1. Norovirus and its Importance in School Cafeterias Dr. Ben Chapman and Katie Overbey North Carolina State University March 26, 2015

2. What is Norovirus? Virus that causes gastrointestinal (GI) illness around the world Leading cause of GI illness You may also know it as: o Norowalk virus o Winter vomiting disease o Cruise ship virus o Stomach flu* http://www.dailymail.co.uk/news/article-2253996/Around- 150-passengers-hit-norovirus-Queen-Mary-2-luxury- Christmas-cruise.html

3. Symptoms Symptoms usually resolve on their own after 2-3 days, but may be more severe in young children, the elderly and immunocompromised people After becoming infected with the virus, it takes 24-48 hours to show symptoms

4. Norovirus Shedding Atmar et al. 2008. Emerg Infect Dis. 14(10):1553-7. AsymptomaticVomiting/diarhea Virus particles shed even up to two weeks

5. About Norovirus Infection Can infect persons of all ages Takes a very small amount of virus to cause infection (Patel, Hall, Vinjé, & Parashar, 2009)

7. Treatment No vaccine or drug for treatment is available, symptoms usually go away on their own Antibiotics will not work Hydration is recommended, and in some severe cases an IV may be necessary http://www.rgvfit.net/proper-hydration-tips-training- physical-events/ Source: CDC

8. Recent outbreaks March 2014: Elementary and High School in Asheville, NC o More than 160 students ill o Appeared to have spread from the Elementary to the High School February 2015: Longwood University in Farmville, VA o Three dozen confirmed cases o Thought to have spread from Hampden-Sydney College where there were about 300 cases

9. How common is Norovirus? About 1 in 15 Americans will get it each year 5.5 million food related cases in the US each year Second leading cause of food related hospitalizations (Scallan et al., 2011; CDC, 2013)

10. Transmission of Norovirus Can spread easily from person to person o Fecal- oral route Contaminated water or food o Contamination originates from human source (Anderson et al., 2001; Maunula et al., 2005; Shieh et al., 2003)

11. Transmission of Norovirus Touching infected surfaces o Can survive on surfaces for up to 2 weeks and in water for up to 2 months From aerosolized particles http://www.cidd.psu.edu/research/synopses/social-contact-network-disease-transmission (Lopman et al., 2004)

12. Norovirus on Surfaces Norovirus is extremely hardy and can survive on surfaces for up to 2 weeks Surface disinfection is crucial https://followtheoutbreak.files.wordpress.com/2014/09/door- knob.jpg?w=2560&h=1200&crop=1 http://onmilwaukee.com/images/articles/sc/schoolcafeteria/schoolcafeteria _story1.jpg (Lopman et al., 2004)

13. Relevance of Norovirus in School Settings Highly infectious Common food lines and eating areas can lead to increased transmission Lives on surfaces for long periods of time (Lee & Greig, 2010)

14. Prevention Strategies Exclusion of sick food handlers o People may be infectious even if they don’t show symptoms o If an employee is showing symptoms, they are infectious and can remain infectious for up to 72 hours after symptoms subside It is important that employees who have been sick are excluded from food preparation while they are ill and 72 hours after getting better (Barrabeig et al., 2010)

15. Food Handling Precautions If you’re sick- do not prepare food! If you think food has come in contact with norovoris- throw it out!

16. Cleaning To Prevent Norovirus Proper hand washing is crucial Hand sanitizer does not work On surfaces, only a bleach solution will work o Products like Lysol or Clorox wipes are not effective o Other sanitizer, like quaternary ammonium compounds, are not recommended either http://www.naturescornernaturalmarket.com/wp-content/uploads/2013/07/hand-sanitizer.jpg (Hall et al., 2011; Liu, Yuen, Hsiao, Jaykus, & Moe, 2010)

17. Cleaning To Prevent Norovirus Use appropriate personal protection o Disposable mask o Disposable gloves If there is a vomit incident, it must be properly cleaned first o Use of absorbent powder (Hall et al., 2011)

18. Preparing a Bleach Solution Need to prepare a fresh bleach solution o No more than 24 hours old Need between a 1:10 and 1:50 dilution o Correct concentration is critical o Because of the way bleach is formulated if there is too little or too much it will not work (Hall et al., 2011)

19. Cleaning to Prevent Norovirus Bleach needs to have appropriate contact time with surface to disinfect properly o Current recommendation is about 4 minutes Radius o When a vomiting incident occurs, particles can spread between 3 and 15 feet around the original site o Important to clean around the area (Tung, 2013)

20. Summary Only takes 1-10 virus particles to cause illness Billions in each poop or vomit event Shedding lasts for 10+ days

22. Dr. Ben Chapman benjamin_chapman@ncsu.edu Follow me on twitter @benjaminchapman 919 809 3205 foodsafetyinfosheets.org foodsafetytalk.com barfblog.com