1. What’s “Flu” to You? Stomach “Flu” vs. Influenza Developed by
Kara Oliver, RN, BSN
Barbara Copple, RN
Marion County Health Department
Communicable Disease/Epidemiology Team

2. “I had the flu…”
If someone said, “I had the flu,” what images would come to mind for you?

3. “I had the flu…”
…or would you see these images

4. Influenza = “flu”

5. Influenza  Stomach “Flu”

6. Stomach “flu” = Norovirus
Stomach “flu”= “Winter Vomiting Disease”
Stomach “flu”= 24-hour bug
Stomach “flu”  Influenza

7. A “flu” by any other name…
Influenza = “flu”
Seasonal Flu
Pandemic Flu
Avian Flu

8. Seasonal Flu Caused by the influenza virus, not Norovirus
Usually occurs during the winter
Easily spreads from person to person
Vaccine is available
Seasonal influenza like all types of influenza is caused by a virus.
In our part of the world the annual flu season usually happens during the winter.
A vaccine is available but is changed from year to year to match the virus so a new shot is needed every flu season.

9. Seasonal Influenza Incubation period is usually 1-3 days Symptoms
-Fever (often sudden), chills, headache, muscle aches, dry cough, sore throat, weakness, runny nose, may last three to five days or more
-People can shed the virus without showing symptoms of infection
Incubation period or time from infection to symptoms developing is usually between 1 and 3 days.
Symptoms are often more severe than a typical cold with body aches, headache, and fever, and general weakness.

10. Seasonal Influenza The virus can be spread: -Cough/Sneeze
Most important (within 3 feet)
-Contact
Contaminated articles
Droplet
Contact
The flu usually spreads from person to person when an infected person coughs or sneezes. When a person coughs or sneezes, an infectious person produces infectious droplets.. These large droplets can then be directly deposited into the nose and throat of uninfected persons who are nearby (usually within 3 feet). Viruses can also be spread when a person touches something that is contaminated and then touches their eyes, nose, or mouth introducing the virus into the respiratory system. Many germs can survive for a long time (2 hours or more) on surfaces like doorknobs, desks, and tables.

11. The Burden of Seasonal Influenza
250,000 to 500,000 deaths globally/yr
36,000 deaths and > 200,000 hospitalizations/yr in U.S.
$37.5 billion in economic costs/yr in U.S. related to influenza and pneumonia
Although we may not pay much attention to the flu season most years, it does have an impact on our health and

12. Prevention Social Distancing Annual flu vaccine Hand hygiene
Respiratory etiquette
“Cover your cough”

13. Social Distancing Three feet from other people
Limit face-to-face contact

14. Hygiene: Wash Your Hands
Before, during, and after you prepare food
Before you eat, and after you use the bathroom
After handling animals or animal waste
When your hands are dirty, and
More frequently when someone in your home is sick
Avoid touching your eyes, nose or mouth

15. Wash Your Hands Use soap and warm running water for
At least 20 seconds OR
Use an alcohol based
hand sanitizer for at
least 15 seconds.
Wash hands that are visibly soiled first before using hand sanitizer.

16. If you become ill…

17. Sneezes and Coughs are powerful germ explosions
Thomas Edison came up with the idea of movies from watching someone sneeze in 1894.
He was looking at still sequential pictures of someone sneeze and realized that if you viewed them quickly in a sequence, that you might be able to make a movie.

18. Cover Your Coughs and Sneezes
Use a tissue or inside of your elbow when sneezing or coughing.
Cough
HERE

19. Stay home when you are sick
Stay home if you have…
A fever of 101 degrees
If needed, seek medical care

20. Influenza is not Stomach Flu
Stomach flu is caused by Norovirus
Like influenza, Norovirus is very contagious
Often in media stories

21. EXTRA! EXTRA! READ ALL ABOUT IT!!!
Norovirus tears across US!!!
3700 patients seen in Boston’s ER’s over last six weeks
Queen Elizabeth 2 is the first cruise ship in 2007 to get hit by Norovirus
Canada notes its been the worst year for Noro in a decade
Russia battling Noro
Norovirus outbreaks in Oregon ahead of last year’s record pace—Headline in 1/12/2007 Statesman Journal

22. 2006 Record Breaking Year
State of Oregon received 119 Noro outbreaks reports
25 were Marion County’s
2007—seven in January (record)

23. On to Another Record Breaking Year
“Norovirus outbreaks in Oregon ahead of last year’s record pace”—Headline in 1/12/2007 Statesman Journal
CDC Norovirus specialist—current outbreak of illness appears to be the worst since
Don’t know why—speculate different strain, easier to transmit, spawns more severe symptoms

24. What are noroviruses?
Group of viruses that cause the “stomach flu,” or gastroenteritis
The term norovirus was recently approved as the official name for this group of viruses
Approximately 23 million cases each year in U.S.
Leading cause of outbreaks of gastroenteritis
Winter vomiting disease
Norovirus used to be called Norwalk virus.
It is now thought that at least 50% of all food borne outbreaks of gastroenteritis can be attributed to noroviruses.

25. Norovirus Symptoms Nausea, vomiting, diarrhea, abdominal cramps
Sometimes low-grade fever, chills, headache, myalgia, fatigue
Often begins suddenly, and the infected person may feel very sick
Norovirus infection usually presents as acute-onset of vomiting, watery non-bloody diarrhea with abdominal cramps, and nausea.
Vomiting is more common in children.

26. Incubation, Duration, Communicability
Incubation period (how long does it take to get sick): hours (median in outbreaks is hours)
Duration of illness: Typically 1 – 2 days
Contagious period: onset through 72 hours after recovery
Presymptomatic viral shedding may occur.
Shedding usually begins with onset of symptoms and may continue for 2 weeks after recovery. It is unclear to what extent viral shedding over 72 hours after recovery plays into transmission of the disease.

27. How serious is it?
Usually not serious, although people may feel very sick and vomit many times a day
Most get better within 1 or 2 days, and they have no long-term health effects related to their illness
Can be serious for the very young, the elderly, and persons with weakened immune systems due to dehydration

28. Transmission Found in the stool and vomit of infected people
Infective dose as few as 10 viral particles
Can be transmitted several ways:
Eating food or drinking liquids that are contaminated with norovirus
Direct person-to-person spread
Airborne and fomite transmission in droplets contaminating surfaces or entering the mouth and being swallowed
Environmental and fomite contamination may also act as a source of infection. Good evidence exists for transmission due to aerosolization of vomitus that presumably results in droplets contaminating surfaces or entering the oral mucosa and being swallowed. No evidence suggests that infection occurs through the respiratory system.

29. Immunity
Limited immunity, may be strain specific and last only a few months
Can recur throughout a person’s lifetime
Some people are more likely to become infected and develop more severe illness than others
Example: people with O blood group most susceptible
In a study conducted at the NCRR-supported General Clinical Research Center (GCRC) at the University of North Carolina at Chapel Hill, Dr. Christine L. Moe and her colleagues found that more than half of 77 volunteers exposed to Norwalk virus, a type of norovirus, were resistant to infection. About half of these protected individuals had FUT2 mutations that blocked production of H type-1, a carbohydrate and blood group antigen found on many cell surfaces. All volunteers who had two copies of the nonfunctional FUT2 gene remained healthy, even after receiving high doses of the virus. The findings suggest that H type-1 is the cellular receptor that binds Norwalk virus and allows it to enter cells. The study also jibes with earlier clinical studies that identified possible links between blood group antigens and norovirus susceptibility.

30. Norovirus (Stomach ‘Flu’) Treatment
Drink plenty of fluids to prevent dehydration
No antiviral medication
No vaccine to prevent Norovirus
Cannot be treated with antibiotics because antibiotics work to fight bacteria, not viruses
By drinking oral rehydration fluids, juice or water people can reduce their chance of becoming dehydrated. Sports drinks do not replace the nutrients and minerals lost during this illness.

31. Cleaning
If possible, wear gloves, mask when cleaning up vomit or diarrhea
Contaminated hard surfaces: soak up excess liquid with paper towels, thoroughly clean with hot water and detergent, and disinfect with a bleach solution (5 Tablespoons of 6% household bleach to one gallon of water)
Contaminated carpets: soak up excess liquid with paper towels, clean with hot water and detergent, then disinfect with bleach solution (if bleach-resistant) or steam clean
Frequently clean hand contact surfaces, e.g. door handles, railings, tabletops, bathroom fixtures, etc. with bleach solution

32. Hand Washing After using restrooms and before eating
Before and after direct contact with ill person
Hand wash sinks have warm water, soap, and paper towels
Alcohol-based hand sanitizer to supplement hand washing
Hand washing is preferred. Alcohol-based hand sanitizer is not a substitute for hand washing, and should only be used when hands are not visibly soiled.
Alcohol-based sanitizer is effective against similar viruses. Resource MMWR 2002 Hand Washing.

33. Critical Characteristics
Highly contagious
Multiple modes of transmission
Stable in the environment
Resistant to routine disinfection methods
Asymptomatic infections
Limited immunity
Not the same as seasonal flu (influenza)
Noroviruses are relatively resistant to environmental challenge: they are able to survive freezing, temperatures as high as 140 degrees F, and have even been associated with illness after being steamed in shellfish. Moreover, noroviruses can survive in up to 10ppm chlorine, well in excess of levels routinely present in public water systems.
Oregon Health Division said that norovirus probably survive on a surface for at least a few days, perhaps several weeks depending on variables such as temperature, UV irradiation, perhaps humidity, etc.
Asymptomatic infection may occur in as many as 30% of infections, although the role of asymptomatic infection in norovirus transmission in not well understood.

34. Stay home when you are sick
Stay home if you have…
Vomiting
Diarrhea
If needed, seek medical care

35. Symptom Norovirus Influenza Headache Common Fatigue Malaise Mylagia
(aka Stomach Flu)
Influenza
(aka Flu)
Headache
Common
Fatigue
Malaise
Mylagia
Fever
Sometimes Low-grade
Common > 102 F
Cough No
Cramps
Uncommon
Nausea
Vomiting
Uncommon (can be seen in children)
Diarrhea

36. Questions?

37. Sources Robert E. Wheeler, MD, FACEP. Voyager Medical Seminars
                                                                                                                                                                                                                                                                                                                                                                                                                                                
Robert E. Wheeler, MD, FACEP. Voyager Medical Seminars
Karen Landers, MD, MPH, Marion County Health Department