08 June 2016 INFECTION CONTROL IN SCHOOLS AND OTHER CHILDCARE SETTINGS: THE IMPORTANCE OF HANDWASHING AND MANAGING GASTROINTESTINAL ILLNESSES OUTBREAKS SUCH AS NOROVIRUS AND E.COLI 0157 Mike King Senior Health Protection Practitioner

Overview Examples of outbreaks Norovirus & the Disease; how it spreads Scenario and control measures Case Study – E.coli 0157

Daily Mail: July 2004 INFECTION STRIKES DOWN SCHOOL Pupils and staff members at a primary school have been struck down with the highly infectious Norovirus, a council says...

London School outbreak One child vomited in class Next day – only two children came to school Vomit not completely cleaned up Other children used the same class Many of them also became ill

Lessons from the outbreaks: Vomiting & Diarrhoea Rapid spread in groups with close contact Hospitals, nursing homes, schools, cruise ships, prisons… Can spread from Vomit Sometimes leads to public hysteria Not always in Winter

Spread 1) Faecal-oral (2) Vomiting – aerosol dissemination (3) Contaminated environment leading to airborne/oral/mucous membrane spread (Including FOOD)

Recognition Definition of an outbreak OUTBREAK – 2 or more (epidemiologically) linked cases of a similar disease. An increase in the observed incidence of cases over the expected within a given time period. Adak GK HPA 2003 OUTBREAK - An incident in which 2 or more people, thought to have a common exposure, experience a similar illness or proven infection (at least one of them being ill) HPA If you suspect that your school is experiencing an outbreak contact SELHPU on call team on:

Why investigate outbreaks? To find out how disease is being transmitted in order to develop and implement control measures and thus prevent more people from becoming ill. THEREFORE EVIDENCE OF CAUSATION IS REQUIRED The three most important practical aspects of the management of diarrhoea and vomiting outbreaks are: 1.Exclusion 2.Enhanced cleaning of equipment and environment 3.Effective hand washing

Sources and spread Diarrhoea and vomiting/gastro- enteritis/food poisoning Bacteria (e.g Salmonella, Shigella, E coli O157) Virus (e.g. Winter vomiting disease) Parasite (less common) (e.g. Cryptosporidium) Sources: people, food, contaminated surfaces such as toilets, kitchens and animals such as pets.

Food Water & Faecal-oral Eating or drinking contaminated food or water From person to person. Germs are carried in the faeces and spread on unwashed hands to other places (e.g. taps, toilet flushes, other people, food) Via contaminated utensils, work surfaces.

CONTAINMENT MEASURES Isolate sick child Exclude affected pupils and staff members until symptom free for 48 hours Staff should not work in other schools or childcare settings during the outbreak, even if they are not symptomatic. Wear gloves and apron for contact with an affected pupil or environment Wash hands with soap and water after contact with an affected patient or environment, after removing gloves and apron. Remove exposed food such as fruit, also condiments, sauce bottles. Regular toilet inspections

HAND HYGIENE Hand washing and drying most important procedures for preventing the spread of infection. VITAL to prevent person to person transmission Encouraged – After going to the toilet, before and after eating, supervision of young children

HAND HYGIENE Easy access to liquid soap and paper towels Hot and cold running water “Mr Soapy Soap”: soap.co.uk/dispenserswww.deb- soap.co.uk/dispensers May be supplied free!

WHY? Liquid soap? Bar soap can become contaminated. Paper towels? Cloth/cotton towels should not be used as they allow re-contamination of the hands. Warm air dryers can blow bacteria back onto the hand if not maintained correctly and take longer to dry hands than paper towels!

Six stage hand washing technique

Throughout the outbreak The EHOs and HPU will: Provide help, advice and support Review the situation daily including prevention and control measures Speak to worried staff and parents and/or reinforce exclusion rule! We can provide fact sheets and educational information

Scenario It’s the Monday before half term. During lunchtime and in the main school dining hall, a child vomits at the dining table whilst having lunch. 1.What would you do immediately?

Scenario What would you do immediately? 1.Contact parents send child home 2.Risk assessment – remove child and clean child 3.Isolate area 4.Personal Protective Equipment 5.Clean and disinfect area

Scenario What could be the cause?

Scenario Food poisoning Norovirus or Winter vomiting

Scenario What infection control measures would you advise?

Scenario Exclude the child from school Until symptom free for 48 hours Practice good hand hygiene

Scenario Enhanced cleaning Increase frequency Toilet areas, handles, fomites

Scenario Later that day another pupil vomits in the library after lunch and complains of stomach cramps.

Scenario Is there anything that you would do differently from the first scenario?

Scenario Dispose of heavily contaminated books Wash and disinfect any hard surfaces Inform parents Inform SELHPU

Scenario Is there anything else that you would do?

Scenario Prepare parent letters Discuss at team meeting – including premises manager Deep clean of premises when outbreak is declared over

Prevention is better than cure Staff and pupil training Good practices Food hygiene Hygienic well maintained toilet facilities Good design Risk assessments before educational visits

What next? Premises manager training Cleaning and disinfection

Thank you

Useful information London Borough of Bexley Health Protection Agency: South East London Health Protection Unit Hands up for Max SELHPU School Health Matters Bog Standard – Better standards for pupils toilets

E coli outbreak June 2006 A case study

E coli Gut bacteria – mainly harmless VTEC (Vero cyto-toxin producing strain) O157 can cause serious disease Incubation 1-14 days (median 3-4) Spread by faecal-oral route Very infectious – only small dose required for infection Excreted for up to several weeks

E coli symptoms Bloody diarrhoea Abdominal cramps Usually no fever Up to 10% patients develop haemolytic uraemic syndrome

E coli outbreak June 2006 DAY 1 In June 2006, SELHPU were notified of 6 pupils at a primary school with GI illness including one child and one member of staff with bloody diarrhoea in hospital. By late afternoon, 28 pupils were reported as being affected – total 636 pupils and 67 staff.

E coli outbreak June 2006 DAY 2 Visit from HPU and EHO Parents notified Initial standard E. Coli questionnaire Samples obtained from affected children GPs and local A& E depts alerted

DAY 3 Samples from original 3 cases were negative to salmonella, shigella, campylocbacter and E coli O157 Questionnaires revealed 7 children with bloody diarrhoea, 12 diarrhoea and vomiting, 9 with vomiting only Dates of onset varied over 5 days No common food source Several year groups affected, one school trip Presumptive E Coli O157 identified in one case

Immediate outbreak control measures Expert advice sought (CfI) Outbreak control team convened that afternoon Actions agreed: Close school from following morning Exclude all children and staff until one negative stool sample Deep clean school Further information sought from pupils/staff via questionnaires Alert/update to local GPs, labs, A&Es, other HPUs

Week one Information, letters, questionnaires, and pots distributed to over 700 pupils/staff. Helpline set up at HPU. EHOs at school to collect pots and collect surface swabs, environmental samples and food samples Fourteen confirmed/presumptive E coli O157.

Next 8 weeks More cases identified – 43 in total positive for E coli O157 Continued investigation (epidemiological / environmental) Including at school Interviewing of dinner ladies, midday supervisors, food handlers Case control study: exploring school dinners link For school trip to Shropshire Information gathering / water sampling Stool sample collection, testing and results letters

Cont…… Follow-up of individuals with missed/repeat samples Commercial cleaning of school Press release Secondary cases in local nursery ­Closure of nursery and deep clean of premises ­EH investigation ­Screening of all children and staff School reopened week before term finished but cleaning continued over summer holidays Last individual cleared at end August

Epidemiology 43 cases (24 symptomatic, 19 asymptomatic carriers) 41 children and 2 adults One child developed haemolytic uraemic syndrome

Investigation findings Confirmed E coli O157 Phage type 21/28 same strain in school & nursery No environmental isolates of E coli O157 identified Point source outbreak with person to person spread Source not proven Strong association with school dinners in particular consumption of salad from salad bar

Thank you

Useful information London Borough of Bexley Health Protection Agency: South East London Health Protection Unit Hands up for Max SELHPU School Health Matters Bog Standard – Better standards for pupils toilets