April 15, 2010 Marcy McMillian Effie Boothe Norovirus Infection April 15, 2010 Marcy McMillian Effie Boothe

What is norovirus? Also known as Viral infection Norwalk-like virus Caliciviruses (family Caliciviridae) Small round structured viruses Viral infection Not improved with antibiotics Live only in human host Most common cause of gastroenteritis outbreaks www.cdc.gov/mmwr/preview/mmwrhtml/mm5822a1.htm - Vol 58, No 22;6092009-06- Gastroenteritis is an inflammation of the lining of the stomach and intestines. Norovirus is the official name; also called NLV, caliciviruses, small-round structured viruses. No vaccine; antibiotic use contraindicated. Suspected cause of >50% of all gastroenteritis outbreaks in nursing homes and LTCFs

Symptoms Nausea Vomiting Diarrhea Abdominal cramping Incubation 10-50 hours Duration 1-2 days Norovirus is not as commonly seen children, and in adults vomiting the most common symptom. Incubation is ~ 10-50 hrs but typically 24-48 hrs. Other symptoms may include low grade fever, chills, headache, muscle aches, and general feeling of tiredness. Onset of symptoms is sudden in most cases.

How is norovirus spread? Found in stool or vomitus Infection spreads by Consuming contaminated food or liquids Touching contaminated surfaces or objects Person-to-person contact Day care centers and nursing homes more vulnerable to both spread and effects of illness Insensible contact to orifices such as mouth should be avoided as a matter of practice. Person to person is the direct contact with another person who is affected, or sharing foods or eating utensils with someone who is ill.

Treatment No vaccine or antibiotic available Supportive care --fluids --rest Hospitalization may occur in vulnerable groups IV rehydration may be indicated Mild dehydration can be treated with non-caffeine and non-alcoholic fluids Oral rehydration fluids examples: Infalyte, Kao Lectrolyte, Naturalyte, Oralyte, and Pedialyte.

Outbreak Data

Enteric Outbreaks 2005-2010 N=255 * * Norovirus # of outbreaks year All other outbreaks # of outbreaks * * year * Preliminary data

Norovirus by Transmission Mode

Norovirus by Setting School/Daycare LTCF

Norovirus Outbreaks 2005-2010 N=112 LTCF All other outbreaks # of outbreaks * * year * Preliminary data

Median Number ill from Norovirus Outbreaks by Year LTCF Median # ill All other settings ill all noro ill LTCF noro 19 37 19=median # ill for all noro; 37 = median ill in LTCF; 4273 total ill; 1344 ill in LTCF (LTCF represents 31% of ill cases) * * year * Preliminary data

Hospitalizations by Setting 86 hospitalizations from 2005-2010

Prevention and Control

Prevention and control of norovirus Frequent handwashing Wash fruits/vegetables, steam oysters Cohort patients Disinfect using bleach-based cleaner Exclude food workers and HCWs for 48 hrs after symptoms end Handwashing after tolieting and diaper change, and before preparing or eating food. Immediately clean washables with hot water and soap Flush or discard vomitus/stool

TDOH response to norovirus Evaluation of trends CDC recommendations Laboratory capacity for identification increased 1. We know much more about the incidence and characterizations of viral gastroenteritis, as Marcy has demonstrated in her talk. 2. The Healthcare Infections Control Practice Advisory Committee is studying its draft on Guideline for prevention and Management of Norovirus Gastroenteritis Outbreaks in healthcare Settings. 3. In a few minutes Amy Woron will talk new developments in viral detection at the TDOH State Lab.

…additional TDOH responses Statewide annual review Fact sheet for long term care facilities Development of viral gastroenteritis fact sheet for Tennessee HDs 1. Education is a leading way to communicate advances in management of diseases. 2. CEDS is preparing a viral gastroenteritis fact sheet for nursing homes and long term care facilities, similar to what has been done by some other states. 3. Daniel Gholston has been instrumental in collaborating with Davidson County health care workers on the control and prevention of GE, and he will share what Nashville has done.

Conclusions Norovirus is a serious illness Illness can spread quickly in congregate settings Important to educate LTCF and other partners about prevention and control

Thank You! 615-741-7247 Effie Boothe: Effie.Boothe@tn.gov Marcy McMillian: Marcy.McMillian@tn.gov 615-741-7247