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Norovirus Outbreak on Campus Mary Crabtree, Workplace Safety Manager Peter A. Reinhardt, Director Department of Environment, Health & Safety University of North Carolina at Chapel Hill Presented at the 50th Anniversary International Conference of the Campus Safety, Health and Environmental Management Association, July 5th, 2004 Presentation Objectives • • • • • • • General Information Review of UNC’s Norovirus Outbreak Actions taken within UNC Debriefing within UNC Attendance at NCSU’s Debriefing Lessons Learned Recommendations for Other Institutions General Information • In January 2004, EHS implemented a Hand Washing Campaign with Orange County Health Dept. • Goal: To reduce overall risk to infectious diseases and food-borne illnesses Carolina Dining Services • Two full dining facilities • Four Snack facilities • ARAMARK: Contractor for food services • Serve 7,000 meals/day in full dining halls Review of UNC’s Norovirus Outbreak • On January 21, 2004, Sixty-six students reported to Student Health Services • Symptoms: nausea, vomiting, diarrhea, acute gastroenteritis Review of UNC’s Norovirus Outbreak Initial Outbreak 120 100 80 SHS Not Seen Total 60 40 20 0 Jan. 20 *Jan. 21* Jan. 22 Jan. 23 About Norovirus Norovirus Infection Symptoms • • • • • • • • Vomiting Diarrhea Nausea Abdominal cramps Headache, muscle aches Fever (minority) Dehydration Up to 30% may be asymptomatic Adapted from Strategies for Norovirus Infection Control Aboard Cruise Ships, Robert E. Wheeler, MD, 2003. About Norovirus Norovirus-Public Health Aspects • 23-25 million cases in 2002 • About 8% of the U.S. population • Restaurants, schools, dormitories at risk Adapted from Strategies for Norovirus Infection Control Aboard Cruise Ships, Robert E. Wheeler, MD, 2003. About Norovirus Norovirus Infection • • • • • • Infectious dose of 10-100 virus particles 24-48 hour incubation period 12-60 hour duration of illness A “mild” and short-lived illness Treatment may indicate IV fluids Viral shedding of 3 weeks or more Adapted from Strategies for Norovirus Infection Control Aboard Cruise Ships, Robert E. Wheeler, MD, 2003. About Norovirus Transmission • • • • • “Oral-fecal” route Food (39%) Hands, person-to-person (12%) Water (3%) Also environmental surfaces: carpets, toilets, etc. Adapted from Strategies for Norovirus Infection Control Aboard Cruise Ships, Robert E. Wheeler, MD, 2003. About Norovirus Modes of Transmission by Food • • • • • Food sources (i.e., food arrives contaminated) Preparation Food handlers Customers Most at risk: ready-to-eat foods that require handling but no subsequent cooking (e.g., salads) Adapted from Strategies for Norovirus Infection Control Aboard Cruise Ships, Robert E. Wheeler, MD, 2003. About Norovirus Norovirus Characteristics • • • • • Highly contagious Multiple modes of transmission Stable in the environment Resistant to routine disinfection methods Carriers may not be symptomatic Adapted from Strategies for Norovirus Infection Control Aboard Cruise Ships, Robert E. Wheeler, MD, 2003. Review of UNC’s Norovirus Outbreak Second Peak – consistent with secondary Norovirus transmissions 20 15 10 SHS 5 0 Jan. 28 Jan. 29 Jan. 30 UNC Student Health Service Epicurve Action Taken by Student Health Services • Immediately notified Orange County Health Department, who began an investigation. • Enacted Disaster Plan and notified EHS • Assisted with Incident Communications Plan • Posted “Student Illness Update” on websites Initial Health Department Findings Based on calls to students who came to SHS, their roommates and other contacts. Environment, Health & Safety • Established contact with entities that would be involved (i.e., Housekeeping, UEOHC, Athletics, Housing & Residential Education) • Coordinated Incident Communications Plan • Prepared clean-up packets for Residential Halls • Discussed clean-up procedures with Athletics (Men’s Basketball Game January 24) • Advice to student dinning operations to deal with rumors, business impact, etc. Action Taken Within UNC Cleaning Guidelines for Housekeepers Housekeeping Department • EHS met with Housekeeping Zone Managers – Review Clean-up procedures – Identification of areas which students exhibit illness • Verify that available cleaners are sufficient • Required cleaning may exceed staff capabilities • Need feedback from housekeepers as to extent of cleaning needs Housing and Residential Education • Distributed EHS clean-up kits to residential halls • Assisted with Incident Communications Plan • Prepared & distributed illness survey (for students who did not go to SHS for treatment) Carolina Dining and ARAMARK • Placed “Hand Wash” tents on dining tables • Placed additional hand washing stations throughout dining halls • Reviewed staff absenteeism records • Fully assisted health investigators • ARAMARK’s SOP is to save food samples • ARAMARK offered corporate investigation and communication resources Calendar of Outbreak Events Sunday Monday January 18 MLK Day 19 Point Source 20 26 UNC Closed Winter Storm 27 2 3 10 25 February 1 Tuesday Wed Thursday 21 22 Friday Saturday 23 66 students sought treatment at SHS 24 Virginia basketball game 28 29 Norovirus confirmed 30 31 4 5 6 7 11 12 13 14 NCSU basketball game OCHD identifies source 8 9 Start of NCSU outbreak County Health Department’s Finding Final Results, February 2, 2004: • • • • • • • • Overall, about 250 students became ill during this outbreak Outbreak from a single source Time limited Common environmental exposure Five times more likely in one location of dining hall Four times more likely if the student ate salad bar No point to a specific salad item No procedural problems found with the Dining Services Debriefing Within UNC • UNC’s Debriefing was conducted on March 2nd • Parties involved: – Environment, Health & Safety – Student Health Services – Carolina Dining Services (including ARAMARK) – Housing & Residential Education – Housekeeping Services Debriefing Within UNC • Reviewed Orange County Health Department Findings • Effectiveness of Communications • Involvement of key groups for decision making • What if any other potential resources were needed? – Further analysis by the UNC School of Public Health • What other action can be taken to prevent/ mitigate reoccurrence? Attendance at NCSU’s Debriefing • Compare experiences and share best practices. • NCSU conducted a highly visible handwashing campaign Attendance at NCSU’s Debriefing • Paralleled UNC’s case • After 6th case at SHS, implemented survey— a best practice UNC could adopt. • Saw 410 students from February 9th to March 4th—longer duration. • No source identified. Lessons Learned • Delay in Health Department investigation results limited University’s response, so—to compliment the Health Department—we plan to initiate medical survey at the time of complaint. • Immediately review geographic data–who ate where and when. • Consider using epidemiology resources from UNC’s School of Public Health. • Continue contingency planning with outside parties. Other Plans of Action • Presentation to the North Carolina Public Health Training and Information Network • Plans for a more aggressive hand washing campaign for winter of 2004-5, including additional hand cleaners in dinning halls in strategic locations. • Consider arrangements to purchase and acquire effective cleaners overnight. • If UNC staff cannot manage cleaning, consider hiring cleaning contractor. Recommendations for Other Institutions • Establish emergency communication procedures • Openly discuss contingency plans and responsibilities internally and with public health officials • Conduct drills (i.e. table top) to identify needs • Review contracts of food service and establish a working partnership • Implement stronger health campaigns • Share information How Our 2003 SARS Experience Helped • Chancellor’s SARS Task Force—Fall 2003 – Promote handwashing – Housing workshop on response to communicable disease outbreak • Everyone better understands resources available at the University, County and the State. • However, we would rather not make an “outbreak” presentation at the 2005 CSHEMA conference. • Strengthened internal and external relationships, communication and decisionmaking. Mark Stinson, an auto mechanic from Chatham County NC, has survived four lightning strikes—in 1985, 1993, 2000 and 2002. Although his resulting disabilities are “a never-ending nightmare,” he says, “I’m still fascinated by lightning.”