Evonne Curran

Outbreak ManagementNorovirus

Norovirus

• Norovirus is the perfect pathogen

• It is important that you are ready for norovirus

• Norovirus improvement in Scotland

‘The perfect human pathogen’(A. J. Hall 2012 J Infect Dis)

• ‘Highly contagious, rapidly and prolifically shed, constantly evolving, evoking limited immunity and only moderately virulent allowing most of those infected to fully recover, thereby maintaining a large susceptible pool of hosts.’ (A. J. Hall 2012 J Infect Dis)

Incubation period

12– 48 hrs (typical)

Infectious dose

Period of infectivityMainly whilst symptomatic

(1-3 days healthy but 4 – 6 days vulnerable)Peak shedding: 2 - 5days post onset

???

18

MMWR: Mch 4 2011(RR03); 1-15

Acute (D&V)Little warning

Low feverAches

Dispersion of infectious material

1 gram of faeces = 100 billion norovirus particles

(100,000,000,000 )= 5 billion infectious doses

Disposal of infectious material

3

3

Multiple routes of transmission

Touch something contaminated then eat

Eat or drink it

Survival of the virus in the environment and on food

28 days + freezing

Who has had norovirus?

How bad did you feel?

Imagine you are 80yrs old and you have co-

morbidities and you had norovirus

How bad do you think you would feel?

Epidemiology & Costs

• NHS Lothian– Sept 2007 – June 2009– 1732 patients– 599 HCWs– 192 unit outbreaks– 3768 bed days lost– £1.2m over 2 seasons

Daniel et al 2011 JHI

Mortality as a consequence of norovirus • 24mths cohort study• 308 nursing homes • 407 norovirus outbreaks• Significantly more hospitalisations• Significantly more deaths when

norovirus outbreaks ongoingTrivedi et al JAMA 2012

Average 442 ward closures per annum (Monday point prevalence)

Peak weeks 1-2

32E coli O157 Salmonella

Streptococcus pyogenesMTB

MRSA

MSSA

1

Norovirus

So why is it important to You?

You the person with norovirus

With the important job

Teaching people who work in care settings

Preparing food

Who work in multiple care settings

Who is going on holiday of a lifetime

With the elderly relative

In shared living accommodation

Receiving healthcare

Delayed surgery because wards

closed

Schools closedExams not possible

Can’t go to work because schools

closed

Businesses closedFinancial

implications

No holiday because cruise liner being disinfected and

stuck in wrong port

Acute gastroenteritis and video camera surveillance : a cruise ship care report: Diskin et al 2014. (International Maritime Health)

• A faecal incident outside a cabin

It is important to YOU because

• You can get it• You can start outbreaks• You can keep outbreaks going • You can help elderly people survive it • You can prevent outbreaks• You can teach others how to do likewise

•Nothing can be done•Nothing works•We just go through rituals•Should not bother

•No one comes into a care setting to get an infection•By being prepared we can reduce the impact of norovirus

If we fail to prepare, we prepare to fail

B Franklin

These outbreaks are people

• Vulnerable – elderly and very young

Hospitalised patients get it worseLopman et al 2004 CID

Improvement work to minimise norovirus in Scotland

Qualitative evaluation:

How was it for you?

= Evaluation Report

+

What should preparedness look like nationally and

locally?

Comms strategy about month to go

+ Season start Season tracker

Escalation planVisits to key areas

Training plans

Identified vulnerable areas

Guidance updates

Bay closures

Single web site

Front door notices

Stay at Home campaign

What can we do nationally to

make it happen?

+ =

Fire Prevention

Preparedness is the norm

What is new in the literature?

Does our guidance need to change?

Consultation+

Approval

What worked well – what additional

preparation?

Season Evaluation: how was it for you?

What do we want to know – Research

Questions?

Every system is perfectly designed to get the results it gets (Batalden)

• Healthcare and care facilities are designed to get norovirus outbreaks

• Because they happen• WINCL

Care home settings focus• Prepare

– Winter is coming so is norovirus....– Know about norovirus...– Know what to do if....– Get letters and posters ready– About a month to go 8 / 9 / 2014

• Prevent– No symptomatic patients staff / relatives

• Manage– Isolate in room– Temporary suspension of visiting– Infection prevention and control– CARE FOR THE RESIDENTS WITH NOROVIRUS

Hospital• Prepare – is guidance ready

– Does everyone know – teaching huddles– Weakest links – what and where are they– How are you going to work different

• Prevent – assessment on admission & patient placement– Early referral = bay closure (50%)

• Manage – close the area– Cleaning to disinfection – 1,000 ppm av cl.– Bide your time.... – Reopening is not outbreak over its outbreak

manageable

In addition

• Tweet.... – 50% attack rate– Vomit can travel 3 metres– Survive for 1 month– 7 touches from 1 hand...

HCW seasonal flu vaccine

• There was a small increase in the uptake of seasonal influenza in front-line health care workers (HCW) across the 2013-14 season (33.8%) compared with 2012-2013 (30.6%).

• The acting CMO is considering additional measures that could be deployed to boost vaccine uptake in the forthcoming season.

• Target remains 75% in front-line HCW.

Summary

• It is the perfect pathogen

• You can minimise its impact on you

• Together we can minimise norovirus on those receiving care in Scotland

• What are you going to do?