Norovirus outbreaks trigger unit closures
Organism tops list of outbreaks
Norovirus is the organism most likely to trigger a shutdown of units in your hospital. And according to a recent survey of infection preventionists, it is responsible for more outbreaks than some deadlier organisms, such as Clostridium difficile and Staphylococcus aureus.1
It poses a risk to patients and employees alike. "Norovirus is different from the other [health-care acquired] organisms because norovirus can affect employees, and in outbreaks many times does," says lead author Emily Rhinehart, RN, MPH, CIC, vice president and division manager of the health care division of Chartis Global Loss Prevention in Atlanta.
In fact, norovirus outbreaks were as likely to occur in behavioral health and rehabilitation units as medical/surgical units, another contrast to other organisms. In those units, patients are more mobile, and therefore more likely to contract or transmit the disease, Rhinehart notes. "They're walking around their environment and interacting with the environment and other patients and the employees are interacting with them," she says.
Last year, the Centers for Disease Control and Prevention issued an updated guideline on norovirus in health care settings, and the agency released a toolkit to help hospitals and other facilities cope with outbreaks. (See box below.)
Norovirus outbreaks are easy to identify because they are often dramatic, with sudden onset of nausea, vomiting and diarrhea. Norovirus "has a very short incubation time, it's very transmissible, and a lot of people can be infected in a short amount of time," says Clifford McDonald, MD, medical epidemiologist at CDC.
The virus is not associated with significant mortality. An unpublished analysis of death certificates found that C difficile was associated with about 14,000 deaths in a year compared with just 800 for norovirus, McDonald says.
Still, it presents significant challenges for both infection control and employee health professionals. Here are some issues to keep in mind:
Monitor employee absences. If you see a pattern of digestive illness among employees, particularly in the same unit, that may be a clue about an outbreak. Being alert can help you detect norovirus and implement strategies to prevent its spread, says Rhinehart.
Don't penalize employees for being sick. You want ill employees to stay home if they're sick – and during an outbreak, you might require some exposed employees to stay home for a two- or three-day incubation period. Make sure your policies don't penalize them for reporting symptoms or an exposure by requiring them to take time from a pool of paid time off. Some employers have used workers' compensation or even a contingency fund to cover those payments for ill or exposed employees to stay home, Rhinehart says.
Identifying a norovirus outbreak
In the absence of clinical laboratory diagnostics or if there's a delay in obtaining laboratory results,
use Kaplan's clinical and epidemiologic criteria to identify a norovirus gastroenteritis outbreak:
1. Vomiting in more than half of symptomatic cases, and
2. Mean (or median) incubation period of 24 to 48 hours, and
3. Mean (or median) duration of illness of 12 to 60 hours, and
4. No bacterial pathogen isolated from stool culture
Consider submitting stool specimens as early as possible during a suspected norovirus gastroenteritis outbreak and ideally from individuals during the acute phase of illness (within 2-3 days of onset).
Specimens obtained from vomitus may be submitted for laboratory identification of norovirus when fecal specimens are unavailable. (Consult with your lab). Testing of vomitus as compared to fecal specimens may be less sensitive due to lower detectable viral concentrations.
Routine collecting and processing of environmental swabs during a norovirus outbreak is not required.
Staff leave policy
Exclude ill personnel from work for a minimum of 48 hours after the resolution of symptoms. Once personnel return to work, the importance of performing frequent hand hygiene should be reinforced.
Establish protocols for staff cohorting in the event of an outbreak of norovirus. Ensure staff care for one patient cohort on their ward and do not move between patient cohorts (e.g., patient cohorts may include symptomatic, asymptomatic exposed, or asymptomatic unexposed patient groups).
Exclude non-essential staff, students, and volunteers from working in areas experiencing outbreaks of norovirus.
Source: Centers for Disease Control and Prevention. A Norovirus Prevention Toolkit, available at www.cdc.gov/HAI/organisms/norovirus.html.
Emphasize glove use and hand hygiene. Alcohol gel may not be as effective against norovirus as hand-washing. But while you can educate staff and encourage hand-washing, don't try to completely revamp your hand hygiene program, says McDonald. Alcohol gel has been extremely effective in combating other organisms, and studies show it improves compliance with hand hygiene, notes McDonald.
You should emphasize glove use and changing gloves between patients, he says. "Glove use is only as good as your practice of changing gloves between patients," he says. "If you don't change them between patients, you're doing nothing for patient safety." It is also important for employees to remove the gloves in a way that prevents contamination of their hands and to perform hand hygiene after removal.
Report outbreaks to the state health department. While hospitals had surveillance programs to detect health care acquired infections, the survey of infection preventionists found that only 52% of the outbreaks had been reported to an external agency, such as the local or state health department. Some hospitals might be reluctant to bring attention to their outbreak, or they might feel they don't need the help of public health authorities, says McDonald. Yet reporting allows for a greater awareness of the disease spread and may even warn nearby hospitals of a circulating organism, he says.
Reference
1. Rhinehart E, Walker S, Murphy D, et al. Frequency of outbreak investigations in US hospitals: Results of a national survey of infection preventionists. AJIC 2012; 40:2-8.
Norovirus is the organism most likely to trigger a shutdown of units in your hospital. And according to a recent survey of infection preventionists, it is responsible for more outbreaks than some deadlier organisms, such as Clostridium difficile and Staphylococcus aureus.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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