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Gastroenteritis Outbreaks in Long-term Care Facilities and Hospitals

Investigative Guidelines

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Outbreak Reporting

In Oregon, norovirus is not a reportable disease.  Although single cases of non-reportable disease are not reportable, Oregon Administrative Rule 333-018 requires all outbreaks to be reported and investigated by the Local Health Department (LHD) (see OAR 333-018.0000 and OAR 333-018-0015).  An outbreak is defined as two or more cases with symptoms clustered in time and space.  Therefore, if there are two or more persons showing symptoms of norovirus or other acute gastroenteritis in a LTCF within a short period of time, it must be reported to the LHD within 24 hours.

 


Data Collection and Basic Descriptive Epidemiology

  • Ask that the Gastroenteritis Case Log be completed on the first 10 or more cases  for whom demographics, time of onset, and symptom profile can be obtained. Use this information to determine the likely cause of the outbreak and to assess the likelihood of point-source transmission (for example, a shared meal).
  • If the symptom profile is consistent with norovirus (vomiting and diarrhea with minimal fever and no blood in stool) and the epi curve is not consistent with a point-source transmission, record any new cases in the Gastroenteritis Case Log with the case’s name and date of illness onset. Monitor daily until no more cases occur. If the outbreak is not noro-like or suggests point-source transmission, please call the Epi On-Call at 971-673-1111.
  • Coordinate with the facility  to have at least 3 stools or vomit specimens tested at the Oregon State Public Health Laboratory (OSPHL). The laboratory will NOT test just one specimen from an outbreak. Instructional information for stool collection kits.
  • Enter case log data in the ACDP GI Case Log Database available via Citrix through the “Directory of Useful Databases for Epidemiologists” (DUDE). For a CDC project attempting near-real time reporting of norovirus-like outbreaks, case log data from the early days of the outbreak should be entered no later than five days after the outbreak is reported to ACDP.
  • Use the tools included in the database to get basic descriptive epidemiology, including an epidemic curve (i.e., cases by onset time) as soon as new data are entered.
  • Monitor the outbreak until the last case has been symptom-free for 48 hours (this is when the outbreak is considered “over”).
  • Complete a Control Measures Report and enter the report in the ACDP Control Measures Report Database available via DUDE.
  • Within 30 days of the onset date of the last case, enter summary reports of the outbreak investigation in the ACDP Outbreak Database available via DUDE.

Suggested Control Measures

  • Handwashing:  Encourage frequent hand washing among staff, food handlers, and residents in the facility.  Staff members should use proper Person Protective Equipment (PPE) to protect themselves from illness and to prevent further person-to-person transmission.  The use of gloves, masks, and gowns should be highly encouraged for staff members working with ill patients and cleaning bodily fluids.  Sick staff members should not be allowed to work until they are asymptomatic for 48 hours.
  • Exclusion and Isolation: Inform and limit the facility’s visitors of the suspect illness to protect the facility residents and the visiting family members.  Stop all transfers within and out of the facility; or provide a descriptive symptom profile to the receiving facility prior to any transfer.  Do not accept new admissions into the infected facility until the outbreak is declared over by the LHD.  Post notices on the entrance of the facility warning them of the outbreak and its highly communicable nature. Stop group activities until the outbreak has been declared over.  Communal meals and social and recreational groups should be stopped to prevent further person-to-person transmission.
  • Environmental Disinfection:  If the facility does not have an Environmental Protection Agency-registered commercial virucide, use bleach.  The CDC recommends the use of a chlorine bleach solution with a concentration of 1000–5000 ppm (5–25 tablespoons of household bleach (5.25%) per gallon of water) on all surfaces (refer to Clean-up and Disinfection for Norovirus recommendations.). Leave the surface wet for ≥5 minutes or follow the directions on the commercial cleaner to allow sufficient time for the bleach to kill the entire virus.  Clean frequently used surfaces as well:
    • chair handles and backs,
    • door handles,
    • counters,
    • hand railings,
    • bed linens,
    • frequently used items (toothbrushes, combs, remote controls, etc.)

For more information, see norovirus outbreak management and disease prevention guidelines (MMWR article, March 4, 2011 / 60(RR03);1-15)


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