1. Mary Crabtree, Workplace Safety Manager Peter A. Reinhardt, Director Department of Environment, Health & Safety University of North Carolina at Chapel Hill Presented at the 50 th Anniversary International Conference of the Campus Safety, Health and Environmental Management Association, July 5 th, 2004 Norovirus Outbreak on Campus

2. Presentation Objectives General Information Review of UNC’s Norovirus Outbreak Actions taken within UNC Debriefing within UNC Attendance at NCSU’s Debriefing Lessons Learned Recommendations for Other Institutions

3. General Information In January 2004, EHS implemented a Hand Washing Campaign with Orange County Health Dept. Goal: To reduce overall risk to infectious diseases and food-borne illnesses

4. Two full dining facilities Four Snack facilities ARAMARK: Contractor for food services Serve 7,000 meals/day in full dining halls Carolina Dining Services

5. Review of UNC’s Norovirus Outbreak On January 21, 2004, Sixty-six students reported to Student Health Services Symptoms: nausea, vomiting, diarrhea, acute gastroenteritis

6. Review of UNC’s Norovirus Outbreak

7. About Norovirus Norovirus Infection Symptoms Vomiting Diarrhea Nausea Abdominal cramps Headache, muscle aches Fever (minority) Dehydration Up to 30% may be asymptomatic Adapted from Strategies for Norovirus Infection Control Aboard Cruise Ships, Robert E. Wheeler, MD, 2003.

8. About Norovirus Norovirus-Public Health Aspects 23-25 million cases in 2002 About 8% of the U.S. population Restaurants, schools, dormitories at risk Adapted from Strategies for Norovirus Infection Control Aboard Cruise Ships, Robert E. Wheeler, MD, 2003.

9. About Norovirus Norovirus Infection Infectious dose of 10-100 virus particles 24-48 hour incubation period 12-60 hour duration of illness A “mild” and short-lived illness Treatment may indicate IV fluids Viral shedding of 3 weeks or more Adapted from Strategies for Norovirus Infection Control Aboard Cruise Ships, Robert E. Wheeler, MD, 2003.

10. About Norovirus Transmission “Oral-fecal” route Food (39%) Hands, person-to-person (12%) Water (3%) Also environmental surfaces: carpets, toilets, etc. Adapted from Strategies for Norovirus Infection Control Aboard Cruise Ships, Robert E. Wheeler, MD, 2003.

11. About Norovirus Modes of Transmission by Food Food sources (i.e., food arrives contaminated) Preparation Food handlers Customers Most at risk: ready-to-eat foods that require handling but no subsequent cooking (e.g., salads) Adapted from Strategies for Norovirus Infection Control Aboard Cruise Ships, Robert E. Wheeler, MD, 2003.

12. About Norovirus Norovirus Characteristics Highly contagious Multiple modes of transmission Stable in the environment Resistant to routine disinfection methods Carriers may not be symptomatic Adapted from Strategies for Norovirus Infection Control Aboard Cruise Ships, Robert E. Wheeler, MD, 2003.

13. Review of UNC’s Norovirus Outbreak

14. UNC Student Health Service Epicurve

15. Immediately notified Orange County Health Department, who began an investigation. Enacted Disaster Plan and notified EHS Assisted with Incident Communications Plan Posted “Student Illness Update” on websites Action Taken by Student Health Services

16. Initial Health Department Findings Based on calls to students who came to SHS, their roommates and other contacts.

17. Established contact with entities that would be involved (i.e., Housekeeping, UEOHC, Athletics, Housing & Residential Education) Coordinated Incident Communications Plan Prepared clean-up packets for Residential Halls Discussed clean-up procedures with Athletics (Men’s Basketball Game January 24) Advice to student dinning operations to deal with rumors, business impact, etc. Environment, Health & Safety

18. Action Taken Within UNC

19. Cleaning Guidelines for Housekeepers

20. EHS met with Housekeeping Zone Managers –Review Clean-up procedures –Identification of areas which students exhibit illness Verify that available cleaners are sufficient Required cleaning may exceed staff capabilities Need feedback from housekeepers as to extent of cleaning needs Housekeeping Department

21. Distributed EHS clean-up kits to residential halls Assisted with Incident Communications Plan Prepared & distributed illness survey (for students who did not go to SHS for treatment) Housing and Residential Education

22. Carolina Dining and ARAMARK Placed “Hand Wash” tents on dining tables Placed additional hand washing stations throughout dining halls Reviewed staff absenteeism records Fully assisted health investigators ARAMARK’s SOP is to save food samples ARAMARK offered corporate investigation and communication resources

23. Calendar of Outbreak Events SundayMondayTuesdayWedThursdayFridaySaturday January 18MLK Day 19 Point Source 2021 66 students sought treatment at SHS 222324 Virginia basketball game 2526 UNC Closed Winter Storm 2728 NCSU basketball game 29 Norovirus confirmed 3031 February 12 OCHD identifies source 34567 89 Start of NCSU outbreak 1011121314

24. Final Results, February 2, 2004: Overall, about 250 students became ill during this outbreak Outbreak from a single source Time limited Common environmental exposure Five times more likely in one location of dining hall Four times more likely if the student ate salad bar No point to a specific salad item No procedural problems found with the Dining Services County Health Department’s Finding

25. UNC’s Debriefing was conducted on March 2 nd Parties involved: –Environment, Health & Safety –Student Health Services –Carolina Dining Services (including ARAMARK) –Housing & Residential Education –Housekeeping Services Debriefing Within UNC

26. Reviewed Orange County Health Department Findings Effectiveness of Communications Involvement of key groups for decision making What if any other potential resources were needed? –Further analysis by the UNC School of Public Health What other action can be taken to prevent/ mitigate reoccurrence? Debriefing Within UNC

27. Attendance at NCSU’s Debriefing Compare experiences and share best practices. NCSU conducted a highly visible handwashing campaign

28. Attendance at NCSU’s Debriefing Paralleled UNC’s case After 6th case at SHS, implemented survey— a best practice UNC could adopt. Saw 410 students from February 9 th to March 4 th —longer duration. No source identified.

29. Delay in Health Department investigation results limited University’s response, so—to compliment the Health Department—we plan to initiate medical survey at the time of complaint. Immediately review geographic data–who ate where and when. Consider using epidemiology resources from UNC’s School of Public Health. Continue contingency planning with outside parties. Lessons Learned

30. Other Plans of Action Presentation to the North Carolina Public Health Training and Information Network Plans for a more aggressive hand washing campaign for winter of 2004-5, including additional hand cleaners in dinning halls in strategic locations. Consider arrangements to purchase and acquire effective cleaners overnight. If UNC staff cannot manage cleaning, consider hiring cleaning contractor.

31. Recommendations for Other Institutions Establish emergency communication procedures Openly discuss contingency plans and responsibilities internally and with public health officials Conduct drills (i.e. table top) to identify needs Review contracts of food service and establish a working partnership Implement stronger health campaigns Share information

32. How Our 2003 SARS Experience Helped Chancellor’s SARS Task Force—Fall 2003 –Promote handwashing –Housing workshop on response to communicable disease outbreak Strengthened internal and external relationships, communication and decisionmaking. Everyone better understands resources available at the University, County and the State. However, we would rather not make an “outbreak” presentation at the 2005 CSHEMA conference. Mark Stinson, an auto mechanic from Chatham County NC, has survived four lightning strikes—in 1985, 1993, 2000 and 2002. Although his resulting disabilities are “a never-ending nightmare,” he says, “I’m still fascinated by lightning.”