1. Evonne Curran Outbreak Management Norovirus

2. Norovirus is the perfect pathogen It is important that you are ready for norovirus Norovirus improvement in Scotland

3. ‘ 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)

4. Incubation period 12– 48 hrs (typical) Incubation period 12– 48 hrs (typical) Infectious dose Period of infectivity Mainly whilst symptomatic (1-3 days healthy but 4 – 6 days vulnerable) Peak shedding: 2 - 5days post onset ??? Period of infectivity Mainly 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

5. Acute (D&V) Little warning Low fever Aches Acute (D&V) Little warning Low fever Aches Dispersion of infectious material 1 gram of faeces = 100 billion norovirus particles (100,000,000,000 ) = 5 billion infectious doses 1 gram of faeces = 100 billion norovirus particles (100,000,000,000 ) = 5 billion infectious doses Disposal of infectious material 3 3

6. 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 Survival of the virus in the environment and on food 28 days + freezing

7. 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?

8. 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

9. Mortality as a consequence of norovirus 24mths cohort study 308 nursing homes 407 norovirus outbreaks Significantly more hospitalisations Significantly more deaths when norovirus outbreaks ongoing Trivedi et al JAMA 2012

10. Average 442 ward closures per annum (Monday point prevalence) Peak weeks 1-2

11. 3 3 2 2 E coli O157 Salmonella Streptococcus pyogenes MTB MRSA MSSA 1 1 Norovirus

12. So why is it important to You?

13. 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

14. Delayed surgery because wards closed Schools closed Exams not possible Can’t go to work because schools closed Schools closed Exams not possible Can’t go to work because schools closed Businesses closed Financial implications Businesses closed Financial implications No holiday because cruise liner being disinfected and stuck in wrong port

15. Acute gastroenteritis and video camera surveillance : a cruise ship care report: Diskin et al 2014. (International Maritime Health) A faecal incident outside a cabin

17. 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

18. 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

19. If we fail to prepare, we prepare to fail B Franklin

20. These outbreaks are people Vulnerable – elderly and very young Hospitalised patients get it worse Lopman et al 2004 CID

21. Improvement work to minimise norovirus in Scotland

22. Qualitative evaluation: How was it for you? = Evaluation Report 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 plan Visits to key areas Training plans Identified vulnerable areas Guidance updates Bay closures Single web site Front door notices Stay at Home campaign Comms strategy about month to go + Season start Season tracker Escalation plan Visits 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

23. Preparedness is the norm

25. What is new in the literature? Does our guidance need to change? Consultation + Approval Consultation + Approval What worked well – what additional preparation? Season Evaluation: how was it for you? Season Evaluation: how was it for you? What do we want to know – Research Questions?

26. 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

27. 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

28. 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

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

30. 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.

31. 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?