You Dont Want It Alexandra De Jesus MPH

You Don’t Want It! Alexandra De Jesus, MPH Epidemiologist Division of Epidemiology and Immunization Bureau of Infectious Disease and Laboratory Sciences Image Source: https: //www. foodpoisonjournal. com/tags/norovirus-lawyer/

Learning Objectives • Provide an overview of norovirus • Explain the burden of norovirus in the U. S. • Discuss interstate collaborations on norovirus • Review follow up for clusters of norovirus • Highlight norovirus resources for LBOHs 2

Overview of Norovirus 3

What is norovirus? • “Stomach flu” or “Stomach bug” • Most common cause of foodborne diarrhea & vomiting • Causes inflammation of the stomach or intestines (acute gastroenteritis) Image Source: https: //www. foodpoisonjournal. com/tags/nor ovirus-lawyer/ • Humans are only known reservoir 4

What is norovirus? (Continued) • Infectious Dose: – As few as 18 viral particles • Shed billions of tiny viral particles in feces and vomit • Incubation Period: – 12 -48 hours • Symptoms: – – Diarrhea Vomiting Nausea Stomach pain • Duration: – 1 -3 days 5

How does norovirus spread? • Person to Person • Fecal-oral • Ingestion of aerosolized vomitus • Indirect via fomites or contaminated environment • Food • Contamination by infected food handlers • Point of service or source (e. g. , raspberries, oysters) Image Source: https: //norocore. ncsu. edu/about/ov erview/ • Recreational and Drinking Water • Well contamination from septic tank • Chlorination system breakdown 6

Viral Shedding • You are most contagious: – When you have symptoms, especially vomiting and diarrhea – During the first few days after you recover • However, studies have shown that you can still spread norovirus for two weeks or more after you feel better 7

Viral Immunity • Complex and not completely understood • In some studies, humans have been reinfected with the same strain as well as infected with different strains of norovirus Image Source: https: //www. medicinenet. com/norovirus_i nfection/article. htm#what_is_a_norovirus 8

Treatment • No specific treatment • Drink plenty of liquids to replace fluid lost from vomiting and diarrhea Image Source: 9 https: //www. iconnutrition. com/blog/hydration-sportingperformance/

Burden of Norovirus in the U. S. • Each year, on average in the United States, norovirus: – Causes 19 to 21 million cases of acute gastroenteritis – Leads to 1. 7 to 1. 9 million outpatient visits and 400, 000 emergency department visits, primarily in young children – Contributes to about 56, 000 to 71, 000 hospitalizations and 570 to 800 deaths, mostly among young children and the elderly • In 2017, MA had approximately 408* cases of norovirus 10

Burden of Norovirus in the U. S. (Continued) • Most norovirus outbreaks in the United States happen from November to April • There can be 50% more norovirus illness in years when there is a new strain of the virus Image Source: https: //www. cdc. gov/norovirus/images/norovirusoutbreaks-lg. jpg 11

Norovirus in the Food Industry

Norovirus in the Food Industry 13 Image Source: https: //www. cdc. gov/vitalsigns/norovirus/index. html

Norovirus in the Food Industry (Continued) • Norovirus is the leading cause of foodborne illness in the United States • 1 in 5 food service workers have reported working while sick with vomiting and diarrhea • Of outbreaks caused by infected food workers, 54% involve food workers touching ready-to-eat-foods with their bare hands – Examples of ready-to-eat foods are washed raw fruits and vegetables for salads or sandwiches, baked goods, or items that have already been cooked 14

Norovirus in the Food Industry (Continued) • Observations of food service workers have shown that they practice proper hand washing only 1 of 4 times that they should • Each year, foodborne norovirus illness costs about $2 billion, mainly due to lost productivity and healthcare expenses in the United States Image Source: https: //www. npr. org/sections/thesalt/2014/06/03/31 8524155/norovirus-far-more-likely-to-come-fromrestaurant-than-cruise-ship 15

Norovirus and Food Surfaces • Norovirus is hard to kill and stays on food, kitchen surfaces, and utensils • Remains infectious on foods even at freezing temperatures and until heated above 140°F • Stays on countertops and serving utensils for up to 2 weeks • Resists many common disinfectants and hand sanitizers 16

Environmental Cleaning • Use a chlorine bleach solution or other disinfectant registered as effective against norovirus by the Environmental Protection Agency (EPA) – It is important to use these disinfectants at their recommended concentrations – For more information, see EPA’s Registered Antimicrobial Products Effective Against Norovirus (Norwalk-like virus) Image Source: https: //dhhr. wv. gov/oeps/disease/Fn. W/Viral/Pa ges/Norovirus. aspx 17

Preventing the Spread of Norovirus • Wash your hands • Handle and prepare food safely – Do not prepare food for others while you have symptoms and for at least 72 hours after symptoms go away • Clean and disinfect surfaces 18

Interstate Collaborations

Noro. CORE Norovirus Collaborative for Outreach, Research, and Education • A food safety initiative with the ultimate goal to reduce the burden of foodborne disease associated with viruses, particularly noroviruses – Collaboration of more than 30 lead scientists and their teams from more than 18 institutions, with North Carolina State University serving as the lead institution 20

Noro. CORE Success Story • A major barrier to research and development of effective interventions for norovirus has been the lack of a robust and reproducible in vitro cultivation system • Dr. Mary Estes and her research team at Baylor College of Medicine have successfully grown the human norovirus in intestinal cells • This will allow for methods to prevent and treat norovirus infection 21

Noro. CORE Success Story Image source: https: //news. ncsu. edu/2015/08/vomiting-machine/ 22

Calici. Net • A national norovirus outbreak surveillance network of federal, state, and local public health laboratories • Norovirus strains can be compared with other norovirus strains in the database, helping CDC link outbreaks to a common source, monitor norovirus strains that are circulating, and identify new emerging norovirus strains Image source: https: //www. cdc. gov/norovirus/re porting/calicinet/index. html 23

Calici. Net & MDPH • MA has participated in Calici. Net since 2012 • MA submits – Genetic sequences of norovirus strains – Basic epidemiologic data, such as transmission route and outbreak setting Image Source: https: //medicalxpress. com/news/2018 -07 summer-norovirus-outbreak-winter-crisis. html 24

Noro. STAT • A collaborative network of eleven state health departments and CDC • Created to improve timeliness and completeness of norovirus outbreak reporting to CDC’s National Outbreak Reporting System (NORS) and Calici. Net Image Source: https: //www. cdc. gov/norovirus/reporting/noros tat/faq. html 25

Investigating Norovirus 26

Investigating Norovirus Image Source: https: //www. cpp. edu/~healthcounseling/health/norovirus. shtml 27

Goals of investigation To identify whether the case may be a source of infection for other persons and if so, to prevent further transmission Food handler Apply appropriate restrictions To identify clusters Example: During follow up, a parent may disclose that other children in the school have been sick To identify transmission sources of public health concern and to stop transmission Identifying food or water sources 28

Investigating Norovirus in a Food Establishment 29

Norovirus in a Food Establishment • Collaborate with Epi and Food Protection Program • Enforce food handler exclusion – Must be excluded from food handling duties for either 72 hours past the resolution of symptoms or 72 hours past the date the specimen positive for norovirus was produced, which ever occurs last • Discard open foods prepared by ill food handlers • Increase environmental cleaning 30

Investigating Norovirus in a Healthcare Setting 31

Norovirus in a Healthcare Setting • In healthcare, the most likely and common modes of transmission are through direct contact with infected persons or contaminated equipment Image Source: https: //www. hfmmagazine. com/articles/2873 heading-off-a-norovirus-outbreak 32

Healthcare Clusters in MA • On average we receive 102 reports of GI illness clusters in long term care (LTC) and assisted living (AL) facilities annually Image Source: http: //www. providencehealthcare. org/tags/norovirus 33

How do you define a cluster? • A cluster is defined as an increase in illness above what is expected for your facility with regard to place and time, regardless of any positive or negative laboratory test results • In a LTC facility, clusters are usually defined as more diarrhea and/or vomiting in a unit or facility than would be expected at a particular time of year Image Source: https: //emssolutionsinc. com/blog/noroviruswinter-vomiting-disease/ 34

How do you define a cluster? (Continued) • Clusters are reportable to MDPH upon initial identification • Clusters should be reported to: – The local board of health and/or the MDPH Division of Epidemiology and Immunization – The licensing or certifying agency 35

How do you report norovirus clusters? • Report using the MDPH GI Illness LTCF reporting form found at: http: //www. mass. gov/eohhs/ gov/departments/dph/progra ms/id/isis/case-reportforms. html – This form can be used for AL as well as skilled nursing facilities, long term acute care facilities, and rehabs 36

What are the goals of a healthcare associated norovirus cluster? • Epidemiological side: – Rule-out a point-source outbreak • Such as an ill food handler in the dining service – Provide direction towards MDPH guidance on control measures – If there is ongoing illness, offer stool testing for norovirus at MA SPHL – Ensure accurate and complete reporting 37

What are the goals of a norovirus investigation? (Continued) • Epis will notify the LBOHs to make sure that they are aware of the cluster • Unfortunately, Epis cannot share cluster events with LBOHs – LBOHs are able to see the event if they search for the MAVEN ID • Remember when searching for the ID to use the magnifying glass icon and switch the “Type” from “Normal” to “Outbreak” 38

Reporting Norovirus in an Acute Care Setting • Report by phone to the LBOH or MDPH 39

Reporting Norovirus in an Acute Care Setting (Continued) 40

GI Illness Cluster Control Recommendations • Cohort symptomatic patients • Minimize staff floating • Increase hand washing • Consider restricting group activities Image Source: http: //professionals. site. apic. org/protect -your-patients/follow-the-rules-forisolation-precautions/ • Place ill individuals on contact precautions • Perform environmental cleaning and disinfection using chlorine bleach or an EPA approved disinfectant 41

GI Illness Cluster Control Recommendations (Continued) • Notify visitors of outbreak • Consider closing to new admissions • Suggest stool cultures on individuals with ongoing diarrhea • If norovirus is suspected or confirmed, exclude ill food handling staff for 72 hours after resolution of symptoms 42

Stool Specimen Submission MDPH will test specimens associated with a cluster MDPH requires a minimum of 2 specimens from symptomatic patrons (including symptomatic food handlers) and maximum of 5 specimens can be tested The samples accepted are raw stool collected within 5 days of symptom onset Image Source: https: //www. mass. gov/files/documents/201 7/12/21/FBI%20 manual%20%20 Chapter%209. pdf 43

Stool Specimen Submission (Continued) MDPH provides norovirus collection kits for stool collection and shipment Specimens/kits can be dropped off and picked up by the couriers to the individual LBOH Stools that test positive for norovirus are sequenced and submitted to Calici. Net along with epidemiological data 44

Environmental Cleaning • Perform routine cleaning and disinfection of frequently touched environmental surfaces and equipment in isolation and cohorted areas, as well as high-traffic clinical areas • Frequently touched surfaces include: – – – – Commodes Toilets Faucets Hand/bedrailing Telephones Door handles Computer equipment Kitchen preparation surfaces Image Source: https: //www. kaivac. com/a_771 Cleaning-Up-After-a-Norovirus-Outbreak 45

Investigating Norovirus in a School or Daycare 46

Reporting Norovirus in a School or Daycare Setting • Reported in a similar fashion as clusters in acute care settings (i. e. by phone to the LBOH or MDPH) 47

GI Illness Cluster Control Recommendations in a School Students or staff who have diarrhea should be excluded until 72 hours past the resolution of symptoms Students or staff who handle food must not prepare food until 72 hours past the resolution of symptoms or 72 hours past the date a positive specimen was provided, whichever occurs last (per 105 CMR 300. 130) 48

GI Illness Cluster Control Recommendations in a School Students or staff who do not handle food, have no diarrhea or have mild diarrhea, and are not otherwise sick, may remain in school if special precautions are taken Image Source: https: //www. npr. org/sections/goatsa ndsoda/2018/03/06/591241255/wha t-you-might-not-realize-about-thebenefits-of-hand-washing 49

Norovirus Resources for LBOHs 50

Resources for LBOHs • MDPH Resources: – Guide to Surveillance, Reporting, and Control • https: //www. mass. gov/handbook/guide-to-surveillance-reporting -and-control – School Health Manual • http: //files. hria. org/files/SH 3001. pdf – MDPH’s Foodborne Illness Investigation and Control Reference Manual • https: //www. mass. gov/lists/foodborne-illness-investigation-andcontrol-manual 51

Resources for LBOHs • MDPH Resources: – Infection Prevention in LTC • https: //www. mass. gov/files/documents/2016/07/qh/gidisease-guide. pdf • Noro. CORE Resources: – https: //norocore. ncsu. edu/resources/factsheets-infographics/ • CDC Resources: – General Resources: • https: //www. cdc. gov/norovirus/resources. html – HAI Resources: • https: //www. cdc. gov/hai/organisms/norovirus. html 52

Questions? 53

References • https: //www. cdc. gov/vitalsigns/norovirus/index. html • https: //www. cdc. gov/Features/Norovirus/ • https: //www. cdc. gov/norovirus/about/symptoms. html • https: //www. cdc. gov/norovirus/about/treatment. html • https: //www. cdc. gov/norovirus/about/transmission. html • https: //www. cdc. gov/mmwr/preview/mmwrhtml/rr 6003 a 1. htm • https: //www. cdc. gov/norovirus/trends-outbreaks/burden-US. html • https: //www. mass. gov/handbook/guide-to-surveillance-reporting-and -control • https: //www. cdc. gov/norovirus/reporting/calicinet/index. html • https: //norocore. ncsu. edu/about/overview/ • https: //news. ncsu. edu/2015/08/vomiting-machine/ • https: //norocore. ncsu. edu/resources/factsheets-infographics/ • Norovirus Gastroenteritis: Management of Outbreaks in Healthcare Settings, CDC Presentation- January 2012 54