1. 1

2. What it is, What it isn’t  Calicivirus with 6 Genogroups Genogroups I, II, and IV cause human illness  Environmentally stable Resists heating to 60 o C & able to survive freezing  AKA - “Food Poisoning” or “Stomach Flu”  Not related to the influenza virus

3. What does it do to you?  Commonly causes diarrhea, vomiting, nausea, stomach cramps  Other symptoms include fever, headache, body aches  Usually no long-term health impacts  Dehydration most common complication

4. How does it spread? Fecal/Oral ○ Eating or drinking contaminated food items ○ Touching contaminated surfaces or objects and then putting your fingers in your mouth, or ○ Having contact with someone who is infected

5. How does it spread? (Cont…) Aerosol ○ Being near someone who is vomiting

6. True or False Questions  You can only get Norovirus once in your life and then you are immune

7. True or False Questions  You can only get Norovirus once in your life and then you are immune. False ○ Many different types of noroviruses ○ Immunity is short-lived

8. True or False Questions  You can spread Norovirus even after your diarrhea stops

9. True or False Questions  You can spread Norovirus even after your diarrhea stops True, see the next slide

10. When can you spread it?  Virus is in stool before symptoms start  Virus can stay in stool for 2 weeks or more after symptoms stop  Most contagious when sick with symptoms and during the first three days after recovery

11. Norovirus Trivia  1929 - First recognized outbreaks of viral gastroenteritis termed “winter vomiting disease”  1940 - Demonstrated that pooled stool filtrates obtained from patients in an institutional outbreak could infect volunteers  1968-CDC investigated vomiting disease in an elementary school in Norwalk, OH

13. Top pathogens contributing to foodborne illnesses, hospitalizations and deaths in US (2011) Pathogen Est. number of cases Est. number of hospitalizations Est. number of deaths Norovirus (#1) 5,461,731 (#1) (#2) 14,663 (#2) (#4) 149 (#4) Salmonella (non-typhoidal) 1,027,56119,336378 Campylobacter spp. 845,0248,46376 C. perfringens970,0004,40026 E.coli (STEC) O157 63,0002,13821 Toxoplasma gondii 87,0004,428327

16. Cruise Ships…Schools…Gatherings… Long Term Care Facilities  Transmits easily when people are in close contact  Very low infectious dose

17. Infectious Dose  Norovirus: 10-100  Shigella: 10-100  Salmonella: 10 5 - 10 8  Campylobacter: 10 4 – 10 6  E. coli: 10 8

20. Investigating Norovirus Outbreaks  Collect illness information  Get a diagnosis – COLLECT STOOL SPECIMENS  Focus on prevention, educate everyone

21. Collect illness information  Onset of symptoms Incubation typically 24-48 hours  Symptoms Diarrhea, vomiting, nausea, stomach cramps Vomiting more common in children  Duration of illness Usually 24-48 hours  Usually see high attack rate & 2° spread

22. Get a Diagnosis Collect stool specimens  Offer to drop off and pick up stool kits, if possible  Send to appropriate laboratory (some labs are unable to test for Norovirus)  Label vials and fill out appropriate paperwork

23. Diagnosing Norovirus  Polymerase chain reaction (PCR)  Takes ~4 hours to complete  High sensitivity Detects concentrations as low as 10 viral particles  Cannot detect all small round viruses, so negative test is not always conclusive

24. Prevention is KEY!!  Noro Cleaning Guidance In the home In restaurants/facilities  Stay home when sick!! If you are out and about, you are spreading norovirus Good hand hygiene  Don’t cook for others… Don’t cook for others until at least 48 hours after symptoms cease

26. Hand Gels and Norovirus Scientific uncertainty over effectiveness of alcohol-based hand gels against norovirus Always wash hands with soap and warm water when able Alcohol-based hand gels should only be used in situations where soap and warm water are not available

27. Guidance documents available for many situations…  Long term care guidance  School /childcare guidance  Healthcare setting guidance  Food handlers

28. General Guidance for Childcare Facilities  Children or staff with diarrhea and/or vomiting: Exclude until 24 hrs after diarrhea & vomiting cease  Staff who handle food and have diarrhea and/or vomiting: Exclude until 48 hrs after diarrhea & vomiting cease Most staff members in child care programs are considered food handlers  Educate staff, parents & children on proper hand washing technique

29. Outbreak Guidance for Childcare Facilities  Consider providing guidance on prevention of norovirus to parents, staff & children  Increase frequency of routine cleaning Focus on disinfection of commonly touched areas: doorknobs, phones, etc. Toys should be cleaned & disinfected daily

30. Outbreak Guidance for Childcare Facilities (cont…)  Ensure restrooms are adequately stocked with soap, paper towels, & warm running water  Request stool specimens from 3-5 of the ill individuals to confirm cause of the outbreak

31. General Guidance for Schools  Students and staff with diarrhea and/or vomiting: Exclude until 24 hrs after diarrhea & vomiting cease  Any staff/student who handles food & has diarrhea and/or vomiting: Exclude from food handling activities until 48 hrs after diarrhea & vomiting cease  Educate staff members, parents, & students on proper hand washing technique

32. Outbreak Guidance for Schools  Consider providing guidance on prevention of norovirus to parents, staff & children  Increase frequency of routine cleaning  Temporarily stop using self-service foods for school breakfast/lunch  Ensure restrooms are adequately stocked with soap, paper towels, and warm running water  Request stool specimens from 3-5 of the ill individuals to confirm the cause of the outbreak

33. Guidance for Community Residential Programs  Actions taken will depend on the type of program and the level of functioning of the residents  General recommendations include: Residents with suspected or confirmed norovirus: ○ Place on Enteric precautions until symptoms subside Staff members with suspected or confirmed norovirus: ○ Exclude until 24 hrs after vomiting and diarrhea cease

34. Guidance for Community Residential Programs (cont…)  Staff and clients with suspected or confirmed norovirus: Refrain from handling or preparing food for other residents until 48 hrs after vomiting or diarrhea cease  Educate staff members, residents, and visitors on proper hand washing technique

35. General Guidance for Hospital & Long-term Care Facilities  Place ill patients in private rooms or cohort ill patients in the same room  Consider grouping ill patients in same area or wing of facility  Minimize un-necessary movement of residents  Consider temporarily discontinuing group activities until outbreak has resolved

36. General Guidance for Hospital & Long-term Care Facilities (cont…)  Consider serving meals in resident rooms instead of dining hall  Educate staff members, residents, and visitors on proper hand washing techniques  Send all ill staff home immediately

37. General Guidance for Hospital & Long- term Care Facilities (cont…)  Staff with diarrhea and/or vomiting: Exclude until 24 hrs after diarrhea & vomiting cease Educate on proper hand hygiene upon returning to work  Patients with suspected norovirus infection: Manage with standard & contact precautions with careful attention to hand hygiene practices

38. General Guidance for Hospital & Long- term Care Facilities (cont…)  Contact precautions should be used when caring for diapered or incontinent persons, during outbreaks in a facility, and when a splash could occur  Persons cleaning areas heavily contaminated with vomitus or feces should wear surgical masks  Food handlers with diarrhea and/or vomiting: Exclude until 48 hrs after vomiting & diarrhea cease

39. General Guidance for Hospital & Long-term Care Facilities (cont…)  Medical equipment used for care of norovirus-infected patients: Dedicate to that patient for duration of patient’s isolation OR Thoroughly disinfect when removed from patient’s room  Select appropriate cleaning agent based on equipment manufacturer’s recommendation for compatibility

40. Outbreak Guidance for Hospital & Long-term Care Facilities  Collect stool specimens from 3-5 patients to confirm cause of outbreak  Assign staff to work with well residents or sick residents, not both Limit staff from moving between affected & unaffected areas of facility & limit any non-essential personnel from affected areas

41. Outbreak Guidance for Hospital & Long-term Care Facilities (cont…)  Consider limiting new admissions to affected areas until all patients are well and no new cases are occurring  Inform visitors about a possible disease outbreak in your facility  Consider limiting or stopping visitation to facility until there have been no new cases for at least 48 hrs  Post extra hand washing signs in various visible areas in the facility

43. IDPH Norovirus Outbreaks - 2012  Only outbreaks are reportable  30 suspected or confirmed Norovirus outbreaks investigated in 2012 9 long-term-care or assisted living 7 restaurant 6 child care/school/college 4 private gathering 2 hospital 2 other  Over 660 people ill

44. Activity Ongoing in 2013-14  Activity slowing but ongoing  Investigated several in the last few weeks Long term care Private gatherings Restaurants

45. Outbreaks  Restaurant Hotel  Casino Hotel / Conference Center / buffet

46. Restaurant Outbreak Phone call March 20, 2012

47. Restaurant Outbreak Phone call Suspected foodborne March 20, 2012

48. Restaurant Outbreak Phone call Suspected foodborne DIA Foodborne illness form March 20, 2012

49. Restaurant Outbreak  EH coordinator and Deputy Director  DIA Foodborne Illness Complaint Form  Staff

50. Complaint Inspection Management On-site Visit

51. Complaint Inspection Management Facility On-site Visit

52. Complaint Inspection Management Facility Employees On-site Visit

53. Customer Interviews Identifying information EPI2000 Outbreak Form

54. Customer Interviews Identifying information Sick? EPI2000 Outbreak Form

55. Customer Interviews Identifying information Sick? Symptoms EPI2000 Outbreak Form

56. Customer Interviews Identifying information Sick? Symptoms Food eaten EPI2000 Outbreak Form

57. Investigation 33 individuals called March 20, 2012 PM

58. Investigation 33 individuals called 21 ill March 20, 2012 PM

59. Investigation 33 individuals called 21 ill Incubation period March 20, 2012 PM

60. Investigation  March 20, 2012 Stool kits Data entry

61. Investigation Person 1B March 21, 2012

62. Investigation Person 1B Norovirus Y/N March 21, 2012

63. Investigation Person 1B Norovirus Y/N Closed for cleaning Bleach March 21, 2012

64. Investigation Employees March 21, 2012

65. Investigation Employees Informed facility March 21, 2012

66. Investigation Employees Informed facility Stool kits March 21, 2012

67. Employee Interviews 17 Employees EPI2000 Outbreak Form

68. Employee Interviews 17 Employees 11 ill EPI2000 Outbreak Form

69. Conference Call  SCHD Staff  IDPH  DIA

70. EPI2000 2-tailed p Data

71. EPI2000 2-tailed p Tossed salad Data

72. Employee Interviews Employee C EPI2000 Outbreak Form

73. Investigation  March 21, 2012 Stool kits

74. Investigation  March 22, 2012 Facility reopened Noro confirmed Employee C Conference call

75. Restaurant OutbreaK Phone call March 23, 2012

76. Restaurant Outbreak Phone call Interviews March 23, 2012

77. Restaurant Outbreak Phone call Interviews Noro confirmed March 23, 2012

78. Review  Conference call  2 groups – 67 total  40 ill Attack rate: 60%  Stool kits  Employee C  Noro cleaning  Case closed

79. Restaurant Outbreak Phone call March 26, 2012

80. Restaurant Outbreak Phone call Thursday, March 22 March 26, 2012

81. Restaurant OutbreaK Phone call Thursday, March 22 Interview March 26, 2012

82. Restaurant Outbreak Phone call Thursday, March 22 Interview Noro Cleaning March 26, 2012

83. Casino Outbreak Report October 18, 2006

84. Casino Outbreak Report Facility October 18, 2006

85. Casino Outbreak Report Facility ER’s notified October 18, 2006

86. Casino Outbreak Incident command October 19, 2006

87. Casino Outbreak Incident command On-site visit October 19, 2006

88. Casino Outbreak Symptoms On-site Visit

89. Casino Outbreak Symptoms Inspection On-Site Visit

90. Casino Outbreak Symptoms Inspection Record review On-Site Visit

91. Casino Outbreak Stool kits October 20, 2006

92. Casino Outbreak Interviews October 23, 2006

93. Casino Outbreak Results October 24, 2006

94. Casino Outbreak Illinois Casino October 27, 2006

95. Casino Outbreak Illinois Casino Conference Call October 27, 2006

96. Conference Call End outbreak quickly Prevent spread Avoid closing Interventions Objectives

97. Interventions Signage/Handouts Public Notice

98. Health Department Interviews October 28, 2006

99. Food Service Shutdown October 28, 2006

100. Conference Call Additional action plans October 31, 2006

101. Action Plan Continue current plan Handwashing procedures” Stay home Employee s

102. Action Plan Chips Counters and tables Slot machines Widespread area Frequent cleanings

103. Continued Surveillance Case definition Interviews Monitor absenteeism Stool samples Decrease of interventions November 1, 2006

105. Questions?

106. Kristen Obbink, DVM, MPH Foodborne Illness Epidemiologist Iowa Department of Public Health Kristen.Obbink@idph.iowa.gov 515-281-6049 Eric Bradley, MPH, REHS, CP-FS, DAAS Environmental Health Specialist Scott County Health Department Eric.Bradley@scottcountyiowa.com 563-326-8618