiting shuld increase the suspicin fr a nrvirus illness, since vmiting is nt a hallmark f ther cmmn gastrintestinal illnesses fund in nursing hmes, such as Clstridium difficile. Als, nrvirus illnesses frequently affect staff members as well as residents. Emplyees shuld reprt a diarrheal illness t their supervisr and shuld nt cme t wrk when they are symptmatic. Outbreaks f Nrvirus may be caused by cntaminated fd r persn-t-persn transmissin. By prmptly ntifying yur cunty health department at the first sign f an utbreak, they can assist in understanding the cause f the utbreak s prmpt cntrl measures can be implemented. Reprting If yu bserve any unusual increase in residents with gastrintestinal symptms r any ther illness, reprt it t yur lcal cunty health department. The cunty health department may be able t assist in cntrlling the utbreak and with labratry diagnsis. Outbreak Management Infectin cntrl measures, which may include cntact islatin, shuld be instituted immediately with a single case f diarrhea f new nset withut a nn-infectius etilgy. Frequent hand washing with sap and water is an effective means f preventin. The recmmended prcedure is t rub all surfaces f lathered hands tgether vigrusly fr at least 20 secnds and then thrughly rinse the hands under a stream f warm water. A paper twel shuld be used t dry hands and t turn ff the water. Alchl-based hand sanitizers are, in general, nt very effective against Nrvirus. It is recmmended that everyne, including (but nt limited t) residents, staff, vlunteers, visitrs, and service persnnel, wash their hands when entering and leaving the facility r resident s/patient s rm, after using the restrm, after assisting with tileting r diaper changes, befre and after handling fd r eating, after having cntact with residents, and/r after having cntact with infective material that may cntain micrrganisms. If a resident is nt able t perfrm gd hand hygiene, staff members shuld assist the patient. Equip all restrms with sap, dispsable paper twels r an electric hand drying device, and trash cntainers s peple can prperly wash their hands after using the restrm. 5/19/2010 Page 2 f 6

3 Educate staff, vlunteers, residents, visitrs, and service persnnel regarding the utbreak, methds f transmissin, and cntrl measures. In situatins in which the utbreak is extended in duratin, the facility r institutin might have t be clsed t new admissins until the utbreak is ver and the facility can be cleaned apprpriately. Cnsider use f anti-emetics fr patients with vmiting. Residents/Patients Islate all symptmatic persns. Symptmatic residents/patients shuld be placed in a private rm, if pssible. When a private rm is nt available, place them in a rm with smene wh has active infectin with the same micr-rganism but with n ther infectin. Ask residents with vmiting r diarrhea t stay in their rm until they are symptm-free fr 72 hurs. Limit the mvement and transprt f the patients fr essential purpses nly. If the resident/patient is transprted ut f the rm, ensure that precautins are maintained t minimize the risk f transmissin f micr-rganisms t ther patients and cntaminatin f envirnmental surfaces r equipment. Limit new admissins until at least 72 hurs after the last identified case. If new admissins are necessary, admit residents t an unaffected unit r t a unit that has had n new cases within the last 72 hurs. Avid discharging ill patients until at least 72 hurs after reslutin f illness. Cancel r pstpne nn-essential grup activities until at least 72 hurs after the last identified case. Cmmn areas such as activity rms and dining rms shuld be clsed. Meals shuld be served in the resident s rms. If a resident is transferred t the hspital, ntify the hspital that the resident is cming frm a facility at which an utbreak is ccurring. Staff Exclude all ill staff members wh wrk in fd service fr at least 48 and preferably 72 hurs after reslutin f their symptms. Exclude all ther staff members fr at least 48 hurs after reslutin f symptms. Since sme infectius agents, including Nrvirus, can be shed fr a lng duratin after recvery frm illness and in the absence f clinical disease, all staff members shuld be required t maintain strict persnal hygiene at all times. Prvide staff, visitrs, and vlunteers with prper persnal prtective equipment when caring fr r visiting an ill resident. Dispsable glves (clean, nn-sterile glves are adequate) shuld be wrn when entering the rm f a symptmatic patient when direct 5/19/2010 Page 3 f 6

4 cntact with ill persns r cntaminated surfaces is pssible. Gwns shuld be wrn when cntaminatin f clthing with fecal material r vmitus is pssible. Peple wh clean areas grssly cntaminated by feces r vmitus shuld wear a surgical mask. Care shuld be taken when changing and laundering siled bed linen, s as t nt aerslize the infectius material. During the curse f prviding care fr a patient, change glves and gwns after having cntact with infective material that may cntain high cncentratins f micr-rganisms (fecal material, vmitus, and wund drainage). Remve glves and gwns befre leaving the patient's rm and wash hands immediately with sap and water and turn ff water with a paper twel. After remving gwns and glves, and hand washing, ensure that hands d nt tuch ptentially cntaminated envirnmental surfaces r items in the patient's rm t avid transfer f micr-rganisms t ther patients r envirnments. D nt allw staff t flat between affected and nn-affected units, if pssible. Staff shuld try t maintain same staff-t-resident assignments, if pssible. Nn-essential staff shuld be excluded frm affected units. Emplyee hand washing vigilance shuld be mnitred thrugh active management reminders and crrectin. Staff respnsible fr cleaning rms and accidents shuld be trained regarding prper persnal prtective equipment, infectin cntrl prcedures, and cleaning and disinfectin f infective material when respnding t fecal r vmitus accidents. Envirnmental Disinfectin Envirnmental surfaces shuld be kept visibly clean and be disinfected n a rutine basis. During an utbreak, the frequency f cleaning and disinfecting high-tuch surfaces thrughut the facility shuld be increased. High-tuch surfaces wuld include, but are nt limited t, dr handles, elevatr buttns, sink and tilet handles, fd preparatin and dining areas, hand and stair rails, telephnes, light switches, cunters, and cmputer keybards. Dispsable cleaning clths and mp heads shuld be used fr all cleaning and sanitizing/disinfectin. Staff shuld use dispsable cleaning clths. Staff shuld use ne clth fr cleaning and a new clth fr sanitizing/disinfecting surfaces. Separate cleaning clths shuld be used in tilet areas. Staff shuld use a new set f cleaning clths fr each rm. Staff shuld use single-use dispsable glves. Glves shuld be remved and discarded befre mving t clean the next rm. In the event f a vmiting r fecal accident, the surfaces that have been siled and the surrunding area shuld be cleaned and sanitized by trained staff wearing apprpriate prtective barriers (i.e., a dispsable mask, glves, eye shield, dispsable she cvers, and plastic dispsable aprn). Residents, guests, and nn-essential staff shuld be excluded frm these areas fr the duratin f the clean-up. 5/19/2010 Page 4 f 6

5 The area shuld first be cleaned f visible material using detergent and ht water and then disinfected with a freshly prepared bleach slutin (see belw fr apprpriate cncentratins) r an Envirnmental Prtectin Agency-apprved disinfectant fr nrvirus (Vikrn-S r NP 9.0). Cntaminated mp heads, cleaning clthes, persnal prtective equipment, and ptentially infectius material (i.e., feces r vmitus) used/cllected during the cleaning prcedure shuld be prmptly discarded in a manner that prevents transfer f this material t ther surfaces r persns (e.g., bihazardus bag). Staff shuld thrughly wash hands after cmpleting the clean-up prcedure and again after cmpleting the dispsal prcedure. Bleach slutin cncentratins: Fr cmmercial bleach-cntaining prducts fllw the manufacturer s recmmendatins. Bleach slutins must be mixed daily fr effectiveness. Fr nn-prus surfaces such as tile flrs, cunter-tps, sinks, etc.: ⅓ cup f bleach in 1 galln f water (1000ppm). Fr stainless steel, fd/muth cntact items: 1 tablespn f bleach in 1 galln f water (200ppm). Fr prus surfaces such as wden flrs: 1⅔ cups f bleach in 1 galln f water (5000ppm). A list f EPA apprved sanitizers fr Nrvirus can be fund n their website: Cntaminated twels, linens, pillws, bedspreads, blankets, and ther fabric materials shuld be placed int separate laundry bags frm nn-cntaminated items. They shuld be washed separately in a ht wash, and dried separately at 170 F. If an utside laundry service is used, they shuld be advised that the laundry is ptentially infectius. Cntaminated carpets shuld be cleaned in a three-step prcess. First, carpets must be cleaned with carpet detergent and ht water. Secnd, carpets must be disinfected by applying an apprpriate disinfectant. Finally, carpets shuld be steam cleaned (158 F fr 5 minutes r 212 F fr 1 minute is needed fr cmplete inactivatin). It is nt recmmended t dry-vacuum a cntaminated carpet prir t this disinfectin prcess. Heat disinfectin (i.e., pasteurizatin t 140 F) has been suggested, and used successfully under labratry cnditins, fr items that cannt be subjected t chemical disinfectants such as chlrine bleach. Facilities shuld mnitr the effectiveness f their cleaning plicies. Case Surveillance/Management Facilities shuld establish and maintain a surveillance prgram fr gastrintestinal disease. During an utbreak, cases shuld be recrded daily using a case lg, which will help with the investigatin f the utbreak. The cunty health department may request daily updates t mnitr the utbreak. 5/19/2010 Page 5 f 6

6 Labratry Testing The lcal cunty health department can prvide stl sample cntainers upn request during an utbreak. The purpse f the testing is t cnfirm the disease causing the utbreak. References Nrvirus infrmatin n the Department f Health web site can be fund at: Barker J, Vipnd IB, Blmfield SF. Effects f cleaning and disinfectin in reducing the spread f Nrvirus cntaminatin via envirnmental surfaces. J Hsp Infect. 2004; 58:42-9. CDC Nrvirus: Fd Handlers - CDC Nrvirus in Healthcare Facilities Fact Sheet - CDC Nrwalk-Like Viruses : Public Health Cnsequences and Outbreak Management - CDC. Guideline fr Hand Hygiene in Health-Care Settings: Recmmendatins f the Healthcare Infectin Cntrl Practices Advisry Cmmittee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Frce. MMWR 2002;51(N. RR- 16): Chadwick PR, Beards G, Brwn D, et al. Management f hspital utbreaks f gastrenteritis due t small rund structured viruses. J Hsp Infect 2000; 45:1-10. Dultree JC, Druce JD, Birch CJ, et al. Inactivatin f feline calicivirus, a Nrwalk virus surrgate. J Hsp Infect 1999; 41: Flrida Department f Health Rule 64D-3, Flrida Administrative Cde. Cntrl f Cmmunicable Diseases and Cnditins Which May Significantly Affect Public Health. Sehulster LM, Chinn RYW, Arduin MJ, Carpenter J, Dnlan R, Ashfrd D, Besser R, Fields B, McNeil MM, Whitney C, Wng S, Juranek D, Cleveland J. Guidelines fr envirnmental infectin cntrl in health-care facilities. Recmmendatins frm CDC and the Healthcare Infectin Cntrl Practices Advisry Cmmittee (HICPAC). Chicag IL; American Sciety fr Healthcare Engineering/American Hspital Assciatin; Siegel JD, Rhinehart E, Jacksn M, et al Guideline fr Islatin Precautins: Preventing Transmissin f Infectius Agents in Healthcare Settings. Smith PW, Bennett G, Bradley S, et. al. SHEA/APIC Guideline: Infectin preventin and cntrl in the lng-term care facility. Am J Infect Cntrl 2008; 36: /19/2010 Page 6 f 6

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