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Rapid Containment of a Norovirus Outbreak in an Acute Care Hospital Rehabilitation Unit

        Thomas C. Button, RN, BSN, CNA, BC, CIC, ICP/Director of Infection Prevention & Control; Judy Clarke, RN, MS, Director of Rehab, Medical Center of McKinney, McKinney, TX
        Issue: Norovirus (calicivirus) is spread through direct contact with an infected person or by touching a contaminated object or surface and then placing the hands near the mouth. Infection generally causes illness within 24-48 hours of exposure, but can occur within 10 hours of exposure. Symptoms include diarrhea, cramps, nausea, and vomiting. Infected persons are contagious from the time of symptom onset until about 2 weeks later. Norovirus is not a serious illness, except when diarrhea and vomiting cause dehydration in the elderly and young. (1, 3)
        Project: The Infection Preventionist was notified that 4 patients had developed diarrhea and some staff had diarrhea and vomiting on 21 January 2008. (2)
        Immediate decisions:
        • ü County Health Department, administration, and medical advisor for Infection Prevention & Control Committee notified
        • ü Staff and patients informed about hand hygiene; washing with soap and water recommended, but use of an alcohol-based sanitizer allowed (3)
        • ü CDC Fact Sheets on norovirus and Clostridium difficile posted (4)
        • ü Housekeeping contacted to begin cleaning all high-touch areas with a 1:50 concentration of bleach solution and to change rags frequently; group areas and rooms underwent a “terminal clean” (6)
        • ü Stool specimens collected from symptomatic patients and staff (3)
        • ü Patients allowed to continue rehabilitation in a group setting, but had to practice good hand hygiene, change clothes afterward, and immediately clean equipment and mats used (1)
        • ü Staff not allowed to “float”
        • ü Outbreak details communicated to other facilities when patients transferred; isolation of patients recommended
        Results: The suspect index case was admitted 4 days before outbreak onset. He was homeless, had diarrhea on admission, and was discharged before others developed symptoms. Five patients and 15 staff developed symptoms; 5 had norovirus-positive stool specimens. The outbreak was contained to 9 days.
        Lessons Learned: Prompt identification of infection and proper cleaning of the environment and hands can prevent a gastrointestinal virus outbreak. The outbreak was contained because the hospital promptly notified the Infection Preventionist of a possible outbreak, the Executive team willingly followed Infection Control recommendations, Environmental Services immediately initiated the appropriate cleaning protocol, and laboratory personnel processed stool specimens quickly.
        References:
        • 1.
          APIC Text, 2nd Ed, 2005 Diarrheal Diseases Chapter 100, p 1-21.
        • 2.
          Infection Control and Hospital Epidemiology September 2008, VOL.29, NO.9, SHEA/APIC Guideline: Infection Prevention and Control in the Long-Term Care Facility
        • 3.
          MMWR, “Norwalk-Like Viruses” Public Health Consequences and Outbreak Management June 01, 2001/50(RR09); 1-18
        • 4.
          Norovirus in Healthcare Facilities Fact Sheet, 2006, http://ncidod/dhqp/id_norovirusFS.html
        • 5.
          Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the HICPAC Committee, 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, June 2007
        • 6.
          Wu HM, FornekM, Kellogg JS, et al. A Norovirus Outbreak at a Long Term-Care Facility: The Role of Environmental Surface Contamination. Infect Control Hosp Epidemiol 2005;26(10)