When an outbreak is suspected, the following checklist of actions need to be completed:

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1 Protecting, maintaining and improving the health of all Minnesotans. Checklist for Nursing Homes/Long Term Care Facilities when Outbreaks of Gastroenteritis are Suspected Question - How do you know if there might be an outbreak of gastroenteritis at your facility? Answer - Outbreaks can generally be defined as an increase in illness above the expected, or normal rate. For general surveillance purposes, you should establish a baseline rate for illnesses characterized by vomiting and/or diarrhea. Once you have a baseline established, it should be readily apparent when a sizeable increase in illness occurs. If you think there might be an outbreak, but you re not sure, please have a low threshold in contacting public health authorities for advice. Question - Whom should I call when there is (or I think there might be) an outbreak of gastrointestinal illness in my facility? Answer You have a couple of options. Call your local (i.e., city or county) health department, or call the Minnesota Department of Health (MDH) at If called, MDH will relay the necessary information to the appropriate local health authorities. When an outbreak is suspected, the following checklist of actions need to be completed: 1. Gather information to characterize the outbreak provide as much of the following as possible: A. Number of residents and staff ill with vomiting or diarrhea. - For residents, provide this information by room number and floor (or wing, if applicable) - For staff, provide this information by work station, including floor and/or wing B. Number of residents and staff in facility. - provide this information by floor and/or wing C. Date of onset of symptoms for each ill individual. D. Type of symptoms for each ill individual. When combining data from all ill individuals, be able to provide: - # of individuals that have had vomiting - # of individuals that have had diarrhea - # of individuals with diarrhea that have bloody diarrhea - # of individuals with fever, including the highest temperature recorded for each individual with fever - Median duration of illness (and range of duration, e.g., shortest to longest) General Information: (651) Minnesota Relay Service: (800) For directions to any of the MDH locations, call (651) An equal opportunity employer K:\ADIC\Units\FVZ\nursing home\for temp website PDF\nursing home outbreak.doc

2 E. A list of food service staff (those who have been ill, and those who have not). F. Document special meals/patient feeding, extracurricular activities, clubs, special events that were held during the 2 weeks prior to the first illnesses (including birthday or holiday treats distributed to individual floors/wings). G. When specifically requested, a dietary menu (breakfast, lunch and dinner) for the 2 weeks prior to the first illness. H. If further investigation is deemed necessary, it likely will involve contacting ill and well residents and staff to determine specific sources of illness. To do this, the health department will need a roster of all residents and staff, including home and work telephone numbers. 2. In conjunction with the cooperating health department, implement interim outbreak control measures while the investigation is ongoing: A. Restrict ill employees (including volunteer workers) from patient care and food handling duties for 72 hours after their vomiting/diarrhea has ended. Food service staff should not handle food if they have been recently ill with any gastrointestinal symptoms until they can be interviewed or further evaluated by public health professionals. B. Consideration should be given to separating ill residents and staff from those who have not experienced illness as well as restricting access to rooms with ill residents. In large outbreaks, consideration should also be given to halting new admissions until the outbreak has ended. C. Stop using self-service food bars and don t let residents/staff serve themselves in any manner which might promote direct hand contact with shared foods (including self-service foods using tongs or other serving utensils). Eliminate common events such as birthday, holiday, and special celebrations until the conclusion of the outbreak. D. Redouble efforts to promote hand hygiene. Educate residents, staff, and visitors on proper technique and promote handwashing prior to patient contact, snacks, and meals. Alcoholbased hand rubs (gel or foam) used in conjunction with proper handwashing may provide additional protection. However, the rubs are not considered a substitute for proper handwashing. E. Restrict sharing of communal food/snack items and foods brought from home. F. Environmental surfaces, especially areas where residents and staff have become ill, and common areas such as restrooms, handrails, and dining facilities, should be thoroughly cleaned and sanitized. Staff members with these duties should pay particular attention to their hygiene so they do not become ill. General Information: (651) Minnesota Relay Service: (800) For directions to any of the MDH locations, call (651) An equal opportunity employer K:\ADIC\Units\FVZ\nursing home\for temp website PDF\nursing home outbreak.doc

3 Norovirus in Healthcare Facilities Fact Sheet hand transfer of the virus to the oral mucosa via contact with materials, fomites, and environmental surfaces that have been contaminated with either feces or vomitus. General Information Virology Noroviruses (genus Norovirus, family Caliciviridae) are a group of related, single-stranded RNA, non-enveloped viruses that cause acute gastroenteritis in humans. Norovirus is the offcial genus name for the group of viruses provisionally described as Norwalk-like viruses. Currently, human noroviruses belong to one of three norovirus genogroups (GI, GII, or GIV), which are further divided into >25 genetic clusters. Over 75% of confirmed human norovirus infections are associated with genotype GII. Clinical manifestations The average incubation period for norovirus-associated gastroenteritis is 12 to 48 hours, with a median period of approximately 33 hours. Illness is characterized by nausea, acute-onset vomiting, and watery, non-bloody diarrhea with abdominal cramps. In addition, myalgia, malaise, and headache are commonly reported. Lowgrade fever is present in about half of cases. Dehydration is the most common complication and may require intravenous replacement fluids. Symptoms usually last 24 to 60 hours. Up to 30% of infections may be asymptomatic. Epidemiology of transmission Noroviruses are highly contagious, with as few as 18 virus particles thought to be suffcient to cause infection. This pathogen is estimated to be the causative agent in over 21 million gastroenteritis cases every year in the United States, representing approximately 60% of all acute gastroenteritis cases from known pathogens. Noroviruses are transmitted primarily through the fecaloral route, either by direct person-to-person spread or fecally contaminated food or water. Noroviruses can also spread via a droplet route from vomitus. These viruses are relatively stable in the environment and can survive freezing and heating to 60 C (140 F). In healthcare facilities, transmission can also occur through Norovirus infections are seen in all age groups, although severe outcomes and longer durations of illness are most likely to be reported among the elderly. Among hospitalized persons who are immunocompromised or have significant medical comorbidities, norovirus infection can directly result in prolonged hospital stays, additional medical complications, and, rarely, death. There is currently no vaccine available for norovirus and, generally, no specific medical treatment is offered for norovirus infection apart from oral or intravenous repletion of volume. The ease of its transmission, a very low infectious dose, a short incubation period, environmental persistence, and lack of durable immunity following infection enables norovirus to spread rapidly through confined populations. Healthcare facilities and other institutional settings (e.g., daycare centers, schools, etc.) are particularly at-risk for outbreaks because of increased personto-person contact. Healthcare facilities managing outbreaks of norovirus gastroenteritis may experience significant costs relating to isolation precautions and personal protective equipment, ward closures, supplemental environmental cleaning, staff cohorting or replacement, and sick time. Diagnosis of norovirus infection Diagnosis of norovirus infection relies on the detection of viral RNA in the stools of affected persons, by use of reverse transcription-polymerase chain reaction (RT-PCR) assays. This technology is available at CDC and most state public health laboratories and should be considered in the event of outbreaks of gastroenteritis in healthcare facilities. Enzyme immune-assays may also be used for identification of norovirus outbreak but are not recommended for diagnosis of individuals. Identification of the virus can be best made from stool specimens taken within 48 to 72 hours after onset of symptoms, although positive results can be obtained by using RT-PCR on samples taken as long as 7 days after symptom onset. Because of the limited availability of timely and routine laboratory diagnostic methods, a clinical diagnosis of norovirus infection is often used, especially when other agents of gastroentertis have been ruled out. U.S. Department of Health and Human Services Centers for Disease Control and Prevention CS ANorovirusFactSheet

4 Measures to Limit Transmission* Patient Cohorting and Isolation Precautions Avoid exposure to vomitus or diarrhea. Place patients on Contact Precautions in a single occupancy room if they present with symptoms consistent with norovirus gastroenteritis Hand Hygiene Avoid exposure to vomitus or diarrhea. Place patients on Contact Precautions in a single occupancy room if they present with symptoms consistent with norovirus gastroenteritis. Patient Transfer and Ward Closure Consider limiting transfers to those for which the receiving facility is able to maintain Contact Precautions; otherwise, it may be prudent to postpone transfers until patients no longer require Contact Precautions. During outbreaks, medically suitable individuals recovering from norovirus gastroenteritis can be discharged to their place of residence. Diagnostics In the absence of clinical laboratory diagnostics or in the case of delay in obtaining laboratory results, use Kaplan s clinical and epidemiologic criteria to identify a norovirus gastroenteritis outbreak. Kaplan s Criteria 1. Vomiting in more than half of symptomatic cases and, 2. Mean (or median) incubation period of 24 to 48 hours and, 3. Mean (or median) duration of illness of 12 to 60 hours and, 4. No bacterial pathogen isolated in stool culture Environmental Cleaning Increase the frequency of cleaning and disinfection of patient care areas and frequently touched surfaces during outbreaks of norovirus gastroenteritis (e.g., increase ward/ unit level cleaning to twice daily to maintain cleanliness, with frequently touched surfaces cleaned and disinfected three times daily using the US Environmental Protection Agency s list of approved products for healthcare settings ( Staff Leave and Policy Develop and adhere to sick leave policies for healthcare personnel who have symptoms consistent with norovirus infection. Exclude ill personnel from work for a minimum of 48 hours after the resolution of symptoms. Once personnel return to work, the importance of performing frequent hand hygiene should be reinforced, especially before and after each patient contact. Establish protocols for staff cohorting in the event of an outbreak of norovirus gastroenteritis. Ensure staff care for one patient cohort on their ward and do not move between patient cohorts (e.g., patient cohorts may include symptomatic, asymptomatic exposed, or asymptomatic unexposed patient groups). Communication and Notification As with all outbreaks, notify appropriate local and state health departments, as required by state and local public health regulations, if an outbreak of norovirus gastroenteritis is suspected. *Prevention and control recommendations taken from priority recommendations in the CDC HICPAC Guideline for the Prevention and Control of Norovirus Gastroenteritis Outbreaks in Healthcare Settings ( Guideline-2011.pdf ) Date last modified: September 6, 2011 Content source: Division of Healthcare Quality Promotion (DHQP), National Center for Preparedness, Detection, and Control of Infectious Diseases (NCEZID) Contact Us: Centers for Disease Control and Prevention 1600 Clifton Road, Atlanta, GA 30333, USA CDC-INFO ( ) TTY: , 24 hours/everyday at cdcinfo@cdc.gov (TTY) U.S. Department of Health and Human Services Centers for Disease Control and Prevention CS ANorovirusFactSheet

5 CDC Answers Your Questions About Noroviruses and Food Handlers What are noroviruses? Noroviruses are members of a group of viruses called caliciviruses also known previously as Norwalk-like viruses. Infection with norovirus affects the stomach and intestines, causing an illness called gastroenteritis, or stomach flu. This stomach flu is not related to the flu (or influenza), which is a respiratory illness caused by influenza virus. In addition, noroviruses are not related to bacteria and parasites that can cause gastrointestinal illnesses. Norovirus is not a new virus, but interest in it is growing as more is learned about how frequently noroviruses cause illness in people (see Why is norovirus infection important for food handlers? ). What are the symptoms of infection with norovirus? Norovirus infection causes gastroenteritis, which is an inflammation of the stomach and the small and large intestines. The symptoms of gastroenteritis are nausea, vomiting, and/or diarrhea accompanied by abdominal cramps. Some people also complain of headache, fever/chills, and muscle aches. Symptoms are usually brief and last only 1 or 2 days. However, during that brief period, people can feel very ill and vomit, often violently and without warning, many times a day. Symptoms usually begin 24 to 48 hours after ingestion of the virus, but can appear as early as 12 hours after exposure (see How is norovirus spread? ). There is no evidence that sick persons can become long-term carriers of the virus, but the virus can be in the stool and vomit of infected persons, from the day they start to feel ill to as long as 2 weeks after they feel better. Other infectious and non-infectious agents can cause symptoms similar to those of norovirus gastroenteritis; people who have these symptoms and have questions about the cause of their illness should consult a physician. How serious is norovirus gastroenteritis? Norovirus gastroenteritis is usually not a serious illness, and other than drinking liquids to prevent dehydration, there is no specific treatment. Most people recover completely within 1 to 2 days, with no long-term complications of norovirus illness. However, persons who are unable to drink enough liquids to replace those lost with vomiting and/or diarrhea may become dehydrated and require special medical attention. These people include young children, the elderly, and persons of any age unable to care for themselves. How is norovirus spread? Noroviruses are found in the stool or vomit of infected people. People can become infected with the virus in several ways, including: eating food (see food handler fact sheet) or drinking liquids that are contaminated with norovirus; touching surfaces or objects contaminated with norovirus, and then placing their hand in their mouth; having direct contact with another person who is infected and showing symptoms (for example, when caring for someone with illness, or sharing foods or eating utensils with someone who is ill).

6 Food and drinks can very easily become contaminated with norovirus because the virus is so small and because it probably takes fewer than 100 norovirus particles to make a person sick. Food can be contaminated either by direct contact with contaminated hands or work surfaces that are contaminated with stool or vomit, or by tiny droplets from nearby vomit that can travel through air to land on food. Although the virus cannot multiply outside of human bodies, once on food or in water, it can cause illness. Some foods can be contaminated with norovirus before being delivered to a restaurant or store. Several outbreaks have been caused by the consumption of oysters harvested from contaminated waters. Other produce such as salads and frozen fruit may also be contaminated at source. Why is norovirus infection important for food handlers? People working with food who are sick with norovirus gastroenteritis are a particular risk to others, because they handle the food and drink many other people will consume. Since the virus is so small, a sick food handler can easily without meaning to contaminate the food he or she is handling. Many of those eating the contaminated food may become ill, causing an outbreak. Outbreaks of norovirus gastroenteritis have taken place in restaurants, cruise ships, nursing homes, hospitals, schools, banquet halls, summer camps, and family dinners in other words, places where often people have consumed water and/or food prepared or handled by others. It is estimated that as many as half of all food-related outbreaks of illness may be caused by norovirus. In many of these cases, sick food handlers were thought to be implicated. What can I do to prevent norovirus gastroenteritis? Many local and state health departments require that food handlers and preparers with gastroenteritis not work until 2 or 3 days after they feel better. In addition, because the virus continues to be present in the stool for as long as 2 to 3 weeks after the person feels better, strict hand washing after using the bathroom and before handling food items is important in preventing the spread of this virus. Food handlers who were recently sick can be given different duties in the restaurant so that they do not have to handle food (for example, working the cash register or hostessing). People who are sick with norovirus illness can often vomit violently, without warning, and the vomit is infectious; therefore, any surfaces near the vomit should be promptly cleaned and disinfected with bleach solution and then rinsed. Furthermore, food items that may have become contaminated with norovirus should be thrown out. Linens (including clothes, towels, tablecloths, napkins) soiled to any extent with vomit or stool should be promptly washed at high temperature. Oysters should be obtained from reputable sources and appropriate documentation kept. Washing raw vegetables thoroughly before eating and appropriate disposal of sewage and soiled diapers also help to reduce the spread of norovirus and prevent illness. In small home-based catering businesses or family owned or operated restaurants, sick children and infants in diapers should be excluded from food preparation areas. How is norovirus gastroenteritis diagnosed? In special cases, when there is an outbreak of gastroenteritis there is a need to identify norovirus as the cause of the illness. In these cases, norovirus can often be found in stool samples of infected persons by using special tests. Sometimes blood tests looking for antibodies against norovirus are also performed, when the stool tests are inconclusive or were not done. Food handlers will often be asked for a stool sample or even a blood sample to help investigate the cause of an outbreak.

7 Can a person have norovirus gastroenteritis more than once? Yes, a person can be infected with norovirus more than once in their lifetime. This is because there are many different noroviruses, and being infected with one type does not prevent infection from another type later. For this reason, it is difficult to develop a vaccine against norovirus.

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9 Minnesota Department of Health; Minnesota Department of Agriculture; University of Minnesota Extension, November 2009 Hand Sanitizers: Not a Replacement for Handwashing in Food Service Settings For Food Service Establishments Introduction Handwashing with soap and water is the single most effective way to prevent the spread of bacteria and viruses--the major causes of foodborne illness. Alcohol-based hand sanitizers are effective in killing bacteria and some viruses on clean hands. However, sanitizers may not be used instead of handwashing by food service employees. Why can t hand sanitizers be used instead of handwashing in food service settings? The hands of foodworkers are often wet; often contaminated with fatty material or with food high in proteins. The presence of water, food, fatty materials, feces and blood on the hands can significantly reduce the effectiveness of an alcohol-based hand sanitizer. Viruses such as norovirus are also a concern in food service settings. Norovirus is the leading cause of foodborne outbreaks. Hand sanitizers do not kill norovirus. Soap and water washing is the most effective way to remove the types of pathogens that foodworkers have on their hands. In order for hand sanitizers to work properly, hands must first be washed with soap, rinsed with running water and completely dried. The Minnesota Food Code requires handwashing with soap and water in food service establishments. When can hand sanitizers be used in a food service setting? The FDA Food Code and the Minnesota Food Code allow the use of hand sanitizers by foodworkers after proper hand washing. How to use hand sanitizers after soap and water handwashing. 1. Wash hands in a designated hand sink. Wet hands with warm water. Apply soap. Lather and scrub for 20 seconds. Rinse. Dry hands with paper towel. Turn off faucet with the towel. (The Minnesota Food Code also requires that fingernails be cleaned with a nailbrush.) 2. Select a hand sanitizer containing at least 60 percent alcohol. 3. Apply a dime-size amount of sanitizer on the palm of one hand. 4. Rub hands together vigorously for 30 seconds covering all surfaces of both hands. If hands are dry after only seconds, not enough sanitizer was used and more must be applied. 5. Wait for the sanitizer to dry completely before touching food contact surfaces. NOTE: Your employee hygiene policy should include handwashing procedures, plus guidelines for hand sanitizer use, and exclusion of foodworkers who have symptoms of diarrhea and/or vomiting. Can food establishments provide hand sanitizers for customers? Food service establishments may provide hand sanitizers for use by the public, in addition to regular soap and water handwashing facilities. If you require this document in another format, such as large print, Braille, or cassette tape, call: (651) MDH TTY (651)

10 Gastrointestinal Illness Report Phone: Fax: Date: / / Facility Name: Contact: Phone: Outbreak onset: / / Number of residents in facility: Number ill: Number died: Number of staff in facility: Number ill: Resident Name Room # Hall or Floor Age Gender Diarrhea Vomit Fever Died? Onset Date/Time Recovery Date/Time Please fax completed forms to the Minnesota Department of Health Revised 03/16/2016

11 Employee Illness Log Symptoms/Illness Reported to the Manager DIAGNOSED? Report Date Employee Name Vomiting** Diarrhea** Jaundice (yellowing of eyes or skin) Fever Respiratory (cough, sore throat, runny nose) Comments or Additional Symptoms Date Returned to Work E. coli O157:H7, Salmonella, Shigella, or hepatitis A Called MDH (877-FOOD- ILL) or local health agency Y or N 01/01/01 John Doe Example x Sent home due to diarrhea 01/03/10 **Employees with diarrhea or vomiting MUST BE EXCLUDED from work for at LEAST 24 HOURS after symptoms are gone. Infected foodworkers present a severe food safety risk. The person-in-charge is required to notify the local health department or MDH, if any food employees are known to be infected with Salmonella, Shigella, E. coli, the hepatitis A virus, or other pathogen that can be transmitted through food. Note: The Minnesota Food Code ( ) requires foodworkers to report information about their health as it relates to illnesses that can be passed through food. Minnesota Foodborne Illness Hotline: FOOD-ILL ( )

12 Today s Date: / / Staff Gastrointestinal Illness Report Facility name: Staff name: Job title: Symptom History Illness Onset: / / Time: Recovery: / / Time: Vomiting Y N Onset: / / Time: Recovery: / / Time: Diarrhea Y N Onset: / / Time: Recovery: / / Time: Number of stools per 24 hour period: Diarrhea duration: days/hours Bloody stools Y N Cramps Y N Fever Y N Temperature F First Symptom: Other Symptoms: Onset Date: / / Time: Onset Date: / / Time: Visited Provider: Y N Office / ER Date of Visit: / / Provider requested stool sample: Y N Stool submitted: Y N Hospitalized: Y N Work History Did you work while experiencing diarrhea and/or vomiting? Y N ---If yes, when? If no, when did you return to work? Please list work schedule and duties performed in the 5 days before your onset Day Hours Duties Performed and Location / / - / / - / / - / / - / / - Are you responsible for feeding or food prep for residents/patients? Y N In this time period, did you assist with the clean-up of any patients with diarrhea or vomiting? Y N Did you wear gloves? Y N Did you change gloves before leaving that patient s room? Y N Did you wash your hands after removing the gloves? Y N Have any members of your household been ill with diarrhea or vomiting in the last week? Y N What symptoms did they have? Cramps Fever Nausea Blood in stool Vomiting If yes, onset: / / Diarrhea If yes, onset: / / # stools in 24 hours: Were any stool samples collected from ill family members? Y N Date: / / Results: