Download Rotavirus - International Scientific Forum on Home Hygiene

Rotavirus: infection and infection prevention
through hygiene in the home
This leaflet has been put together to provide background information and advice on
what to do if there is risk of spread of rotavirus in the home (household) setting, and
in everyday life. The target audiences for this briefing material are those in healthcare
professions, the media and others who are looking for background understanding of
rotavirus infection and/or those who are responsible for providing guidance to the
public on how to prevent the spread of rotavirus in their homes.
What is rotavirus?
Six groups of rotavirus have been identified, three of which (groups A, B, and C)
infect humans. The most common and widespread rotavirus is group A rotavirus.
Rotavirus is now known to be the most important cause of diarrhoea in children
worldwide. Rotavirus infections are highly seasonal, peaking in winter months.
Though almost every child will have an infection before her/his fifth birthday, the later
in life this occurs, and the lower the dose, the milder the infection. Once someone
has had a rotavirus infection they usually become immune to the virus, therefore
infections in adults are uncommon.
Rotavirus gastroenteritis is a self-limiting, mild to severe disease characterised by
vomiting, watery diarrhoea, and mild fever. The vomiting and fever go away after a
day or two, followed by watery diarrhoea that lasts up to 9 days. Generally speaking,
children recover with little difficulty but occasionally severe dehydration results which
can require hospital treatment. It can be life-threatening in children under 2 years of
age. In older children or adults rotavirus gastroenteritis may result in mild diarrhoea.
The incubation period is 48h.
Rotaviruses are the leading cause of severe dairhoea among infants and young
children. Each year an estimated 453,000 children die from diarrhoeal disease
caused by rotavirus, most of whom live in developing countries, and another two
million are hospitalised. Rotavirus is highly contagious and resistant and, regardless
of water quality and available sanitation nearly every child in the world is at risk of
infection.
How does rotavirus get into the home?
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Rotavirus is most likely to be carried into the home by people, particularly
children, who have become infected, or are carrying and shedding it, perhaps
after recovery from an infection.
It can also enter the home in sewage-contaminated water.
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It is very rarely present in the food we buy, but food can become contaminated in
the home during handling by an infected family member.
How does rotavirus spread in the home and cause infection?
Rotavirus spreads via the common routes for stomach bugs. It enters the body to
infect the gastrointestinal tract via the mouth. It enters the mouth either by
contaminated hands (fingers) touching the mouth or handling food. Rotavirus
transmits very easily to other children in the family. The main routes of infection are:
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Person-to-person spread within the family from an infected person is probably the
most frequent means by which rotaviruses are transmitted in close communities
such as paediatric wards, nurseries, infant schools and family homes
It can be spread from person-to-person mainly via hands but also via hand
contact surfaces and other environmental surfaces
Rotavirus is shed in large numbers from an infected person in their faeces.
Faeces may contain up to one thousand billion (1012) particles per gram
Because it has a very low infectious dose (as little as 10 particles) and can
survive for a long time on surfaces around the home, good hygiene is the most
important way of preventing the spread of rotavirus
Shared toys are an important risk factor because infants often place objects in
their mouths
Infected family members may contaminate raw foods through handling, such as
salads, sandwiches and fruits
Parents of children infected with rotavirus frequently become ill.
From recent investigations, it is now recognised that a substantial proportion of the
total gastrointestinal disease burden in the community is due to person-to-person
spread within households. This is particularly so for viral infections such as rotavirus:
Further information on the occurrence, survival and transmission of rotavirus in the
home can be found in a 2013 IFH report1
Who is at risk?
Anyone can be infected by rotavirus, but children under 5 are most at risk, especially
those not breastfed and those in day care. Most adults have good immunity such that
symptoms are very mild, but the elderly can be more susceptible.
Frequency of the disease
Since 2006 2 rotavirus vaccines have become available. A vaccine has recently been
developed in India. Phase III trials have been conducted for the vaccine. In June
2009, the WHO recommended that rotavirus vaccine be included in all national
immunization programs. The Rotavirus Vaccine Program and the Accelerated
Vaccine Introduction initiative have worked to study rotavirus vaccines among
developing-country populations to assist developing countries in introducing rotavirus
vaccines into routine immunization programs.
 Rotavirus is the leading cause of gastroenteritis in children under 5 years of age
worldwide. By the age of 5, nearly every child will have had an episode of
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rotavirus gastroenteritis. Globally, it causes more than a half a million deaths each
year in children younger than 5 years of age. Most of these children live in
developing countries, and another two million are hospitalised.2,3,4,5
The incidence of rotavirus infection is similar in developing and developed
countries. However, children in developing countries die more frequently.
In reality only a small proportion of the total cases (which includes outbreaks and
sporadic (individual) infections) are reported to surveillance. An estimate of the
true GI infection rates comes from a UK study of the incidence of GI in the UK in
the community which indicates that there are up to 17 million sporadic community
cases of IID and 1 million GP consultations annually. The data suggest that up to
1 in 4 people in the UK suffer from a GI illness every year. This community-based
study, estimated that only one in 147 cases of rotavirus illness is detected by
surveillance and that, for every one reported case of rotavirus, another 43 288
cases, respectively, occur in the community.6
From a community study carried out in The Netherlands between 1996 and 1999,
it was estimated that about 1 in 3.5 people experience a bout of infectious
gastrointestinal disease each year, about 5% of which are rotavirus infections.7
In a 2007 report of infectious disease outbreaks in Germany, 90% were caused by
pathogens of the intestinal tract. Households were reported as the most frequent
settings for outbreaks associated with Salmonella, rotavirus and Campylobacter
(accounting for 38, 25 and 14% of total outbreaks respectively). It was estimated
that only 0.2% (2 of 940) rotavirus outbreaks were associated with food.8
Before rotavirus vaccine was introduced for U.S. in 2006, a 1999 US report
estimated that the annual number of reported cases of rotavirus at 3.9 million,
90% of which are non-foodborne.9 Each year in the United States in the prevaccine period, rotavirus was responsible for more than 400,000 doctor visits;
more than 200,000 emergency room visits; 55,000 to 70,000 hospitalizations; and
20 to 60 deaths in children younger than 5 years of age.
Further information on the incidence and prevalence of Salmonella food borne
infection can be found in a 2009 IFH report10
Complications of disease
Infants can experience lactose malabsorption and intolerance when infected with
rotavirus. If they are fed lactose the diarrhoea increases, thus non-lactose containing
formula milk should be given. Some children with rotavirus infections have respiratory
tract problems (cough, runny nose). Without fluid and electrolyte replacement
rotavirus infection may result in severe diarrhoea and death. Association with other
enteric pathogens may play a role in the severity of the disease. It has been
estimated that approximately 18,000 children are hospitalised annually in England
and Wales due to rotavirus-related disease.
Preventing the spread of rotavirus infection in the home
In situations where there is risk of spread of infection in the home the following
hygiene measures should be rigorously implemented. It must be remembered that
rotavirus can be spread by people who have no symptoms – both those who have
apparently recovered and those who have not yet developed symptoms. The
following hygiene measures also apply to preventing the spread of infection in the
workplace and schools.
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Since the risk of family members introducing rotavirus into the home is constant and
may not be recognised until an outbreak of infection occurs within the family, this
means that good day-to- day hygiene including good food hygiene makes sense.
General hygiene
To prevent transmission of infection from an infected family member (or a family
member who may have been exposed to infection outside the home) to other family
members, or to food:
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Good handwashing practice is the single most important infection control
measure. Hands should be thoroughly washed with soap and running water*. If
access to soap and running water is a problem, use an alcohol hand rub or hand
sanitiser. Hand washing is preferred because some strains of rotavirus may be
relatively less susceptible to alcohol. In “high risk” situations where there is an
outbreak of rotavirus in the home, it is suggested that handwashing followed by
use of an alcohol rub/sanitiser should be encouraged.
Hygienically clean surfaces in the bathroom and toilet, with particular attention to
washbasins, baths, toilet seats, toilet handles and showers. This can be achieved
by cleaning with a detergent cleaner followed by thorough rinsing under running
water, or when this is not possible, e.g. for toilet seats, toilet flush handles etc.,
using a disinfectant cleaner which is effective against rotavirus**. If someone has
diarrhoea, toilets should be disinfected after each use.
Keep the infected person’s immediate environment hygienically clean. The most
important surfaces are those which come into contact with the hands, e.g. door
handles, telephones, bedside tables, bed frames, computer keyboards and TV
remote controls. To make these surfaces hygienically clean use a disinfectant
cleaner or disinfectant product which is effective against rotavirus**, although, for
items such as computer keyboards which might be damaged, it is better to make
sure the family always wash their hands before using shared family computers. In
a busy household it is not always possible to keep hand contact surfaces
hygienically clean at all times. This is why it is so important to wash hands as
frequently as possible to break the chain of infection.
Cleaning cloths can easily spread rotavirus around the home. They should be
hygienically cleaned after each use, particularly after use in the immediate area of
the infected person or the bathroom and toilet used by that person. This can be
done in any of the following ways:
- wash in a washing machine at 60C using a powder or tablet detergent
containing active oxygen bleach (see ingredients on back of pack).
- clean with detergent and warm water, rinse and then immerse in disinfectant
solution which is effective against rotavirus for at least 20 minutes or as
prescribed
- clean with detergent and water then immerse in boiling water for 20 minutes.
Alternatively use disposable cloths.
Where floors or other surfaces become contaminated with faeces or vomit, they
should be hygienically cleaned at once:
- remove as much as possible of the excreta, from the surface using paper or a
disposable cloth, then
- apply disinfectant cleaner** which is effective against rotavirus to the surface
using a fresh cloth or paper towel to remove residual dirt – then
- apply disinfectant cleaner** to the surface a second time using a fresh cloth or
paper towel to destroy any residual contamination.
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Disposable gloves should be worn if in contact with faeces, and hands should be
washed after removing gloves.
Clothing, sheets and pillows and linens from the infected person (or carrier)
should be kept separate from the rest of the family laundry and should be
laundered in a manner which kills any rotavirus. Either:
- for preference, wash at 60C or above, using a powder or tablet detergent
containing active oxygen bleach (see ingredients on back of pack).
- alternatively wash at 40C with a powder or tablet detergent containing
active oxygen bleach (see ingredients on back of pack)
Note: washing at 40C without the presence of bleach will not destroy rotavirus.
Do not share towels, facecloths, toothbrushes and other personal hygiene items
with the infected or carrier person
Where young children are ill, or at particular risk:
- their handwashing, personal and toilet hygiene may need supervision
- nappies should be disposed of safely, or cleaned, disinfected and washed.
Contrary to popular perception, the faeces of babies can be highly infectious.
Where possible, infected people should stay in their own room and use their own
facilities, cutlery, crockery etc. Infected people should particularly avoid contact
with those who may be more vulnerable to infection, and their personal items
Food and Kitchen hygiene
Where there is an infected person in the home, food hygiene is important in
preventing the spread of rotavirus. Food hygiene practices should focus on
preventing contamination of food, particularly ready-to-eat foods such as sandwiches
and salads.
 Infected people should try to stay away from the kitchen and should not prepare
food for others.
 Wash hands after handling food which may be contaminated and disinfect using
an alcohol handrub or sanitiser.
 Wash hands before handling ready to eat foods and disinfect using an alcohol
handrub or sanitiser.
 Hygienically clean all food contact surfaces, utensils and cloths after handling and
preparation of raw foods using a disinfectant cleaner which is effective against
rotavirus**. Hygienically clean all contact surfaces, utensils and cloths before
handling and/or preparing ready to eat foods.
*How to wash hands
Handwashing “technique” is very important. Rubbing with soap and water lifts the
germs off the hands, but rinsing under running water is also vital, because it is this
process which actually removes the germs from the hands. The accepted procedure
for handwashing is:
 Ensure a supply of liquid soap, warm running water, clean hand towel/disposable
paper towels and a foot-operated pedal bin
 Always wash hands under warm running water
 Apply soap
 Rub hands together for 15–30 seconds, paying particular attention to fingertips,
thumbs and between the fingers
 Rinse well and dry thoroughly.
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In situations where soap and running water is not available an alcohol- based hand
rub or hand sanitiser should be used to achieve hand hygiene:
 Apply product to the palm of one hand
 Rub hands together
 Rub the product over all surfaces of hands and fingers until your hands are dry.
Note: the volume needed to reduce the number of germs on hands varies by product.
In high risk situations where there is an outbreak in the home, handwashing followed
use of an alcohol rub/sanitiser should be encouraged.
Reducing any rotavirus present on hands is best accomplished by thorough
handwashing with running water and plain soap. Washing with plain soap and water
reduces the number of microbes on hands via mechanical removal of loosely
adherent microorganisms. Though 60–70% alcohol gels have been demonstrated to
have good effect against gram-positive and negative bacteria, enveloped viruses,
mycobacteria and fungi, WHO conclude that they have only moderate effect against
non-enveloped viruses, including rotavirus, adenovirus and rhinovirus. The efficacy
of alcohol hand santizers as used in the home setting is given in a 2013 review,
including data on new formulations, formulated to give enhanced efficacy against
norovirus.11
One very simple thing which people can do which can significantly reduce the risk of
disease is to avoid putting their fingers to their mouth.
**Disinfectants and disinfectant cleaners
Make sure you use a disinfectant or disinfectant/cleaner such as a bleach-based
product, which is active against rotavirus. For more details on choosing the
appropriate disinfectant, see the IFH information sheet “Cleaning and disinfection:
Chemical Disinfectants Explained”. The most usually recommended disinfectant for
rotavirus is hypochlorite bleach. Consult the manufacturers’ instructions for
information on the “spectrum of action”, and method of use (dilution, contact time
etc). For bleach (hypochlorite) products, use a solution of bleach, diluted to 0.5% w/v
or 5000ppm available chlorine. Household bleach (both thick and thin bleach) for
domestic use typically contains 4.5 to 5.0% w/v (45,000-50,000 ppm) available
chlorine. In situations where “concentrated bleach” is recommended a solution
containing not less than 4.5% w/v available chlorine should be used. Bleach/cleaner
formulations (e.g sprays) are formulated to be used “neat” (i.e. without dilution). It is
always advisable however to check the label as concentrations and directions for use
can vary from one formulation to another.
Other “facts about” sheets giving information on rotavirus
 Public
Health
England:
Rotavirus:
guidance
data
and
analysis.
https://www.gov.uk/government/collections/rotavirus-guidance-data-and-analysis
 US
Centre
for
Disease
Control
and
Prevention.
Rotavirus.
http://www.cdc.gov/rotavirus/index.html.
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IFH Guidelines and Training Resources on Homes Hygiene
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Guidelines for prevention of infection and cross infection the domestic
environment. International Scientific Forum on Home Hygiene. Available from:
http://www.ifh-homehygiene.com/best-practice-care-guideline/guidelinesprevention-infection-and-cross-infection-domestic
Guidelines for prevention of infection and cross infection the domestic
environment: focus on issues in developing countries. International Scientific
Forum
on
Home
Hygiene.
Available
from:
http://www.ifhhomehygiene.org/best-practice-care-guideline/guidelines-preventioninfection-and-cross-infection-domestic-0
Recommendations for suitable procedure for use in the domestic environment
(2001). International Scientific Forum on Home Hygiene. http://www.ifhhomehygiene.org/best-practice-care-guideline/recommendations-suitableprocedure-use-domestic-environment-2001
Home hygiene - prevention of infection at home: a training resource for carers
and their trainers. (2003) International Scientific Forum on Home Hygiene.
Available from: http://www.ifh-homehygiene.com/best-practice-training/homehygiene-%E2%80%93-prevention-infection-home-training-resource-carersand-their
Home Hygiene in Developing Countries: Prevention of Infection in the Home
and Peridomestic Setting. A training resource for teachers and community
health professionals in developing countries. International Scientific Forum on
Home Hygiene. Available from: www.ifh-homehygiene.org/best-practicetraining/home-hygiene-developing-countries-prevention-infection-home-andperi-domestic. (Also available in Russian, Urdu and Bengali)
This fact sheet was last updated in 2015
Further Information
1
Bloomfield SF. Exner M, Signorelli C, Nath KJ, Scott EA. 2012. The chain of
infection transmission in the home and everyday life settings, and the role of
hygiene in reducing the risk of infection.
http://www.ifh-homehygiene.com/best-practice-review/chain-infectiontransmission-home-and-everyday-life-settings-and-role-hygiene
2
Dennehy PH (2000). "Transmission of rotavirus and other enteric pathogens in the
home". Pediatr. Infect. Dis. J. 19 (10 Suppl): S103–5. doi:10.1097/00006454200010001-00003.
3
Tate JE, Burton AH, Boschi-Pinto C, Steele AD, Duque J, Parashar UD (February
2012). "2008 estimate of worldwide rotavirus-associated mortality in children
younger than 5 years before the introduction of universal rotavirus vaccination
programmes: a systematic review and meta-analysis". Lancet Infect Dis 12 (2):
136–141. doi:10.1016/S1473-3099(11)70253-5.
4
Simpson E, Wittet S, Bonilla J, Gamazina K, Cooley L, Winkler JL (2007). "Use of
formative research in developing a knowledge translation approach to rotavirus
vaccine introduction in developing countries". BMC Public Health 7: 281.
doi:10.1186/1471-2458-7-281..
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Patel MM, Steele D, Gentsch JR, Wecker J, Glass RI, Parashar UD (January
2011). "Real-world impact of rotavirus vaccination". Pediatr. Infect. Dis. J. 30 (1
Suppl): S1–5. doi:10.1097/INF.0b013e3181fefa1f.
6
The Longitudinal study of infectious intestinal disease in the UK (IID2 study):
incidence in the community and presenting to general practice Tam CC,
Rodrigues LC, Viviani L, et al. Gut (2011). doi:10.1136/gut.2011.238386.
7
de Wit MA, Koopmans MP, Kortbeek LM, van Leeuwen NJ, Bartelds AI, van
Duynhoven YT. Gastroenteritis in sentinel general practices in The Netherlands.
Emerging Infectious Diseases 2001;7:82-91.
8
Krause G, Altmann D, Faensen D, et al. SurvNet electronic surveillance system
for infectious disease outbreaks, Germany. Emerging Infectious Diseases 2007;
13:1548-55.
9
Mead PS, Slutsker L, Dietz V, McCaig LF, Bresee JS, Shapiro C, et al. Foodrelated illness and death in the United States. Emerg Infect Dis 1999;5:607-25.
10
Bloomfield SF, Exner M, Fara GM, Nath KJ, Scott, EA; Van der Voorden C. The
global burden of hygiene-related diseases in relation to the home and community.
(2009) International Scientific Forum on Home Hygiene.
http://www.ifh-homehygiene.org/review/global-burden-hygiene-related-diseasesrelation-home-and-community.
11
Bloomfield SF, Scott EA A risk assessment approach to use of antimicrobials in
the home to prevent spread of infection American Journal of Infection Control
2013; 41: (5, Suppl) A1-A10, In Disinfection, Sterilization and Antisepsis: Current
Issues, New Research and New Technologies. Edited by William A. Rutala and
David J. Weber
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