Strategies For Norovirus Infection Control
Strategies forNorovirus Infection ControlRobert E. Wheeler, MD, FACEPVoyager Medical Seminars 2004 Robert E. Wheeler, MD / Voyager Medical Seminars1
Viruses!!!Ultra-microscopic obligate IC parasitesRelatively simple in structure and compositionWith or without a lipoprotein envelopeNucleic acid genome(DNA or RNA)Lipid-protein envelope 2004 Robert E. Wheeler, MD / Voyager Medical SeminarsProtein shell(capsid)20-300 nanometers diameter2
Norovirus!!!Norwalk Virus, Norwalk-like virus, NLVSRSV (Small Round Structured Virus)2002!!!!Family – CaliciviridaeGenus – NorovirusGenogroups – I, II, III, IVMultiple clusters/strains 2004 Robert E. Wheeler, MD / Voyager Medical SeminarsNorovirusElectron Micrograph3
Norovirus!!!!!!NorovirusNon-enveloped ssRNA virus3-D27-35 nm in size (SRSV)Infectious dose of 10-100 virus particlesViral shedding of 3 weeks or moreSurvives 0 C, 60 C, chlorine 10 ppmLimited (few months) immunity 2004 Robert E. Wheeler, MD / Voyager Medical Seminars4
Norovirus Transmission!!!!!!!“Fecal-oral” routeMouthGut (Replication)AnusFoodHANDSWaterFOODAirESH 2OEnvironmental surfacesAIRHands 2004 Robert E. Wheeler, MD / Voyager Medical Seminars5
Norovirus Transmission!!!!!!Food (39%)Hands (12% “person to person”)Water (3%)Air (aerosolization with vomitus)Environmental surfaces (fomites)46% unknown or no data availableMMWR 2001; 50: RR-9 2004 Robert E. Wheeler, MD / Voyager Medical Seminars6
Foods Most at Risk!!Shellfish (oysters, clams, mussels)Ready to eat foods that require handling butno subsequent cooking!!!!!!!SaladsPeeled fruitsDeli-sandwichesFinger foodsHors d’oeuvresDipsCommunal foods 2004 Robert E. Wheeler, MD / Voyager Medical Seminars7
NorovirusFood Contamination!Source!!!!!!!!Shellfish from contaminated waterContaminated water used for irrigationSewerage used as fertilizerProcessingPreparationFood handlersGuestsInsects 2004 Robert E. Wheeler, MD / Voyager Medical Seminars8
NorovirusWater Contamination!!Typically via improper seweragetreatment or overflowSurface water!!!!Ponds, lakes, streams, rivers, reservoirsWell waterSwimming pool waterIce 2004 Robert E. Wheeler, MD / Voyager Medical Seminars9
Evidence for airborne transmission of Norwalk-like virus(NLV) in a hotel restaurant;PJ Marks; Epidemiol. Infect. 2000, 124: 481-48771%!91%!56%!Hotel restaurant with 126 patronsPatron ( ) vomited at table52 of 83 survey responders ill!50%40%25%!!63% overall attack rateAttack rates higher at closer tablesConsistent with airbornetransmission of NLV 2004 Robert E. Wheeler, MD / Voyager Medical Seminars10
Viral istanceTimeAir flow71%91%56%50%40%25%2468 Meters
Transmission of Norwalk Virus During a Football Game;Becker KM, Moe CL, Southwick KL, MacCormack JN;NEJM, 2000 Oct 26; 343(17):1223-7!!!!!Duke vs. FSU, September 19, 199836 Blue Devils with N/V/D on game day11 Seminoles became ill 24 hours laterwith the Blue Devils RevengeOnly association was contact on the fieldBarf Bowl final score: FSU 62, Duke 13 2004 Robert E. Wheeler, MD / Voyager Medical Seminars12
Widespread environmental contamination with NLVdetected in a prolonged hotel outbreak ofgastroenteritis; JS Cheeseborough; Epidemiol Infect2000, 125: 93-98!RT-PCR environmental surface testing !!!!!!!!!Carpets (known vomiting)Carpets (no vomiting)Toilet rims/seatsToilet handles, taps, basinsHorizontal surfaces below 1.5 mHorizontal surfaces above 1.5 mPhones, door handles, etc.Soft furnishingsTotalIt’s Everywhere! 2004 Robert E. Wheeler, MD / Voyager Medical Seminars5/8 (62%)9/12 (75%)8/11 (73%)13/39 (39%)11/29 (37%)6/12 (50%)7/29 (24%)2/10 (20%)61/144 (42%)13
Norovirus Infection!!!!!!“Stomach flu”“Lurgy”“Winter vomiting disease”24-48 hour incubation period12-60 hour duration of illnessA “mild” and short lived illness 2004 Robert E. Wheeler, MD / Voyager Medical Seminars14
Norovirus Infection Symptoms!!!!!!!!DiarrheaVomitingNauseaAbdominal crampsHeadache, muscle achesFever (minority)Dehydration in young and elderly victimsUp to 30% may be asymptomatic 2004 Robert E. Wheeler, MD / Voyager Medical Seminars15
Norovirus Detection!Reverse transcriptase polymerase chainreaction (RT-PCR) of stool, vomitus andenvironmental surfaces!!!!Sequencing for genotype and cluster IDELISA test kit (IDEIA NLV)Direct & immune EM of stool samples4-fold increase in acute and convalescentIgG serum antibodies 2004 Robert E. Wheeler, MD / Voyager Medical Seminars16
Norovirus Infection Treatment!Symptomatic therapy! PO, IV fluids! Antispasmodics! Analgesics! Antipyretics 2004 Robert E. Wheeler, MD / Voyager Medical Seminars17
2002: “Year of The Norovirus”!!!!VSP reports 23 shipboard AGE outbreaks12 determined to be due to Norovirus9 others of unknown or pending etiologyIn excess of half of the outbreaks weredefinitely due to Norovirus and severalothers were probably due to Norovirus 2004 Robert E. Wheeler, MD / Voyager Medical Seminars18
2002: “Year of The Norovirus”It really wasn’t our fault! 2004 Robert E. Wheeler, MD / Voyager Medical Seminars19
2002: “Year of The Norovirus”Similar increase in Norovirus cases Nursing homesDay care centers 2004 Robert E. Wheeler, MD / Voyager Medical Seminars!!!!!!SchoolsDormitoriesMilitary barracksTrainsBusesAircraft20
Amplification ofDisease TransmissionAMPLIFICATIONCONVERGENCE 2004 Robert E. Wheeler, MD / Voyager Medical SeminarsDIVERGENCE21
2002: “Year of The Norovirus”!!!!Accounts for 2/3 of all acute gastroenteritis(AGE) in the United StatesCauses 33% of hospitalizations and 7% ofdeaths due to AGE23-25 million cases, 8% of population in U.S.Incidence of cases aboard cruise ships in2002 was only 0.025% of total cruisepassengers 2004 Robert E. Wheeler, MD / Voyager Medical Seminars22
NorovirusCritical Characteristics!!!!!!Highly contagiousMultiple modes of transmissionStabile in the environmentResistant to routine disinfection methodsAsymptomatic infectionsLimited immunity 2004 Robert E. Wheeler, MD / Voyager Medical Seminars23
Norovirus Control 2004 Robert E. Wheeler, MD / Voyager Medical Seminars!Prevention Plan!Surveillance Plan!Response Plan24
Prevention & Surveillance!!NOROVIRUS AWARENESSShipboard Sanitation!!!!!!International maritime regulationsCruise industry guidelinesCorporate policies and proceduresMulti-departmental shipboard protocolsCDC Vessel Sanitation ProgramDisease surveillance and reporting by theshipboard medical staff 2004 Robert E. Wheeler, MD / Voyager Medical Seminars25
Shipboard Sanitation!!Cruise ships are often characterized as”floating cities”Sanitation needs and requirements areindeed similar to those of a small town 2004 Robert E. Wheeler, MD / Voyager Medical Seminars26
Shipboard Sanitation!!!!!Food, water, airLiving quarters (passenger and crew)Public areasWaste (trash, garbage, sewerage, HAZMAT)Pests (vermin, insects) 2004 Robert E. Wheeler, MD / Voyager Medical Seminars27
Shipboard SanitationDepartment Collaboration!!!!!!!!!Industry guidelines and standardsCorporate policies & proceduresShip’s CommandHotelFood & l 2004 Robert E. Wheeler, MD / Voyager Medical Seminars28
Shipboard Sanitation - Food!!!!!!HACCP ProgramReliable suppliersStrict quality controlProper food storageInventory controlFood separation 2004 Robert E. Wheeler, MD / Voyager Medical Seminars29
Shipboard Sanitation - Food!!!!Sanitary preparation and serving areasAppropriate cooking and serving tempsClean-rinse-sanitize process for cookwareand dinnerwareStrict hygiene protocols for food handlers 2004 Robert E. Wheeler, MD / Voyager Medical Seminars30
Shipboard Sanitation - Water!!Bunkering of water only from safe sourcesWater desalination!!!!!DistillationReverse osmosisFilteringHalogenationContinuous monitoring of water quality 2004 Robert E. Wheeler, MD / Voyager Medical Seminars31
Shipboard Sanitation - Air!!!!!FilteringAir exchangeTemperature controlHumidity controlDuct cleaning 2004 Robert E. Wheeler, MD / Voyager Medical Seminars32
Passenger Living Quarters!!Passenger staterooms are cleaned atleast twice dailyDisinfectants routinely used onbathroom and high hand-contact areas 2004 Robert E. Wheeler, MD / Voyager Medical Seminars33
Crew Living Quarters!!!Daily cleaningCrew sanitation regulationsWeekly inspections 2004 Robert E. Wheeler, MD / Voyager Medical Seminars34
Public Areas!!!Daily cleaningRepeat cleaning with additional useDisinfection of heavy hand-contact andsoiled/contaminated areas 2004 Robert E. Wheeler, MD / Voyager Medical Seminars35
Waste Management!!!!!Adherence to international regulationsSeparation & recyclingIncinerationBilge, waste water & sewerage treatmentOff-loading of hazardous materials 2004 Robert E. Wheeler, MD / Voyager Medical Seminars36
Pests!!!!Rare on modern cruise ships due to thestrict sanitation protocols in placeRats, mice, flies, ants, cockroaches,silverfishContinuous surveillancePesticides as needed 2004 Robert E. Wheeler, MD / Voyager Medical Seminars37
The Vessel Sanitation Program!!!!Centers for Disease Control & PreventionEstablished in 1975Minimize the risk of diarrheal outbreaksAssist the cruise industry in thedevelopment and implementation ofenvironmental health programs 2004 Robert E. Wheeler, MD / Voyager Medical Seminars38
The Vessel Sanitation Program!!Environmental Health Officers (EHO)Twice-yearly unannounced comprehensivefood safety and environmental sanitationinspections of vessels with a foreignitinerary that call on a U.S. port and carry13 or more passengers 2004 Robert E. Wheeler, MD / Voyager Medical Seminars39
The Vessel Sanitation Program!!!Ongoing surveillance of GI illnessConduction & coordination of outbreakinvestigations on affected vesselsFood safety and environmentalsanitation training seminars for vesseland shore operations managementpersonnel 2004 Robert E. Wheeler, MD / Voyager Medical Seminars40
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/vsp 2004 Robert E. Wheeler, MD / Voyager Medical Seminars41
VSP Inspections!!!!!100 point scoring systemScore of 86 is considered satisfactoryStorage, distribution and halogenation ofwater supplyStorage, preparation and service of foodPractices and personal hygiene of employees 2004 Robert E. Wheeler, MD / Voyager Medical Seminars42
VSP Inspections!!!!!Equipment maintenanceDishwashing proceduresSolid and liquid waste disposalToilet and hand-washing facilitiesPest and toxic substances control 2004 Robert E. Wheeler, MD / Voyager Medical Seminars43
VSP InspectionsReportable GI Illness!Diarrhea!!3 or more episodes of loose stools in a 24hour periodorVomiting plus one additional symptom!One or more episodes of loose stools in a 24hour period, or abdominal cramps, orheadache, or muscle aches, or fever 2004 Robert E. Wheeler, MD / Voyager Medical Seminars44
VSP InspectionsDisease Surveillance & Reporting!!!!!!Gastrointestinal Illness LogAnti-diarrheal Medications LogGastrointestinal Illness Questionnaire24 hour GI Illness Report2% and 3% threshold GI Illness ReportsPassenger and crew pre-boardingquestionnaire for Norovirus symptoms 2004 Robert E. Wheeler, MD / Voyager Medical Seminars45
Norovirus Response tionInformation/Education 2004 Robert E. Wheeler, MD / Voyager Medical SeminarsNORO - COMMANDO46
Isolation!!!Confine infected crew and passengers toquarters until 3 days after cessation ofsymptoms or disembark them from the shipfor that periodConsider relocating unaffected cabin matesProvide instruction on appropriate personalhygiene, especially handwashing 2004 Robert E. Wheeler, MD / Voyager Medical Seminars47
Natural History of Human Calicivirus Infection:A Prospective Cohort StudyB Rockx; CID 2002, 35: 246-5399 people infected with NorovirusViral Shedding (via RT-PCR):! Day 178%! Day 845%! Day 15 35%! Day 22 26%! 2004 Robert E. Wheeler, MD / Voyager Medical Seminars48
Containment!!Restrict access to soiled/contaminated areasuntil cleaned and disinfectedUtilize specially trained and equipped “HitSquads” or “SWAT Teams” for vomitus ordiarrhea contamination incidents 2004 Robert E. Wheeler, MD / Voyager Medical Seminars49
NOROVIRUSSPECIAL WEAPONS AND TACTICS!!!!!!!!Covered 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 2004 Robert E. Wheeler, MD / Voyager Medical Seminars50
NOROVIRUSSPECIAL WEAPONS AND TACTICS!!!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 contaminants 2004 Robert E. Wheeler, MD / Voyager Medical Seminars51
NOROVIRUSSPECIAL WEAPONS AND TACTICS!!!Apply 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 2004 Robert E. Wheeler, MD / Voyager Medical Seminars52
NOROVIRUSSPECIAL WEAPONS AND TACTICS!!!Open the room to outside airSoiled carpets and upholstery can be steamcleaned after the chemical disinfectionAir dry rugs and furniture in the sunlight 2004 Robert E. Wheeler, MD / Voyager Medical Seminars53
Containment!!!Provide 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 2004 Robert E. Wheeler, MD / Voyager Medical Seminars54
Containment!!!Promptly bag & clean soiled linens ordispose of them as hazardous wasteAdvise against the use of public restroomsHalt inter-ship crew transfers 2004 Robert E. Wheeler, MD / Voyager Medical Seminars55
Containment!!Remove any potentially contaminatedfood, beverages and ice from serviceClose self-serve buffet lines or frequentlychange the serving utensils or change toa served buffet line 2004 Robert E. Wheeler, MD / Voyager Medical Seminars56
Disinfectants for Norovirus!!The Norovirus cannotbe grown in cultureEfficacy testing ofdisinfectants forNorovirus is done usinga surrogate virus,typically the felinecalicivirus (FCV), asimilar non-envelopedssRNA virus 2004 Robert E. Wheeler, MD / Voyager Medical SeminarsFCVDonor CardName: DIVAAge:5 yearsBreed: PersianAttitude: BAD57
DISINFECTANT LEVEL FOR VARIOUS PATHOGENSPATHOGENBacteria with sporesProtozoa with cystsMycobacteriaNon-enveloped virusesNorovirusFungiVegetative bacteriaEnveloped virusesCoronavirusDISINFECTANT LEVELChemical SterilantHighIntermediateIntermediateLowLow
Inactivation of Feline Calicivirus, a Norwalk VirusSurrogate; JC Doultree; J Hosp Infect 1999, 41:51-57!Effective disinfection agents!!!!Glutaraldehyde 0.5%Iodine 0.8%Hypochlorite 1000 ppm (freshly reconstituted)Household bleach required 5000 ppmIneffective disinfection agents!!!QUAT 1:10Ethanol 75%Anionic detergent 1% 2004 Robert E. Wheeler, MD / Voyager Medical Seminars59
Inactivation of Feline Calicivirus, a Norwalk VirusSurrogate; JC Doultree; J Hosp Infect 1999, 41:51-57!Heat inactivation of FCV!!!!56 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 2004 Robert E. Wheeler, MD / Voyager Medical Seminars60
Inactivation of Feline Calicivirus, a Norwalk VirusSurrogate; JC Doultree; J Hosp Infect 1999, 41:51-57!Surface survival of dried FCV!!!4 C, 60 days20 C (RT), 21-28 days37 C, less than 1 day 2004 Robert E. Wheeler, MD / Voyager Medical Seminars61
Efficacy of Commonly Used Disinfectants for theInactivation of Calicivirus on Strawberry, Lettuce andFood Contact Surfaces; BR Gulati; J of Food Protection2001, 64(9):1430-1434!!!Phenolic compounds at 2-4 times therecommended concentration completelyinactivated FCV on contact surfacesHypochlorite (liquid bleach) 5000 ppm wasneeded to inactivate FCVQUATS were ineffective!Effective when 2% sodium bicarbonate added 2004 Robert E. Wheeler, MD / Voyager Medical Seminars62
Disinfectants for NorovirusConsider:! Efficacy! Spectrum! Versatility! Ease of use! Safety profile! Cost 2004 Robert E. Wheeler, MD / Voyager Medical SeminarsWhat’s in your bottle?63
Disinfectants for Norovirus!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. 2004 Robert E. Wheeler, MD / Voyager Medical Seminars64
Disinfectants for Norovirus!!!!!!Accelerated Hydrogen Peroxide (AHP )Chlorine dioxide QUAT (Cryocide 20 )Hypochlorite (bleach)Parachlorometaxylenol (EcoTru )Peroxymonosulphate (Virkon )Phenols (Mikro-Bac II , Mikro-Bac 3 ) 2004 Robert E. Wheeler, MD / Voyager Medical Seminars65
AcceleratedHydrogen Peroxide AHP !!!!0.5% hydrogen peroxide solutionBroad spectrum biocideCleans and disinfectsConcentrate, wet-wipes and RTU liquid 2004 Robert E. Wheeler, MD / Voyager Medical Seminars66
AcceleratedHydrogen Peroxide !!!!!Non-toxic in RTU formEnvironmentally safe5 minute dwell time24 month shelf lifeMay leave an easily removed, non-toxicsurfactant residue on some surfaces 2004 Robert E. Wheeler, MD / Voyager Medical Seminars67
Chlorine Dioxide/QUAT!!!!!CRYOCIDE 20Stabilized ClO2 (0.75%)plus twin chain QUAT solutionClO2 is a strong oxidizing agentBroad spectrum biocideReportedly effective in several UK andEuropean hotel Norovirus outbreaksTM 2004 Robert E. Wheeler, MD / Voyager Medical Seminars68
Chlorine Dioxide/QUAT!!!Wet fog and spray/wipe disinfectionUse full strength or a 1:4 dilution12 month shelf life (dated at plant) 2004 Robert E. Wheeler, MD / Voyager Medical Seminars69
Chlorine Dioxide/QUAT!!!!!Effective as a surface disinfectant andfogging agent with a 30 minute dwell timeSafe with most fabricsNon-corrosiveMay be mildly irritating to skin & eyesAvoid mixing with acids or chlorine!Can promote toxic ClO2 gas formation 2004 Robert E. Wheeler, MD / Voyager Medical Seminars70
Hypochlorite (bleach)!!!Broad spectrum biocideInexpensive and readily availableUse freshly prepared (daily) solutionreconstituted from a dry hypochloritecompound to ensure the 1000 ppm effectiveconcentration required for Norovirus 2004 Robert E. Wheeler, MD / Voyager Medical Seminars71
Hypochlorite (bleach)!Organic debris reduces its effectiveness!!!!Cleaning of surface required prior to disinfectionUsed mainly on hard, non-porous surfacesDamaging to many textilesCorrosive to metals 2004 Robert E. Wheeler, MD / Voyager Medical Seminars72
Hypochlorite (bleach)!!!May produce toxic chlorine gas if combinedwith certain other compoundsCan be irritating to skin, eyes, mucousmembranes and lungs (fumes)The gold (“plated”) standard for Norovirusdisinfection 2004 Robert E. Wheeler, MD / Voyager Medical Seminars73
Parachlorometaxylenol (PCMX)!!!!!!!!EcoTru (EnviroSystems, Inc.)0.20% parachlorometaxylenolBroad spectrum biocideCleans and disinfectsLeaves no residueNon-stainingRTU liquid and wipes18 month shelf life 2004 Robert E. Wheeler, MD / Voyager Medical Seminars74
Parachlorometaxylenol (PCMX)!Non-toxic (EPA Tox Category IV)!!!!!!No cautionsNo oral, dermal or inhalation toxicityNo eye or skin !Approved for use on aircraft 2004 Robert E. Wheeler, MD / Voyager Medical Seminars75
Parachlorometaxylenol (PCMX)!!Nano-emulsion of charged spheresEfficacy against Norovirus!!!30 minute dwell timeSpray and air dryFogging! Cold! Electrostatic 2004 Robert E. Wheeler, MD / Voyager Medical Seminars76
Peroxymonosulphate!!!!!!!Virkon (Antec International)Broad spectrum disinfectionSix synergistic biocides 1000 ppm free chlorine in solutionPowder formNon-toxic in prepared 1% or 2% solutionBiodegradable 2004 Robert E. Wheeler, MD / Voyager Medical Seminars77
Peroxymonosulphate!!!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 solution 2004 Robert E. Wheeler, MD / Voyager Medical Seminars78
Phenols!!!!!Mikro-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) 2004 Robert E. Wheeler, MD / Voyager Medical Seminars79
Phenols!!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 systems 2004 Robert E. Wheeler, MD / Voyager Medical Seminars80
Phenols!Potential toxicity from o-phenylphenol,o-benzyl-p-chlorophenol and ethyleneglycol (anti-freeze)!!!!Skin, brain, kidneys, liver, lungso-phenylphenol is listed as a carcinogenEthylene glycol is listed as a teratogenHazardous to the aquatic environment 2004 Robert E. Wheeler, MD / Voyager Medical Seminars81
PerfectCLEAN Microfiber !!!!!!!A 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 fabric 2004 Robert E. Wheeler, MD / Voyager Medical Seminars82
Disinfectants for NorovirusTo 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 surfaces 2004 Robert E. Wheeler, MD / Voyager Medical Seminars83
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 2004 Robert E. Wheeler, MD / Voyager Medical Seminars84
Disinfection!!!!!!!!RestaurantsBars, loungesShowroomsCasinosGame roomsLibraryAll passenger and crew public areasAll passenger and crew cabins 2004 Robert E. Wheeler, MD / Voyager Medical Seminars85
Disinfection!Consider any and all heavy hand contact surfacesto be contaminated!!!!!!!!Door handles, push platesRailings, elevator buttonsTelephones, keyboardsPens, pencilsTables, countersCasino chips, cards, slot machinesSports equipmentEtc., etc., etc. 2004 Robert E. Wheeler, MD / Voyager Medical Seminars86
Disinfection!Public restrooms!!!!!! 2004 Robert E. Wheeler, MD / Voyager Medical SeminarsStall doors and latchesToilet seats and handlesFaucetsTowel dispensersFloorCabin bathrooms87
Disinfection!Indoor and outdoor facilities!!!!!Lounge chairsSwimming poolsHot tubsGymnasiumChildren’s areas 2004 Robert E. Wheeler, MD / Voyager Medical Seminars88
Disinfection!Steam cleaning!!!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 cleaning 2004 Robert E. Wheeler, MD / Voyager Medical Seminars89
Fogging!!!!Applies 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 2004 Robert E. Wheeler, MD / Voyager Medical Seminars90
Major Uses for Fogging!!Livestock pens/barnsFood processing plants!!!!Usually 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 2004 Robert E. Wheeler, MD / Voyager Medical Seminars91
Fogging!Most 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 agents 2004 Robert E. Wheeler, MD / Voyager Medical Seminars92
Fogging!Increasingly 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. 2004 Robert E. Wheeler, MD / Voyager Medical Seminars93
Fogging Aboard Ship!Should 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 2004 Robert E. Wheeler, MD / Voyager Medical Seminars94
Fogging Checklist!!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 room 2004 Robert E. Wheeler, MD / Voyager Medical Seminars95
Fogging Checklist!Fogger 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!Disinfectant will concentrate on these surfaces 2004 Robert E. Wheeler, MD / Voyager Medical Seminars96
Fogging Checklist!Active fogging period for surface disinfection!!!May 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 dispersal 2004 Robert E. Wheeler, MD / Voyager Medical Seminars97
Fogging Checklist!Active fogging period for air disinfection!!!Should be at least as long as the disinfectant’srecommended contact timeLonger periods allow for better disinfectantdispersal and extended contact timeDwell/contact time!!As required by the specific disinfectant agentFor NV disinfectants, typically 5-10 minutes 2004 Robert E. Wheeler, MD / Voyager Medical Seminars98
Fogging Checklist!Room closure!!Allows time for disinfectant particles to settle onsurfaces after active foggingMay be influenced by safety profile of disinfectant!!Higher toxicity Longer closure time45-60 minutes is recommended to ensureadequate contact time of disinfectant settled onsurfaces and the safety of workers and occupants 2004 Robert E. Wheeler, MD / Voyager Medical Seminars99
Investigation!!!!!Food 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 curves 2004 Robert E. Wheeler, MD / Voyager Medical Seminars100
Norovirus Epidemic CurveMMWR 2002, 51(49) 2004 Robert E. Wheeler, MD / Voyager Medical Seminars101
Information/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 hygiene 2004 Robert E. Wheeler, MD / Voyager Medical Seminars102
Hand Hygiene!Contaminatedhands are probablythe single mostcommon vector forthe spread ofNorovirusStay Healthy–Wash Your Hands 2004 Robert E. Wheeler, MD / Voyager Medical Seminars103
Hand Hygiene!Proper hand hygiene practiced by amajority of passengers and crew memberscould significantly decrease the incidenceand extent of Norovirus outbreaks aboardcruise shipsClean Hands are Healthy Hands 2004 Robert E. Wheeler, MD / Voyager Medical Seminars104
Handwashing and Respiratory Illness Among YoungAdults in Military TrainingMA Ryan; AJPM 2001, 21(2): 79-83!!!! 90% attack rate for URI in 1996Operation Stop Cough 1997 through 1998Ordered to wash hands 5 times/dayIncidence of URI decreased by 45% 2004 Robert E. Wheeler, MD / Voyager Medical Seminars105
Hand Hygiene!Can help to break the “recontamination cycle”CONTAMINATIONDISINFECTIONRECONTAMINATION 2004 Robert E. Wheeler, MD / Voyager Medical Seminars106
Basic Handwashing Procedure!!!!!!Wet hands with waterApply soapScrub hands together vigorouslyfor at least 15 secondsRinse with running waterDry (paper towel or blow dryer)Turn off faucet/open door with paper towel 2004 Robert E. Wheeler, MD / Voyager Medical Seminars107
Efficacy of Handwashingfor FCV/Norovirus!!!Running water 2 log10 (99%) reductionSoap & water 3 log10 (99.9%) reductionAntibacterial soaps offer no significantincreased benefit for FCV/NorovirusFRICTION & FLOW 2004 Robert E. Wheeler, MD / Voyager Medical Seminars108
HandwashingIt’s aNO B
2004 Robert E. Wheeler, MD / Voyager Medical Seminars 1 Strategies for Norovirus Infection Control Robert E. Wheeler, MD, FACEP Voyager Medical Seminars
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!
Bruksanvisning för bilstereo . Bruksanvisning for bilstereo . Instrukcja obsługi samochodowego odtwarzacza stereo . Operating Instructions for Car Stereo . 610-104 . SV . Bruksanvisning i original
guidelines to assist both healthcare institutions and communities on preventing the transmission of norovirus infections and helped develop the themes and key questions to answer through an evidencebased review. - This guideline addresses prevention and control of norovirus gastroenteritis outbreaks in healthcare setting s.
PD2005_414 Infection Control Program Quality Monitoring PD2007_036 Infection Control Policy PD2007_084 Infection Control Policy Prevention and Management of Multi-Resistant Organism PD2009_030 Infection Control Policy – Animals as Patients in Health Organisations PD2010_058 Hand Hygiene Policy. ATTACHMENTS 1. Infection Prevention and Control Policy: Procedures. Infection Prevention and .
traditional method, the MVA-BAC system allows us to quickly generate high titer recMVAs. Keywords: Bacterial artificial chromosome, Recombinant MVA, Self-excising, Norovirus Background Norovirus is highly infectious and can be serious to indi-viduals with underlying conditions, the elderly, young chil-dren and immunocompromised patients. GII.4 .
NCDHHS/DHSR/HCPEC Module 7 Infection Control and Prevention July 2021 1 NCDHHS/DHSR/HCPEC Module 7 Infection Control and Prevention July 2021 1 . 1.Define vocabulary words related to infection control 2.Describe the history of infection control 3.Discuss the importance of infection control measures, such as hand
10 tips och tricks för att lyckas med ert sap-projekt 20 SAPSANYTT 2/2015 De flesta projektledare känner säkert till Cobb’s paradox. Martin Cobb verkade som CIO för sekretariatet för Treasury Board of Canada 1995 då han ställde frågan
Using Python like a programming language We will do lots with lists. But Python is there for us to use as a programming language so, after spending a while using it as a manually operated calculator, we will start to use it as a fully-fledged programming language. As part ofd this we will look at how Python stores values and assigns names to these stored values. We will look at the three .
