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The 2007 Norovirus Season Food Safety Partnership October 15, 2008 April Bogard, MPH, RS Minnesota Department of Health [email protected] 651.201.5076 Characteristics of Norovirus • Highly infectious • No long-term immunity • Low infectious dose (10 – 100 viral particles) • All ages at risk of infection • Asymptomatic infection occurs in ~30% of people • More frequent in winter months • Cannot culture the virus Potential Transmission Level of NoV • NoV is shed in the feces at levels up to 10,000,000 viral particles per gram • One projectile vomiting incident can include up to 30,000,000 viral particles • Reminder: Infectious dose of NoV is estimated to be 10 – 100 viral particles Duration of Symptoms and Shedding of Norovirus • Community-based cohort study of 99 cases in the Netherlands – all age groups represented • Median duration of symptoms: 5 days • Shedding (virus detected in stool) – Day 1: – Day 8: – Day 15: – Day 22: 78% 45% 35% 26% Rockx, et al 2002 Transfer of NoV from Contaminated Fingers • NoV can transfer from contaminated fingers, sequentially to 7 different environmental surfaces. • Secondary transfer of NoV (from contaminated surfaces → clean fingers → other surfaces): can transfer sequentially to 4 different surfaces. • Detergent cleaning, followed by rinsing was not effective in cleaning contaminated surfaces (unless followed by a disinfectant). Norovirus Outbreak Example 1: Minnesota Bakery Norovirus Infections Associated with Frosted Bakery Products, 1982 • Ill foodworker prepared 76 L of buttercream frosting for use on ~10,000 products • Frosting maker during 6-hour shift: – 5 episodes of diarrhea – 2 episodes of vomiting Norovirus Infections Associated with Frosted Bakery Products, 1982 • Frosting maker’s children had GI illness onset 1, 2, and 3 days prior to his onset of illness • Bare arm up to elbow in frosting • Estimated 3000 illnesses (including several other foodworkers at the bakery) Norovirus Infections Associated with Frosted Bakery Products, 1982 35 30 N um ber of C ases 25 20 15 10 5 0 4 8 12 16 20 24 28 32 36 40 44 48 52 56 60 64 68 72 76 H o u rs A fte r E x p o s u re MN Statistics (< 2005) Confirmed Foodborne Outbreaks Confirmed Foodborne Outbreaks, Minnesota, 1995-2005 50 45 40 35 30 25 20 15 10 5 0 Hotline initiated 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Year of Outbreak Confirmed Foodborne Outbreaks, by Etiology, Minnesota, 2005 (n=41) E. coli O157:H7 Other Salmonella Norovirus Bacterial Intoxications Confirmed Foodborne Outbreaks, by Setting, Minnesota, 2005 (n=41) Church Potluck Commercial Product Workplace Private Restaurant 0 5 10 15 20 25 30 Number of Confirmed Foodborne Outbreaks 35 Confirmed Foodborne Outbreaks, by Contributing Factor, Minnesota, 2005 (n=41) Unknown Contributing Factor Histamine/Escolar Contaminated Raw Product Ill Attendee Ill Foodworker 0 2 4 6 8 10 12 14 16 18 20 Number of Confirmed Foodborne Outbreaks MN Statistics (2006) Confirmed Foodborne Outbreaks Confirmed Foodborne Outbreaks, Minnesota, 1995-2005 50 45 40 35 30 25 20 15 10 5 0 Hotline initiated 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Year of Outbreak Confirmed Foodborne Outbreaks, Minnesota, 1995-2006 Confirmed Foodborne Outbreaks 90 80 70 60 50 40 30 20 Hotline initiated 10 0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Year of Outbreak Etiologies of Confirmed Foodborne Outbreaks, Minnesota, 2006 (n=83) Pathogen________ Norovirus Salmonella Scombroid Clostridium perfringens E. coli O157:H7 Shigella Staphylococcus aureus Cyclospora Listeria Amatoxin No. (%)__ 56 (67%) 9 (11%) 5 (6%) 5 (6%) 3 (3%) 1 (1%) 1 (1%) 1 (1%) 1 (1%) 1 (1%) Please Note: 2006 data are preliminary and subject to change. Confirmed Foodborne Outbreaks by Setting, Minnesota, 2006 (n=83) Other Commercial Outbreak Setting Church Workplace School Prison Private Caterer Restaurant 0 5 10 15 20 25 30 35 40 45 50 55 60 65 Number of Confirmed Foodborne Outbreaks Please Note: 2006 data are preliminary and subject to change. Selected Norovirus Outbreak Reporting, 20061 Month Location Facility Type Number Ill Jan Indiana Middle School 245 Jan Michigan Restaurant >430 Jan – Feb Chicago Hotel >150 Feb Minnesota Mar FL & CA Cruise ships >500 Apr Florida University 150 Vancouver Assisted living facility 55 residents & staff (3 deaths) Apr 1 Restaurants, hotels, >29 outbreaks nursing homes, schools As reported to CDC (by special request for information) Norovirus Outbreak Example 2: Minnesota Restaurant Norovirus Outbreak After Eating at a Restaurant in Winona • MDH received a complaint on June 27 from a group of five that had eaten at a Winona restaurant on June 24. • Credit card receipts were obtained from people who dined on June 24. • Employees were interviewed to assess illness and work history. Norovirus Outbreak After Eating at a Restaurant in Winona • 40 patrons interviewed – 12 patrons met the case definition – 3 cases called or visited their health care provider; none were hospitalized • 48 foodworkers were interviewed – 4 admitted having GI symptoms in the weeks before June 24, and several stated that “the flu” had been going around work Norovirus Outbreak After Eating at a Restaurant in Winona • 4 patrons tested positive for norovirus • 2 employees tested positive for norovirus • All had identical nucleic acid sequences Outbreak of Norovirus Gastroenteritis Associated with a Restaurant in Winona, Minnesota, June 2005 9 Patrons 8 Employees Cases 7 6 Confirmed norovirus 5 4 3 2 1 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 June Norovirus Outbreak After Eating at a Restaurant in Winona • Environmental assessment: – Inadequate employee illness logs – Poor reporting of illness by employees – Lack of management support to find and exclude ill employees – Washing lettuce in the handsink How do we find out about foodborne outbreaks in Minnesota? • Foodborne disease reporting and investigation • FoodNet • Foodborne Illness Hotline Reportable Foodborne Illnesses • Campylobacteriosis* • • Cholera* • • Escherichia coli * infection • (E. coli O157:H7 and other • pathogenic E. coli) • Listeriosis* • Salmonellosis*, including typhoid • Shigellosis* • Yersiniosis* * Submit isolates to MDH Botulism Cryptosporidiosis* Giardiasis Hemolytic uremic syndrome • Toxoplasmosis Foodborne Disease Surveillance in Minnesota • FoodNet • Active surveillance – Laboratory audits – Follow-up with health care providers – Interview cases Team Diarrhea and Vector Squad March 2006 To order a copy of the 2005 Gastroenteritis Outbreak Summary, go to: www.health.state.mn.us • Type “summary gastroenteritis” in the search box. • Complete the online order form. • Hard copies will be mailed to you in a couple of weeks. Norovirus Outbreak Example 3: Sandwich Shop Norovirus infection associated with eating sandwiches at a restaurant • MDH was notified of illnesses in a group of people after they ate a catered lunch • MDH received numerous additional independent illness complaints about the same restaurant Norovirus infection associated with eating sandwiches at a restaurant • 39 persons interviewed • 34 persons (87%) met the case definition • 4 ill foodworkers were identified; one additional foodworker had an ill family member • One patron and one ill foodworker tested positive for norovirus Norovirus infection associated with eating sandwiches at a restaurant Controlling NoV • MEANS PREVENTING TRANSFER OF VIRUS • Handwashing • Prohibiting bare-hand contact with RTE food items • Removing food workers with active vomiting and/or diarrhea • Restricting recently ill foodworkers (for 72 hours after symptoms subside) • Sanitizing No Bare-Hand Contact with RTE Foods • “Utensils” (i.e. gloves, papers, tongs, etc) • Education on proper use • Choosing the proper utensil • Glove integrity • When to change/how to change gloves You can help prevent these outbreaks! • The key to implementing a solid employee health program is communication. • Talk to foodworkers about the hazards of vomiting and diarrhea. • Work as a team to find innovative ways to keep ill foodworkers out of the restaurant. You can help prevent these outbreaks! • Inform foodworkers that they MUST report GI symptoms to the PIC. • Educate foodworkers about the need to: – Report GI symptoms to the PIC – Comply with strict handwashing requirements – Comply with the no-bare hand contact requirements • Use teachable moments to communicate key facts about handwashing, illness, foodsafety Questions?