<Re-posted>

Healthcare Facility-associated Infections

By Lillian Burns, MT, MPH, CIC

Norovirus, commonly called the “stomach flu,” is a highly contagious viral infection that can affect anyone. The norovirus infection causes inflammation of the stomach and intestines, inducing common symptoms such as diarrhea, vomiting and stomach pains. Symptoms can last from one to three days and there is no treatment or vaccine for this unpleasant infection. Healthcare and long-term care facilities are the most commonly reported settings for norovirus outbreaks.

Controlling and preventing norovirus outbreaks is a constant focus among healthcare facilities during the winter months. While norovirus outbreaks occur throughout the year, more than 80 percent of them occur from November to April. When people are indoors and in close proximity for long periods of time, there is a greater risk of spreading this very contagious virus because it can quickly spread after one person is infected.  According to the U.S. Centers for Disease Control and Prevention (CDC), in the United States norovirus is the cause of more than 23 million cases of acute gastroenteritis each year.(1)

Preventing Norovirus Outbreaks

Since there is no treatment available for norovirus, implementing prevention strategies is the best approach a facility can take. These steps include: providing education on prevention, maintaining thorough cleaning and disinfecting procedures and isolating patients suspected of being infected with norovirus.

Infection Prevention Education

Education is an important part of any prevention strategy. The emphasis for infection prevention education should first and foremost be placed on the healthcare workers and staff who provide care to the patient on a daily basis. Staff should be instructed in necessary precautions such as wearing the appropriate attire of gowns and gloves when providing patient care. Frequent hand hygiene is also stressed, as well as limiting contact with potentially contaminated surfaces in the patient’s room.

In addition to educating the staff, patients and visitors should also be instructed on prevention measures. Since norovirus is spread quickly and easily through contact, it’s important that visitors understand the risks and do not inadvertently contribute to an outbreak. Touching contaminated surfaces and then subsequently touching the mouth, eating contaminated foods or having direct contact with an infected person can spread the virus.

Visitations should be limited during an outbreak and visitors should be encouraged to wash their hands frequently or use alcohol-based hand sanitizers. As an added precaution, visitors should also wear gowns and gloves when visiting a patient with norovirus. Facilities can also make use of educational tools to spread the prevention message. The CDC publishes factsheets, guidelines and handouts which can be helpful education and training tools. These resources are reliable and can be used to develop materials to distribute to visitors and patients.

Cleaning and Disinfecting

Implementing a proper disinfecting protocol is a critical part of preventing the spread and elimination of norovirus. Frequent cleaning and disinfecting is necessary to curtail outbreaks of norovirus, which can be difficult to control.

When patients become infected and begin to vomit, the norovirus particles can be transmitted through the air and can land on many surfaces. This creates difficulties because so many items can become contaminated with norovirus—everything from laundry and patient care equipment to doorknobs; and other high touch items. All patient care equipment and medical devices should be disinfected as appropriate with a bleach solution or a product that contains bleach such as Clorox® Germicidal Wipes. The label of any disinfecting product should be read to confirm that the product is registered to kill norovirus.

All hard, non-porous surfaces should be thoroughly cleaned and then disinfected with a bleach solution. The CDC Guidelines recommend using a 1:10 bleach solution to disinfect healthcare facilities where patients with norovirus are cared for.(2) The New York State Department of Health’s Advisory: Prevention and Control of Nosocomial Gastrointestinal Illness Outbreaks recommends disinfecting hard, non-porous environmental surfaces with a bleach and water solution.(3)

Careful handling of laundry should also be considered when caring for someone with norovirus. A gown and gloves should always be worn by the healthcare worker when handling contaminated laundry. Contaminated laundry should be placed in an impervious bag until it can be washed.(4) It is important to disinfect contaminated items such as sheets, towels and bedding as well as the washing machines and laundry room to prevent cross-contamination of clean laundry. Washing machines should be disinfected with a three-quarter cup bleach (depending on washer size) and hot water or as the product label instructions dictate.(5)

Placing patients on isolation is also an important step in preventing transmission to others. However if stringent cleaning and disinfecting measures are not carried out appropriately, isolation will not be as effective in containing the spread of norovirus. Touching frequently used items such as a contaminated computer keyboard, bedrail or IV pump could be instrumental in transferring the virus to other patients.

Challenges Facilities Face

Trying to contain an outbreak can be very difficult, because not only must healthcare facilities have the cooperation from the staff on prevention measures but also from the patients and visitors.

Getting the cooperation from the patients and visitors may be difficult because they will often forget to wash their hands. With pediatric units, the challenge is often trying to limit visitors. Parents naturally want to spend time with their children, but do not always fully understand how easily they could contract the virus and spread it to others. Education is a critical step in any norovirus prevention plan.

Getting consistent staff compliance with prevention measures is a challenge for healthcare facilities. Placing reminders such as posters and educational materials on the nursing units can help with compliance. Hand hygiene is the single most effective way of preventing the spread of norovirus and should be encouraged among healthcare workers, patients and visitors. Hands should be washed with soap and water or an alcohol-based sanitizer. The use of personal protective attire such as gown and gloves is also a necessity when caring for patients.

Norovirus outbreaks may also affect institutions operationally. Admission restrictions to the affected unit, staff shortages due to illness and visitor restrictions all may interfere with the daily operations of the healthcare organization.  Adherence to prevention measures, frequent disinfection of surfaces and continued education of patients, visitors and staff will greatly help in controlling outbreaks of this highly contagious and very unpleasant virus.

References

(1) http://www.cdc.gov/ncidod/dvrd/revb/gastro/norovirus-factsheet.htm

(2) http://www.cdc.gov/ncidod/dvrd/revb/gastro/downloads/noro-hc-facilities-fs-508.pdf

(3) http://www.health.state.ny.us/professionals/diseases/reporting/communicable/infection/docs/2006-12-22_gi_advisory.pdf

(4) http://www.cdc.gov/hicpac/pdf/guidelines/eic_in_HCF_03.pdf

(5) http://www.clorox.com/products/clorox-regular-bleach/how-to/

Lillian Burns, MT, MPH, CIC, is an infection control practitioner and a consultant to healthcare organizations and Administrative Director of Infection Control and Epidemiology at Staten Island University Hospital. She has experience in implementing norovirus prevention plans that combine education, isolation and disinfecting protocols.