1. Viral Gastroenteritis: Prevention and Control in Long- Term Care Facilities Daniel Golson, MPH Epidemiologist daniel.golson@nashville.gov 615-340-5651

2. Practical Guidance for LTCFs www.health.nashville.gov/healthdata

3. Development of Document early 2009 – 4 confirmed norovirus outbreaks –LTCF, retirement community, restaurant, social gathering only one was determined to be foodborne internal work group formed –internal communication, outbreak response, guidance for public facilities (e.g. hotels and LTCFs) –CDIs, environmentalists, & epidemiologists –Food Division, Public Facilities, Epidemiology

4. And Then.... Swine flu!

5. Next Thing You Know...Fall 2009 5* Assisted Living facilities 2** Retirement communities 2 Social gatherings –wedding (confirmed norovirus G2 etiology) –work environment (confirmed norovirus G2 etiology) *1 confirmed etiology – norovirus G2 **1 confirmed etiology – norovirus G2 Viral Gastroenteritis Outbreaks in Davidson County

6. Lessons Learned Some large institutions have very clear control protocols Many do not Many HCWs lackadasical about viral gastroenteritis – its going around Closed communities must be prepared

7. Guidance Needed for LTCFs Prepare for eventuality of a viral gastroenteritis outbreak When to suspect an outbreak Control measures Info to collect for CDIs, epis Notification the LHD Examples of info to hand out to residents & signs to discourage visitors

8. Guidance Needed for LTCFs Isolation practices Dining facilities & community activities Ill staff Home-health workers Transfers, EMS transports New admissions Environmental cleaning & disinfection Flexible step by step guide

9. Outbreaks 2 residents or staff with new onset of V and/or D w/n 48 hrs of each other suspect norovirus early recognition critical to control aggressive implementation of control measures

10. Preparation is Critical! Review guidance & share with staff Think about what info your audience will want during an outbreak – be transparent in your communications Prepare for specific audiences: –residents –residents families/friends –staff (food, maintenance, volunteers, home-health workers, etc) –the media?

11. You suspect an outbreak, now what? Notification – Everyone plays a role –Residents, Staff – Report SxS to Mgmt –Mgmt or ICP Consult with MPHD (615-340-5632) Log cases daily using line list Alert sister facilities, hospitals, hospice, EMS Provide staff, residents, family, visitors with fact sheet on norovirus

13. Isolation and Case Management 48 hrs rule –isolate those with SxS until 48 hrs SxS-free –send ill staff home until 48 hrs SxS-free –discontinue communal activities until 48 hrs after last case IDd –close dining facility until 48 hrs after last case Limit staff to one area of assignment Postpone transfers & new admissions Discourage visitors

14. Managing the Environment Norovirus resistant to most disinfectants Clean & disinfect (C&D) contaminated areas promptly Step up C&D and continue enhanced C&D 72 hrs after last case IDd Chlorine bleach is best Lysol®409®Pinesol®

15. Managing the Environment Do Not bring non-essential equip into contaminated areas Do Not vacuum until after steam cleaning (carpets, rugs, furnishings) Segregate clean & soiled linens/laundry Wear PPE when handling soiled laundry

16. Viral Gastroenteritis Outbreaks in Davidson County since Fall 2009 Over 175 illnesses in total At least 8 hospitalizations, many ED visits No fatalities Attack rates among residents ranged from 16% to 73%

17. Propagated Outbreak in 3 phases?

18. Questions? www.health.nashville.gov/healthdata