national guidelines on the management of outbreaks of norovirus ...
national guidelines on the management of outbreaks of norovirus ...
national guidelines on the management of outbreaks of norovirus ...
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Nati<strong>on</strong>al Guidelines <strong>on</strong> <strong>the</strong> Management <strong>of</strong> Outbreaks <strong>of</strong> Norovirus Infecti<strong>on</strong> in Healthcare Settings NDSC<br />
quantify <strong>the</strong> extent <strong>of</strong> <strong>the</strong> outbreak. This should be d<strong>on</strong>e by means <strong>of</strong> a properly c<strong>on</strong>structed questi<strong>on</strong>naire.<br />
The outbreak should be described in terms <strong>of</strong> time, place and pers<strong>on</strong> to ensure that its full extent is<br />
recognised. Epidemiological assistance may be required for this.<br />
• Envir<strong>on</strong>mental health investigati<strong>on</strong>: to ensure food safety is protected and <strong>the</strong> kitchen/ food and food<br />
workers are not ei<strong>the</strong>r at risk <strong>of</strong> c<strong>on</strong>taminati<strong>on</strong> or a source <strong>of</strong> c<strong>on</strong>taminati<strong>on</strong> and hence prevent fur<strong>the</strong>r<br />
cases. If a point source is suspected, epidemiological and envir<strong>on</strong>mental investigati<strong>on</strong>s should be<br />
undertaken to identify or exclude a c<strong>on</strong>taminated food or water source.<br />
• Microbiological investigati<strong>on</strong>: to identify definitively and document <strong>the</strong> causative pathogen.<br />
• Analytical studies: more complex analytical studies may be necessary to determine possible exposures<br />
and methods <strong>of</strong> transmissi<strong>on</strong>.<br />
• Declarati<strong>on</strong> that <strong>the</strong> outbreak is over.<br />
• Producti<strong>on</strong> <strong>of</strong> a final report.<br />
3.3 Identificati<strong>on</strong> <strong>of</strong> an Outbreak <strong>of</strong> Norovirus<br />
The first pers<strong>on</strong> that becomes aware <strong>of</strong> or suspects an outbreak, should<br />
inform a known member <strong>of</strong> Infecti<strong>on</strong> C<strong>on</strong>trol staff in <strong>the</strong>ir area. In each<br />
hospital or residential home, a lead pers<strong>on</strong> should be designated to manage<br />
<strong>the</strong> outbreak. In hospitals <strong>the</strong> preliminary investigati<strong>on</strong> should be led by <strong>the</strong><br />
C<strong>on</strong>sultant Microbiologist and/ or Infecti<strong>on</strong> C<strong>on</strong>trol Nurse and/or designated<br />
clinician. Senior <strong>management</strong> in all hospitals should be resp<strong>on</strong>sible for<br />
producing outbreak plans.<br />
The designated lead pers<strong>on</strong> should:<br />
• Decide whe<strong>the</strong>r or not <strong>the</strong> cases are likely to have <strong>the</strong> same illness and establish a tentative diagnosis.<br />
• Decide <strong>on</strong> whe<strong>the</strong>r to c<strong>on</strong>vene an Outbreak C<strong>on</strong>trol Team.<br />
• If <strong>norovirus</strong> is suspected, ensure that c<strong>on</strong>trol measures are put in place immediately.<br />
• Report <strong>the</strong> suspected outbreak at an early stage to senior hospital <strong>management</strong> and to <strong>the</strong> regi<strong>on</strong>al<br />
Director <strong>of</strong> Public Health.<br />
• Form a preliminary hypo<strong>the</strong>sis as to <strong>the</strong> cause.<br />
Infecti<strong>on</strong> due to <strong>norovirus</strong> can usually be diagnosed <strong>on</strong> <strong>the</strong> basis <strong>of</strong> typical clinical and outbreak<br />
characteristics. Characteristic clinical features with sudden <strong>on</strong>set <strong>of</strong> projectile vomiting and simultaneous<br />
involvement <strong>of</strong> patients and staff is highly suggestive <strong>of</strong> an outbreak <strong>of</strong> illness due to <strong>norovirus</strong>.<br />
Gastrointestinal symptoms are very comm<strong>on</strong> in healthcare settings especially am<strong>on</strong>g <strong>the</strong> elderly and children.<br />
A clinical case definiti<strong>on</strong> for gastroenteritis has been proposed to identify possible cases <strong>of</strong> gastroenteritis. 12<br />
This includes:<br />
• Three or more loose stools in 24 hours<br />
and/ or<br />
• Vomiting three or more times in 24 hours<br />
and/ or<br />
• Loose stools or vomiting with two<br />
additi<strong>on</strong>al symptoms, such as nausea,<br />
fever, abdominal pain, abdominal cramps,<br />
and blood or mucus in stool.<br />
Once a patient is suspected <strong>of</strong> having symptoms <strong>of</strong> gastroenteritis, a decisi<strong>on</strong> must be made as to whe<strong>the</strong>r<br />
<strong>the</strong> symptoms could be due to <strong>norovirus</strong>.<br />
- Page 6 -<br />
Key Message<br />
An early, rapid resp<strong>on</strong>se<br />
to an outbreak due to<br />
<strong>norovirus</strong> within hospitals<br />
and o<strong>the</strong>r healthcare<br />
settings is <strong>the</strong> key to its<br />
c<strong>on</strong>trol<br />
Box 1 –Criteria for suspecting an outbreak is due<br />
to <strong>norovirus</strong> (amended from Kaplan et al. 1982) 13<br />
• Vomiting (<strong>of</strong>ten projectile) in ≥ 50% <strong>of</strong> cases<br />
• Durati<strong>on</strong> <strong>of</strong> illness 12–60 h<br />
• Incubati<strong>on</strong> period <strong>of</strong> 15–48 h<br />
• Staff and patients affected<br />
• Stools negative for bacteria (including C. difficile)<br />
and o<strong>the</strong>r viruses