1. Heather Mazakas, Ph.D. student Walden University PUBH-8165-3 Instructor: Dr. Raymond Thron Winter Quarter, 2010

2. Purpose The purpose of this presentation is to increase awareness about Norovirus. It reviews information on how Norovirus is spread, and offers tips for prevention.

3. Audience Food handlers Cruise ships Restaurants Nursing homes Schools Child care centers Summer camps Banquet Halls Students or others interested in learning about Noroviruses and prevention

4. Expected Learning Outcomes Define Norovirus Describe significance of Norovirus Describe how Norovirus is transmitted List symptoms of Norovirus Describe diagnosis and treatment of Norovirus List methods of prevention

5. What is Norovirus? Virus that causes gastroenteritis, or stomach flu Got its name from an outbreak of acute gastroenteritis among elementary school children in Norwalk, Ohio in 1968 Also known as Norwalk-Like Viruses, or NLVs Calcivirus Small Round Structured Viruses (SRSVs) Sapovirus, Sapporo-Like Viruses, or SLVs (2007). Norovirus. Emerging Infectious Diseases, 13(3), 403. Retrieved from Academic Search Complete database.

6. Significance Every year in the United states, Noroviruses cause an estimated 23 million epiosodes of gasteroenteritis 50,000 hospitalizations 300 deaths Gastroenteritis is the most frequently reported illness in the US (second to the common cold) Moeller, D. W. (2005). Environmental health (3rd ed.). Boston: Harvard University Press. United States Department of Health & Human Services. Foodborne Pathogenic Microorganisms and Natural Toxins Handbook (2009). Retrieved January 26, 2010. Available at http://www.fda.gov/Food/FoodSafety/FoodborneIllness/FoodborneIllnessFoodbornePathogensNaturalToxins/BadBugBo ok/ucm071344.htm

7. Outbreak statistics 1997-2000 232 outbreaks reported Causes 57% foodborne 16% person-to-person contact 3% waterborne 23% undetermined Common Settings 36% restaurants and catered meals 23% nursing homes 13% schools 10% vacation settings or cruise ships Centers for Disease Control and Prevention. Norovirus: Technical Fact Sheet (2006). Retrieved January 28, 2010. Available at http://www.cdc.gov/ncidod/dvrd/revb/gastro/norovirus-factsheet.htm

8. How is Norovirus transmitted? Through the fecal-oral route Consuming food or beverage that is contaminated Touching contaminated surfaces that are contaminated, such as doorknobs, railings, elevator buttons, utensils, etc. Person to person contact Highly contagious Infection can occur with exposure to as few as 10 viral particles Centers for Disease Control and Prevention. Norovirus: Q & A (2009). Retrieved January 26, 2010. Available at http://www.cdc.gov/ncidod/dvrd/revb/gastro/norovirus-qa.htm

9. Symptoms Nausea Vomiting Abdominal pain Abdominal cramps Watery or loose diarrhea Weight loss Malaise Headache Low-grade fever Mayo Clinic. Norovirus infection (2009). Retrieved January 12, 2009. Available at http://www.mayoclinic.com/health/norovirus/DS00942/DSECTION=symptoms

10. Symptoms continued Symptoms appear 24-48 hours after being infected Symptoms can last 12-60 hours Chris, A. (2003). Noroviruses: When the runs can slow you down. CMAJ: Canadian Medical Association Journal, 168(1), 64. Retrieved from Academic Search Complete database.

11. Diagnosis and Treatment Most commonly diagnosed based on symptoms, can be confirmed with lab test Treatment includes: Hydration Bed rest IV fluids in extreme cases National Institute of Allergy and Infectious Diseases. Norovirus Infection (2007). Retrieved January 26, 2010. Available at http://www3.niaid.nih.gov/topics/norovirus/treatment.htm

12. Prevention Wash hands thoroughly with soap and warm water After using the restroom After changing a diaper Before handling food After smoking Rinse raw vegetables with uncontaminated water before eating Cook shellfish thoroughly Employees who are ill with gastroenteritis should not report to work Sanitize all food surfaces after each use Accessible Journeys. Cruise Ship Illness (2005). Retrieved January 26, 2010. Available at http://www.disabilitytravel.com/cruise/cruise_ship_illness.htm

13. Case Study World-acclaimed Fat Duck Restaurant in Bray, Berkshire, England temporarily closed in February 2009 following an outbreak of Norovirus More than 500 diners were affected by the outbreak Investigation conducted by the Royal Borough of Windsor and Maidenhead, Health Protection Agency Cause of outbreak was contaminated oysters Infected staff members also contributed to spreading the virus Katz, Basil.(2009 September 11). Illness at Fat Duck Tied to Shellfish and Hygiene. The New York Times. (Retrieved January 28, 2010. Available at http://dinersjournal.blogs.nytimes.com/2009/09/11/illnesses-at-fat-duck-tied-to-shellfish-and- hygiene/?scp=3&sq=fat%20duck%20norovirus&st=cse Manos, J.. (2009). Food handler health checks would have limited Fat Duck norovirus outbreak. Occupational Health, 61(10), 30. Retrieved January 28, 2010, from ABI/INFORM Global. (Document ID: 1887306051).

14. Case Study continued Restaurant reopened in March 2009 after making improvements to procedures and protocols Policy of exclusion for food handlers to wait 72 hours to report back to work following gastrointestinal illness Ensure prompt notification of illnesses to Environmental Health Department Improve training for staff whose first language was not English Resulted in losses of approximately $167,000 Katz, Basil.(2009 September 11). Illness at Fat Duck Tied to Shellfish and Hygiene. The New York Times. (Retrieved January 28, 2010. Available at http://dinersjournal.blogs.nytimes.com/2009/09/11/illnesses-at-fat-duck-tied-to-shellfish-and- hygiene/?scp=3&sq=fat%20duck%20norovirus&st=cse Manos, J.. (2009). Food handler health checks would have limited Fat Duck norovirus outbreak. Occupational Health, 61(10), 30. Retrieved January 28, 2010, from ABI/INFORM Global. (Document ID: 1887306051).

15. Review of key points Norovirus is a virus that causes gastroenteritis It is one of the most frequently reported illnesses in the United States It is highly contagious and can be transmitted through contaminated food or water, or from one person to another Symptoms include nausea, abdominal pain, abdominal cramps, diarrhea, weight loss, malaise, and low-grade fever.

16. Review of Key Points continued Treatment includes hydration and bed rest Prevention is the key to avoiding Norovirus Handwashing Properly rinsing raw vegetables Sanitizing food surfaces Staying home for 72 hours following a gastrointestinal illness

17. Sources for Further Reading Websites Centers for Disease Control and Prevention. Norovirus (2009). Available at http://www.cdc.gov/ncidod/dvrd/revb/gastro/norovirus.htm Hazard Analysis & Critical Control Points (HACCP). Available at http://www.fda.gov/Food/FoodSafety/HazardAnalysisCriticalControlPointsHACCP/ default.htm United States Department of Health & Human Services. Bad Bug Book – The Norwalk virus family (2009). Available at http://www.fda.gov/Food/FoodSafety/FoodborneIllness/FoodborneIllnessFoodborn ePathogensNaturalToxins/BadBugBook/ucm071344.htm WHO Food Safety. Available at http://www.who.int/foodsafety/en/ Books Goyal, Sagar (Ed.), Viruses in Foods. New York: Springer Science + Business Media, LLC (2006). Nash, Claire. Food Safety Management Principles, Second Ed. Chadwick House Group Limited (2004)

18. Sources for Further Reading Continued Research Articles Kaplan, J., Feldman, R., Campbell, D., Lookasaugh, C., & Gary, G. (1982). The Frequency of a Norwalk-Like Pattern Of Illness in Outbreaks of Acute Gastroenteritis. American Journal of Public Health, 72(12), 1329. Retrieved from Academic Search Complete database. Surgeoner, B., Chapman, B., & Powell, D. (2009). University Students' Hand Hygiene Practice During a Gastrointestinal Outbreak in Residence: What They Say They Do and What They Actually Do. Journal of Environmental Health, 72(2), 24-28. Retrieved from Academic Search Complete database. Review Articles Babcock, D. (2007). It's Not Just Montezuma's Revenge Anymore…. Journal of Environmental Health, 70(4), 49-51. Retrieved from Academic Search Complete database. Chris, A. (2003). Noroviruses: When the runs can slow you down. CMAJ: Canadian Medical Association Journal, 168(1), 64. Retrieved from Academic Search Complete database.

19. References (2007). Norovirus. Emerging Infectious Diseases, 13(3), 403. Retrieved from Academic Search Complete database. Accessible Journeys. Cruise Ship Illness (2005). Retrieved January 26, 2010. Available at http://www.disabilitytravel.com/cruise/cruise_ship_illness.htm Centers for Disease Control and Prevention. Norovirus: Food Handlers (2006). Retrieved January 12, 2010. Available at http://www.cdc.gov/ncidod/dvrd/revb/gastro/norovirus-foodhandlers.htm Centers for Disease Control and Prevention. Norovirus (2009). Retrieved January 26, 2010. Available at http://www.cdc.gov/ncidod/dvrd/revb/gastro/norovirus-qa.htm Centers for Disease Control and Prevention. Norovirus: Technical Fact Sheet (2006). Retrieved January 28, 2010. Available at http://www.cdc.gov/ncidod/dvrd/revb/gastro/norovirus-factsheet.htm Chris, A. (2003). Noroviruses: When the runs can slow you down. CMAJ: Canadian Medical Association Journal, 168(1), 64. Retrieved from Academic Search Complete database. CNN. Officials: Staff at top restaurant carried virus (2009). Retrieved January 30, 2010. Available at http://www.cnn.com/2009/WORLD/europe/03/20/britain.restaurant.fat.duck/

20. References continued Katz, Basil.(2009 September 11). Illness at Fat Duck Tied to Shellfish and Hygiene. The New York Times. (Retrieved January 28, 2010. Available at http://dinersjournal.blogs.nytimes.com/2009/09/11/illnesses-at-fat-duck-tied-to- shellfish-and-hygiene/?scp=3&sq=fat%20duck%20norovirus&st=cse Manos, J.. (2009). Food handler health checks would have limited Fat Duck norovirus outbreak. Occupational Health, 61(10), 30. Retrieved January 28, 2010, from ABI/INFORM Global. (Document ID: 1887306051). Mayo Clinic. Norovirus infection (2009). Retrieved January 12, 2009. Available at http://www.mayoclinic.com/health/norovirus/DS00942/DSECTION=symptoms Moeller, D. W. (2005). Environmental health (3rd ed.). Boston: Harvard University Press. National Institute of Allergy and Infectious Diseases. Norovirus Infection (2007). Retrieved January 26, 2010. Available at http://www3.niaid.nih.gov/topics/norovirus/treatment.htm The Fat Duck Restaurant. http://www.fatduck.co.uk/intro.html United States Department of Health & Human Services. Foodborne Pathogenic Microorganisms and Natural Toxins Handbook (2009). Retrieved January 26, 2010. Available at http://www.fda.gov/Food/FoodSafety/FoodborneIllness/FoodborneIllnessFoodbornePathogensNaturalToxins/BadBug Book/ucm071344.htm