Challenges in the Public Health Management of a Community Outbreak before a Major Event. Tracy Bladen Public Health Nurse

Transcription

1 Challenges in the Public Health Management of a Community Outbreak before a Major Event Tracy Bladen Public Health Nurse

2 AIMS 1. Understand the characteristics of Norovirus that make outbreaks difficult to manage 2. Explore the difficulties with the Public Health management of an outbreak within a boarding and day school

3 Norovirus why it is tough to manage Highly contagious Low infective dose Stable in the environment and attaches to fomites Prolonged viral shedding Found in faeces and vomit of infected person; can aerosolise Genetically diverse group of RNA-viruses - difficult to develop long-lasting immunity It has a bad reputation during mass gatherings!

4 One gram of faeces may contain up to 5 billion infectious doses of NOROVIRUS

5 Literature Review: School Setting Gastroenteritis outbreaks under reported Delayed notification, and implementation of preventative measures Gastroenteritis outbreaks frequent in confined environments Opportunities for direct transmission of illness between individuals Increased number of people Increased personal contacts Seldom washing of hands Schools have an important role to play in preventing illness among students and the community Mellou K. et al, A. Epidemiological investigation of two parallel gastroenteritis outbreaks in school settings. BMC Public Health 2013,13:241. Lee MB., Greig JD: A Review of Gastrointestinal Outbreaks in Schools: Effective Infection Control Interventions, Journal of School Health, 2010, Vol. 80.No.12

6 Guidelines. The Communicable Disease Network Australia (CDNA) formed a working group in 2005 in order to develop national guidance regarding outbreaks of norovirus and suspected viral gastroenteritis, in response to increasing reports of outbreaks. These Guidelines were designed to complement existing state and territory guidelines.

7 Background: Outbreak Notification On Thursday 1/2/18, Gold Coast Public Health Unit (GCPHU) was notified of an outbreak of gastroenteritis (nausea, vomiting and/or diarrhoea) amongst senior boarding students at a local independent day and boarding school 40 students reported to have been unwell over the previous 12 hours Non clinical setting This facility expected to be used as a 310 bed accommodation venue and training venue for the upcoming commonwealth games in March 2018

8 The Context - numbers Total 624/2340 Senior school 502/1608 Junior school 122/732 Boarders 258/310 Day students 230/960 Staff 14/338 Day students 113/612 Staff 9/120

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10 GCPHU Report of Food Handler Illness GCPHU notification of food handler vomiting in kitchen / dining area 20/02/2018 Joint inspection with City of Gold Coast and GCPHU Issues Uncertain as to the correct cleaning and sanitising procedures Lack of staff training Washing of food contact surfaces did not include a sanitiser step Displaying ready to eat food fruit, drinks on the self serve bench and not protected from contamination Cutlery stored in open baskets with a high likelihood of contamination Staff not following correct reporting procedures for illness, and sick staff not excluded from work for 48 hours after symptoms cease. All open food currently in the kitchen considered potentially contaminated due to unwell food handler at work

11 City of Gold Coast Recommendations At the time of assessment all open food currently in the kitchen was considered potentially contaminated and required disposal - Immediate kitchen closure The kitchen was not to reopen until a thorough forensic clean had been undertaken The product Acti-chlor was the correct concentration and agent to be used after each food service for cleaning of all surfaces Disposable plates, cups and cutlery to be used whilst the kitchen was closed and every item in that kitchen and dining area washed Cease storing cutlery in open containers on the counter Cease displaying ready to eat food on the self serve bench unless it is enclosed, contained or wrapped

12 Disease Prevention Measures Quarantine facility established initially Stool and vomit collection Difficult to obtain 9 /17 samples detected Norovirus genogroup 1 or 2 Unwell boarders cared for in Health Centre for 48 hours under nursing supervision Several Alert letters reminding of the Public Health Act (2005) mandated that parents must not send a child to school if they have a contagious condition.

13 Challenges: Within the boarding houses Administration Limited communication to ground staff, especially cleaning Personal protective equipment not being used by cleaning or house staff Environmental cleaning incorrect cleaning solutions incorrect processes for cleaning vomit/faeces no contaminated mop system visibly dirty toilets and surfaces overflowing external rubbish bins no mattress or pillow protectors damaged furnishings and scratched surfaces ground staff unaware of requirements theatre used for unwell abandoned Laundry over-filled soiled laundry bags no hot water to dissolve alginate bags

14 Challenges related to Pathogen Altered cleaning frequency and products Use of non-recommended processes (fogging) Exclusion (48 h requirement) Parents not excluding unwell day children on line listing multiple days Isolation and co-horting Designated toilets and hand basins established for unwell boarders in each house Pressure to participate in sport and other extra-curricula activities cricket, rowing, debating, swimming, orchestra Staff movement across campus ie junior and senior Catering staff, visitors and potentially unwell students utilised the same toilet block Visitor restriction Use of school facilities by other groups

15 Challenges related to Upcoming Event Commonwealth games GCPHU / Hospital and Health Service / Department of Health balance between local management of outbreak (HHS) and preparation for international event (state-level) Reputational risk Early and ongoing media involvement Financial Impact Nursing wages for quarantining of unwell students, environmental cleaning agents and extra staff Kitchen closure with disposable consumables and purchasing of take away food ie pizza Laboratory testing, ongoing cases of Norovirus School students part of Commonwealth Games training teams

16 Overall Specific Measures to address Challenges Change in practices at the School Establishment of Outbreak Control Team within school with GCPHU support each meeting Electronic exclusion programs Improved cleaning processes and increased staff to achieve this Improved kitchen practices provided regular food samples prior to workforce moving in Better facilities in boarding houses with steam cleaning of curtains and mattresses after students vacated the buildings New pillows, plastic pillow and mattress protectors Separate linen and blanket provision for workforce which was not utilised by students Early school closure (School Directive) Alcoholic hand rub available at entry points to all accommodation houses and common areas Regular reporting to local and State authorities

17 Site Preparedness

18 Outcomes All Public Health recommendations implemented Successful transition from outbreak mode to accommodation suitability Nil workforce staff who stayed at the school reported gastroenteritis illness Nil outbreaks of gastroenteritis during the commonwealth games Improved reporting of school outbreaks, resulting in early Public Health management and support

19 Learnings Public Health Significance Key personnel involvement at first visit to school during an outbreak School Executive team School Facilities Manager Cleaning / catering staff City of Gold Coast EH GC PHU assist in the establishment of an Outbreak Control Team Limited understanding of clinical issues and applications - Assistance with interpretation / implementation of guidelines required Early and regular site visits help establish good working relationships Understanding complexities that are specific to the settings

20 References Australian Government (Department of Health and Ageing). (2010). Guidelines for the public health management of gastroenteritis outbreaks due to norovirus or suspected viral agents in Australia. Lee MB., Greig JD: A Review of Gastrointestinal Outbreaks in Schools: Effective Infection Control Interventions, Journal of School Health, 2010, Vol. 80.No.12 Mellou K., Sideroglou T., Potamiti-Komi M.' Kokkinos P., Ziros P., Georgakopoulou T., and Vantarakis A. Epidemiological investigation of two parallel gastroenteritis outbreaks in school settings. BMC Public Health 2013,13:241.