Wheeler Strategies For Norovirus - Virox-resources.yy

STRATEGIES FOR NOROVIRUS INFECTION CONTROL ABOARD CRUISE SHIPSThe Vessel Sanitation ProgramOngoing surveillance of GI illnessConduction & coordination of outbreakinvestigations on affected vesselsFood safety and environmentalsanitation training seminars for vesseland shore operations managementpersonnel!!!The Vessel Sanitation Program!!!Consultative services for reviewing plans forrenovations and new constructionConstruction inspections at the shipyardsand when the vessel makes its initial call ata U.S. portDissemination of information to the publicwww.cdc.gov/nceh/vsp4950VSP Inspections!!!!!VSP Inspections100 point scoring systemScore of 86 is considered satisfactoryStorage, distribution and halogenation ofwater supplyStorage, preparation and service of foodPractices and personal hygiene of employees!!!!!Equipment maintenanceDishwashing proceduresSolid and liquid waste disposalToilet and hand-washing facilitiesPest and toxic substances control5152VSP InspectionsReportable GI Illness!Diarrhea!!VSP InspectionsDisease Surveillance & Reporting!3 or more episodes of loose stools in a 24hour period!!orVomiting plus one additional symptom!!!One or more episodes of loose stools in a 24hour period, or abdominal cramps, orheadache, or muscle aches, or fever!Gastrointestinal Illness LogAnti-diarrheal Medications LogGastrointestinal Illness Questionnaire24 hour GI Illness Report2% and 3% threshold GI Illness ReportsPassenger and crew pre-boardingquestionnaire for Norovirus symptoms53ROBERT E. WHEELER, MD, FACEPVOYAGER MEDICAL SEMINARS54

STRATEGIES FOR NOROVIRUS INFECTION CONTROL ABOARD CRUISE SHIPSVSP 1986-1993!!!!!!!!7,626 passengers601 crew!!Bacterial - 39%NLV - 29%Unknown - 32%JAMA 1996-Vol. 275, No. 71.4 outbreaks/1000 cruises2.3 outbreaks/10 million passenger-days!13,442 cruises of 3-15 days duration31 outbreaks!VSP 1986-1993JAMA 1996-Vol. 275, No. 7!1975-1979, 8.1 outbreaks/10 million p-days1980-1985, 3.0 outbreaks/10 million p-days 60% decrease in AGE outbreaks 1975-1985 23% decrease 1985-19936 outbreak-related illnesses/100,000 p-daysHypothetical 1045 passenger 7 day cruise –0.2% probability of an outbreak!!55VSP 1990-2000!!56VSP 1990-2000AJPM Dec 2002Mean inspection scores increased from89 in 1990 to 93 in 2000Baseline passenger diarrhea!!!!Diarrheal disease outbreak related illness!!23.6/100,000 passenger days or 2/cruise29.2 in 1990, 16.3 in 2000Ships that received a satisfactory VSP inspectionscore had lower incidence of diarrheal illness,21.7 vs. 30.1/100,000 passenger-days!1990-1995, 4.2/100,000 passenger days1996-2000, 3.5/100,000 passenger daysA 40% improvement between 1986-1993and 1996-2000 in addition to the morethan 60% decrease in AGE outbreaksfrom 1975-1979 to 1980-19855758Norovirus Response Plan!!!!!AJPM Dec 2002IsolationNORO - ionInformation/Education!!!Confine infected crew and passengers toquarters up to 3 days after cessation ofsymptoms or disembark them from the shipfor that periodConsider relocating unaffected cabin matesProvide instruction on appropriate personalhygiene, especially handwashing59ROBERT E. WHEELER, MD, FACEPVOYAGER MEDICAL SEMINARS60

STRATEGIES FOR NOROVIRUS INFECTION CONTROL ABOARD CRUISE SHIPSNatural History of Human Calicivirus Infection:A Prospective Cohort StudyB Rockx; CID 2002, 35: 246-53Containment99 people infected with NorovirusViral Shedding (via RT-PCR):78%! Day 145%! Day 8! Day 15 35%! Day 22 26%!!!Restrict access to soiled/contaminated areasuntil cleaned and disinfectedUtilize specially trained and equipped “HitSquads” or “SWAT Teams” for vomitus ordiarrhea contamination incidents6162NOROVIRUSSPECIAL WEAPONS AND TACTICS!!!!!!!!NOROVIRUSSPECIAL WEAPONS AND TACTICSCovered 2½-5 gallon SWAT BUCKETGloves, mask, gown, safety glassesDisinfectant in 1 liter/quart spray bottleAbsorbent powder or gelScraper, dust panPaper towels / disposable ragsAlcohol-based hand sanitizerRED plastic biohazard bags!!!Cordon off the contaminated areaSpray disinfectant directly onto grosscontaminants (vomitus or stool) and/orcover the area with disinfectant soakedpaper towels or rags for the appropriatecontact/dwell time (5-10 minutes)Clean surface of gross contaminants6364NOROVIRUSSPECIAL WEAPONS AND TACTICS!!!NOROVIRUSSPECIAL WEAPONS AND TACTICSApply disinfectant to the soiled surface fora 5-10 minute dwell time or let air dryDispose of vomitus/stool, contaminatedrags, paper towels, gloves, gown, mask,etc. in a RED plastic biohazard bagClean hands with soap & water and/or analcohol-based hand sanitizer!!!Open the room to outside airSoiled carpets and upholstery can be steamcleaned after the chemical disinfectionAir dry rugs and furniture in the sunlight65ROBERT E. WHEELER, MD, FACEPVOYAGER MEDICAL SEMINARS66

STRATEGIES FOR NOROVIRUS INFECTION CONTROL ABOARD CRUISE SHIPSContainment!!!ContainmentProvide medical evaluation for those withactive vomiting or diarrhea in an area of theinfirmary away from non-afflicted patientsor in their cabinsAdhere to universal precaution protocols(gloves, gown, mask) when providingmedical care to acutely ill patientsWaive charges for medical services!!!Promptly bag & clean soiled linens ordispose of them as hazardous wasteAdvise against the use of public restroomsHalt inter-ship crew transfers6768Containment!!Disinfectants for Norovirus!Remove any potentially contaminatedfood, beverages and ice from serviceClose self-serve buffet lines or frequentlychange the serving utensils or change toa served buffet line!Norovirus is difficult toreplicate in cell cultureEfficacy testing ofdisinfectants forNorovirus is done usinga surrogate virus,typically the felinecalicivirus (FCV), asimilar non-envelopedssRNA virusFCVDonor CardName: DIVAAge:6 yearsBreed: PersianAttitude: BAD6970DISINFECTANT LEVEL FOR VARIOUS PATHOGENSPATHOGENBacteria with sporesProtozoa with cystsMycobacteriaNon-enveloped virusesNorovirusFungiVegetative bacteriaEnveloped virusesCoronavirusInactivation of Feline Calicivirus, a Norwalk VirusSurrogate; JC Doultree; J Hosp Infect 1999, 41:51-57DISINFECTANT LEVELChemical Sterilant!Effective disinfection aldehyde 0.5%Iodine 0.8%Hypochlorite 1000 ppm (freshly reconstituted)Household bleach required 5000 ppmIneffective disinfection agents!!!QUAT 1:10Ethanol 75%Anionic detergent 1%72ROBERT E. WHEELER, MD, FACEPVOYAGER MEDICAL SEMINARS

STRATEGIES FOR NOROVIRUS INFECTION CONTROL ABOARD CRUISE SHIPSInactivation of Feline Calicivirus, a Norwalk VirusSurrogate; JC Doultree; J Hosp Infect 1999, 41:51-57!Heat inactivation of FCV!!!!!!!Inactivation of Feline Calicivirus, a Norwalk VirusSurrogate; JC Doultree; J Hosp Infect 1999, 41:51-5756 C for 60 minutes, complete inactivation70 C for 3 minutes, 6.5 log10 reduction70 C for 5 minutes, complete inactivation100 C for 1 minute, complete inactivation!!!!4 C, 60 days20 C (RT), 21-28 days37 C, less than 1 day7374Efficacy of Commonly Used Disinfectants for theInactivation of Calicivirus on Strawberry, Lettuce andFood Contact Surfaces; BR Gulati; J of Food Protection2001, 64(9):1430-1434Efficacy of Commonly Used Disinfectants for theInactivation of Calicivirus on Strawberry, Lettuce andFood Contact Surfaces; BR Gulati; J of Food Protection2001, 64(9):1430-1434Phenolic compounds at 2-4 times therecommended concentration completelyinactivated FCV on contact surfacesHypochlorite (liquid bleach) 5000 ppm wasneeded to inactivate FCVQUATS were ineffective!Surface survival of dried FCV!Effective sanitizers on FCV contaminatedstrawberries and lettuce!!!15% peroxyacetic acid 11% hydrogenperoxide at 4X normal concentrationHypochlorite (liquid bleach) at 5000 ppmWater alone produced a 2 log10 reductionEffective when 2% sodium bicarbonate added7576Disinfectants for NorovirusConsider:! Efficacy! Spectrum! Versatility! Ease of use! Safety profile! CostDisinfectants for Norovirus!What’s in your bottle?When selecting a disinfectant, it’s importantto consider the product’s entire formulationsince there may be significant disinfectantaction synergism produced by the specificcombination of ingredients.77ROBERT E. WHEELER, MD, FACEPVOYAGER MEDICAL SEMINARS78

STRATEGIES FOR NOROVIRUS INFECTION CONTROL ABOARD CRUISE SHIPSAcceleratedHydrogen Peroxide Disinfectants for Norovirus!!!!!!Accelerated Hydrogen Peroxide (AHP )Chlorine dioxide (Selectrocide )Hypochlorite (bleach)Peroxymonosulphate (Virkon )Phenols (Mikro-Bac II , Mikro-Bac 3 )Super-oxidized water (Sterilox )AHP !!!!0.5% hydrogen peroxide solutionBroad spectrum biocideCleans and disinfectsConcentrate, wet-wipes and RTU liquid7980AcceleratedHydrogen Peroxide !!!!!Chlorine dioxideNon-toxic in RTU formEnvironmentally safe5 minute dwell time24 month shelf lifeMay leave an easily removed, non-toxicsurfactant residue on some surfaces!!!On site ClO2 gas/solution generationBroad spectrum disinfectant100 ppm/10 minutes for FCV/NV8182Chlorine dioxide!!!!!Hypochlorite (bleach)Neutral pHLow toxicity in RTU formConcentration dependent metal corrosionMay damage textiles15 day prepared solution shelf life!!!Broad spectrum biocideInexpensive and readily availableUse freshly prepared (daily) solutionreconstituted from a dry hypochloritecompound to ensure the 1000 ppm effectiveconcentration required for Norovirus83ROBERT E. WHEELER, MD, FACEPVOYAGER MEDICAL SEMINARS84

STRATEGIES FOR NOROVIRUS INFECTION CONTROL ABOARD CRUISE SHIPSHypochlorite (bleach)!Organic debris reduces its effectiveness!!!!Hypochlorite (bleach)!Cleaning of surface required prior to disinfectionUsed mainly on hard, non-porous surfacesDamaging to many textilesCorrosive to metals!!May produce toxic chlorine gas if combinedwith certain other compoundsCan be irritating to skin, eyes, mucousmembranes and lungs (fumes)The gold (“plated”) standard for PeroxymonosulphateVirkon (Antec International)Broad spectrum disinfectionSix synergistic biocides 1000 ppm free chlorine in solutionPowder formNon-toxic in prepared 1% or 2% solutionBiodegradable!!!Proven efficacy (as a 2% solution) on carpetmaterial against FCV, a Norovirus surrogateMay leave a fine film on some surfacesAcid sensitive surfaces require rinsing!!!Granite, marbleAluminum, brass, copper3 year shelf life (powder)7 days mixed solution8788Phenols!!!!!PhenolsMikro-Bac II , Mikro-Bac 3 o-phenylphenol, o-benzyl-p-chlorophenolLiquid concentrateCleans & disinfectsDilute concentrate with water 1:128!!!Consistent with the concentration reported tobe effective for the disinfection of FCV as aNorovirus surrogate (Gulati; JFP 2001)Phenols should not be used in foodpreparation/food service areas or in areaswhere infants and young children might beexposed to the solution or its residuePhenols now have very limited use in healthcare facilitiesThese restrictions are due to the toxicity ofphenols to various organ systems89ROBERT E. WHEELER, MD, FACEPVOYAGER MEDICAL SEMINARS90

STRATEGIES FOR NOROVIRUS INFECTION CONTROL ABOARD CRUISE SHIPSPhenols!Super-oxidized waterEO (electrolyzed oxidizing) waterPotential toxicity from o-phenylphenol,o-benzyl-p-chlorophenol and ethyleneglycol (anti-freeze)!!!!HOCl "# OCl- H Skin, brain, kidneys, liver, lungso-phenylphenol is listed as a carcinogenEthylene glycol is listed as a teratogenHazardous to the aquatic environmenthypochlorous acid0hypochloritepH911492Super-oxidized water!!!!!Broad spectrum biocide300-400 ppm/2 minutes for Polio 2Low toxicity in RTU formConcentration dependent metal corrosionMay damage textilesThe Sterilox generator produces a pH neutral solution ofhypochlorous acid and other oxy-chloro compounds viaelectrolytic conversion of brine solution94PerfectCLEAN Microfiber!!!!!!!Disinfectants for NorovirusA non-chemical alternative for disinfectionFiber matrix of 8 triangular threads 90,000 microfibers per square inchCleaning wipes, towels, mopsPathogens absorbed into the fabric3-4 log10 reduction of surface FCVEssentially no transfer of FCV from fabricTo make an informed choice of disinfectants:! Request/demand company and independenttesting data from the manufacturer ordistributor that supports their efficacy claimsagainst FCV/Norovirus! Test the disinfectant for adverse effects onyour own ships’ environmental surfaces95ROBERT E. WHEELER, MD, FACEPVOYAGER MEDICAL SEMINARS96

STRATEGIES FOR NOROVIRUS INFECTION CONTROL ABOARD CRUISE SHIPSDisinfection!!Disinfection!Institute enhanced food preparation andfood service environmental surfacedisinfection proceduresApply hypochlorite (bleach) 1000 ppmand then rinse with potable water!!!!!The usual 200 ppm “no-rinse” hypochloritesolution is not effective against Norovirus!!!RestaurantsBars, loungesShowroomsCasinosGame roomsLibraryAll passenger and crew public areasAll passenger and crew cabins9798Disinfection!DisinfectionConsider any and all heavy hand contact surfacesto be contaminated!!!!!!!!!Public restrooms!Door handles, push platesRailings, elevator buttonsTelephones, keyboardsPens, pencilsTables, countersCasino chips, cards, slot machinesSports equipmentEtc., etc., etc.!!!!!Stall doors and latchesToilet seats and handlesFaucetsTowel dispensersFloorCabin bathrooms99100Disinfection!!Indoor and outdoor facilities!!!!!DisinfectionLounge chairsSwimming poolsHot tubsGymnasiumSteam cleaning!!Children’s areas!Soiled carpets and furnitureMust reach 70 C for 5 minutes at thecontaminated surface to be effective againstFCV/NorovirusConsider chemical disinfection of soiledareas prior to steam cleaning101ROBERT E. WHEELER, MD, FACEPVOYAGER MEDICAL SEMINARS102

STRATEGIES FOR NOROVIRUS INFECTION CONTROL ABOARD CRUISE SHIPSFogging!!!!Major Uses for FoggingApplies small droplets of disinfectants tothe air and environmental surfacesRapid environmental surface coverageEffective for disinfection of horizontalsurfaces and air but not vertical surfaces,under surfaces, or shadowed areasCold vs. thermal vs. electrostatic!!Livestock pens/barnsFood processing plantsUsually preceded by surface cleaning and spraydisinfectionReduces airborne microbial contamination andapplies disinfectants to surfaces15-30 minutes of active fogging45-60 minutes for fog to settle and air to clear!!!!103104Fogging!FoggingMost health authorities do not recommendthe use of fogging in healthcare facilities!!!!!Efficacy vs. spray & wipe disinfectionQuestion need for full surface disinfectionLogistics – where do we put the patients?Potential adverse reactions of already ill peopleto the fogging agentsIncreasingly used in hotels, cruiseships, trains, tour buses, airliners!Anecdotal reports indicate that foggingmay be a useful mode of disinfection forNorovirus outbreaks aboard ship as wellas in shoreside hotels.105106Fogging Aboard Ship!Fogging ChecklistShould be considered an adjunct tothorough surface cleaning and disinfection!!Allows for supplemental disinfection of knownand potentially contaminated surfacesSoft surface coverage – furniture, drapes,carpets, wall coverings!!Efficacy & spectrum of disinfectantVolume of disinfectant!!!As per manufacturer’s recommendationGeneral recommendation is 1 liter/100 m3Particle size!10-20 micron diameter is optimal, will settlein 45-60 minutes in a non-ventilated room107ROBERT E. WHEELER, MD, FACEPVOYAGER MEDICAL SEMINARS108

STRATEGIES FOR NOROVIRUS INFECTION CONTROL ABOARD CRUISE SHIPSFogging Checklist!Fogging ChecklistFogger nozzle location in room/cabin!1-2 meters above floor!!!!!!Higher location improves dispersal of disinfectantLess coverage at higher areas of roomLess coverage at areas posterior to nozzleAvoid wall and ceiling contact with nozzle plume!Active fogging period for surface disinfection!!Disinfectant will concentrate on these surfacesMay be as little as the time needed to fog therequired volume of disinfectantLonger periods allow for better disinfectantdispersal and extended contact timeHandheld foggers and fans may help to increasedisinfectant dispersal109110Fogging Checklist!Active fogging period for air disinfection!!!Fogging Checklist!Should be at least as long as the disinfectant’srecommended contact timeLonger periods allow for better disinfectantdispersal and extended contact time!!!Allows time for disinfectant particles to settle onsurfaces after active foggingMay be influenced by safety profile of disinfectant!Dwell/contact time!Room closure!As required by the specific disinfectant agentFor NV disinfectants, typically 5-10 minutesHigher toxicity Longer closure time45-60 minutes is recommended to ensureadequate contact time of disinfectant settled onsurfaces and the safety of workers and occupants111112Surface Fogging Protocol!!!!!!Surface Fogging ProtocolDisable the room’s ventilation systemSet fogger for a particle size of 10-20 micronsSet appropriate fogging rateHave an adequate volume of an effective Norovirusdisinfectant available in the fogger reservoirFog the entire volume of disinfectantIf using a handheld portable fogger, disperse fogevenly about the room!!!!!Keep the fogger nozzle 1-2 meters above the floorAvoid contact of the fogger nozzle plume with thewalls and ceiling of the roomMaintain room closure for 45-60 minutesEnable the ventilation system/open to outside airWipe off residual disinfectant from sensitive surfaces113ROBERT E. WHEELER, MD, FACEPVOYAGER MEDICAL SEMINARS114

STRATEGIES FOR NOROVIRUS INFECTION CONTROL ABOARD CRUISE SHIPSAir Surface Fogging Protocol!!!!!!Disable the room’s ventilation systemSet fogger for a particle size of 10-20 micronsSet appropriate fogging rateHave an adequate volume of an effective Norovirusdisinfectant available in the fogger reservoirActively fog the room for at least 5-10 minutesIf using a handheld portable fogger, disperse fogevenly about the roomAir Surface Fogging Protocol!!!!!Keep the fogger nozzle 1-2 meters above the floorAvoid contact of the fogger nozzle plume with thewalls and ceiling of the roomMaintain room closure for 45-60 minutesEnable the ventilation system/open to outside airWipe off residual disinfectant from sensitive surfaces115116Investigation!!!!!Norovirus Epidemic CurveFood intake history (72 hrs prior to illness)Passive and active surveillance surveysIdentification of potential index case(s)Collection of stool, vomitus and bloodsamples for testingDevelopment of epidemic curvesMMWR 2002, 51(49)117Norovirus Epidemic Curve118Information/Education!!!!!Alert passengers and crew of any outbreakTell them what Norovirus is and how it istransmittedAdvise them to seek medical evaluation forsymptoms of vomiting and/or diarrheaIf ill, strictly follow the isolation proceduresProvide instructions for proper hand hygieneMMWR 2002, 51(49)119ROBERT E. WHEELER, MD, FACEPVOYAGER MEDICAL SEMINARS120

STRATEGIES FOR NOROVIRUS INFECTION CONTROL ABOARD CRUISE SHIPSHand Hygiene!Hand HygieneContaminatedhands are probablythe single mostcommon vector forthe spread ofNorovirus!Stay Healthy–Wash Your HandsProper hand hygiene practiced by amajority of passengers and crew memberscould significantly decrease the incidenceand extent of Norovirus outbreaks aboardcruise shipsClean Hands are Healthy Hands121CDCAPICU.S. Centers for Disease Control and PreventionAssociation for Professionals in Infection Contr

ROBERT E. WHEELER, MD, FACEP VOYAGER MEDICAL SEMINARS 1 Strategies for Norovirus Infection Control Aboard Cruise Ships Robert E. Wheeler, MD, FACEP Voyager Medical Seminars 2 Today’s Topics! Cruise Ships as Destination Resorts! The Norovirus! Cruise Ship Norovirus Outbreaks! Shipboard Sanitation and the VSP! Disinfectants for Norovirus!