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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? 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. 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: 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 Page 2/8 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. Page 3/8 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: 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 60C 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. Page 4/8 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 60C or above, using a powder or tablet detergent containing active oxygen bleach (see ingredients on back of pack). - alternatively wash at 40C with a powder or tablet detergent containing active oxygen bleach (see ingredients on back of pack) Note: washing at 40C 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. Page 5/8 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. Page 6/8 IFH Guidelines and Training Resources on Homes Hygiene 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.. Page 7/8 5 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 Page 8/8