Puking Veronica: The real indicators of a Norovirus outbreak in a university residence

Been there, done that.

Chapman wrote this back in 2009

Brae Surgeoner, Doug and I had a paper published in the September 2009 Journal of Environmental Health about some research we conducted in the Winter of 2006. The study came about because a whole bunch of kids in the University of Guelph’s residence system started puking from an apparent norovirus outbreak. There were lots of handwashing signs up and we wanted to know whether they changed hygiene behavior (especially if kids were using the tools available when entering the cafeteria). Turns out that the kids weren’t doing as good of a job at hand hygiene as they reported to us.

NC State’s press release is below (the Kansas State release is here):

As public health experts warn of potential widespread outbreaks of H1N1 flu this school year, a new study from North Carolina State University shows that students do not comply with basic preventative measures as much as they think do. In other words, the kids aren’t washing their hands.

“Hand washing is a significant preventative measure for many communicable diseases, from respiratory diseases like H1N1 to foodborne illness agents, such as norovirus,” says Dr. Ben Chapman, assistant professor of family and consumer sciences and food safety extension specialist at NC State. The new study, which examined student compliance with hand hygiene recommendations during an outbreak of norovirus at a university in Ontario, finds that only 17 percent of students followed  posted hand hygiene recommendations – but that 83 percent of students reported that they had been in compliance. Norovirus causes gastrointestinal problems, including vomiting and diarrhea. Every year there are 30 to 40 outbreaks of norovirus on university campuses, affecting thousands of students.

Chapman, who co-authored the research, says this is the first study to observe student hygiene behavior in the midst of an outbreak. Previous studies examined self-reporting data after an outbreak – and the new research shows that the self-reporting data may be inaccurate.

“Typically, health officials put up posters and signs and rely on self-reporting to determine whether these methods are effective,” Chapman says. “And people say they are washing their hands more. But, as it turns out, that’s not true.

“The study shows that while health authorities may give people the tools we think they need to limit the spread of an outbreak, the information we’re giving them is not compelling enough to change their behavior. Basically, it doesn’t work. But we do it again with every outbreak, and we’re doing it now with H1N1.”

Chapman says the study shows that health officials need to target specific audiences, such as students in a particular dorm or who eat at a particular cafeteria, and tailor their information to those audiences. For example, telling them where the nearest washrooms are, or pointing out where hand sanitizer units are located. “The more specific the information is for an audience, the better off you are,” Chapman says.

Chapman adds that health authorities also need to use language appropriate to their target audience. “For example, don’t refer to something as a ‘gastrointestinal illness,’” he says, “instead, tell them ‘this could make you puke’ or ‘dude, wash your hands.’ The idea is to craft compelling messages that create discussion in that audience. Make them talk about it.”

Chapman also says that health officials should take advantage of social media, such as text messaging and Facebook, to raise awareness. “If your audience consists of students,” he explains, “you should use media that students use.

“Campuses need to expect outbreaks will happen and plan accordingly. Have the response tools in hand.”

The study, “University Students’ Hand Hygiene Practice During a Gastrointestinal Outbreak in Residence: What They Say They Do and What They Actually Do,” was co-authored by Chapman, Dr. Douglas Powell of Kansas State University and Brae Surgeoner, a former graduate student at the University of Guelph. The study was published in the September issue of the Journal of Environmental Health.

Lacey Burkholder, Katherine Allensworth, Haley Schaffter

https://ideaexchange.uakron.edu/cgi/viewcontent.cgi?article=1815&context=honors_research_projects

Illness contributes to a decrease in student class attendance which can lead to increased academic stress. Decreasing the spread of illness among those living in residence halls is essential to academic success. The purpose of this systematic review was to identify interventions implemented in residence halls on college campuses to reduce the spread of illness. The PICO question directing the research for this study asks, “How do interventions affect the spread of illness in university residence hall populations?”. The research conducted was completed by means of a systematic review of literature including 20 peer reviewed articles published between 1999-2017 from the databases CINAHL Plus, PsychInfo, and PubMed. Findings from this review revealed a focus on three interventions used to decrease illness among college students living in residence halls: (1) hand washing, (2) lifestyle initiatives, and (3) education. Of the three, hand washing and educational measures were found to decrease the spread of illness, while lifestyle initiatives were found to have no direct correlation to the spread of illness.

48 sick: Raw is risky: Icelandic oysters cause noro at top notch restaurant

There’s nothing like people forking over huge coin only to end up barfing.

Irony is sometimes ironic.

The Iceland Monitor reports infected Icelandic oysters caused food poisoning for 48 individuals at Skelfisksmarkaðurinn, a relatively new restaurant owned by succcessful tv chef and restaurant owner Hrefna Sætran. Icelandic oysters are a novelty in Iceland as all oysters on menus until now have been imported from Ireland or other countries. 

The oysters were imported as youngsters and raised in Skjálfandaflói bay by company Víkurskel. This is the first time that the noro virus is confirmed in oysters in Iceland. 

Forty-four individuals ate oysters at the restaurant from November 8th to November 13th and four further individuals ate oysters between October 29th and November 4th. Oysters infected by the noro virus were on the menu during this period of time, confirms the Icelandid food and veterinary authority. According to the health authorities they found that the restaurant complied to all regulations and standards with regards to food safety and hygiene. 

 

120 sick: California wildfire evacuees face the misery of norovirus

The European Cleaning Journal reports that more than 120 people forced to flee the deadly California wildfires are now battling the norovirus to add to their woes.

Sick evacuees are being housed in separate shelters and active monitoring of all shelter residents is being carried out. Meanwhile, separate washrooms are being allocated to the ill and protective equipment is being supplied to medical staff.

Outbreaks of the norovirus is not uncommon in situations where hundreds of people live in close quarters, says public information officer for Butte County Public Health Lisa Almaguer. The health department is working with the Red Cross plus state and federal partners to reduce the spread of the illness.

One evacuee claims to have seen someone “puking into a toilet”, adding that health officials were urging all evacuees to wash their hands repeatedly, avoid handshakes and to use hand sanitiser before eating.

Clemson researchers target vomit cleanup methods in new norovirus research

Ever since that time in 2008 when one of Amy’s French students barfed in class, we’ve sorta been obsessed with, what is the proper way to clean up barf?

Especially if norovirus is involved.

The previous story gives an idea of just how infectious this stuff is.

Two Clemson researchers who are working with the federal government to combat stomach bug outbreaks among the elderly are convinced that advancements in this field could be lifesaving. 

Clemson University professors Angela Fraser and Xiuping Jiang catered their new norovirus research project to the needs of residents in long-term care facilities.

“I just think that those of us who are fortunate need to look out for those who are vulnerable,” Fraser said. “And this is a vulnerable population.”

One of the main goals of their new project, which recently received more than $1 million in funding from the federal Agency for Healthcare Research and Quality, is to come up with easy-to-implement, cost-efficient and effective vomit cleanup procedures for soft surfaces. The hope is that this will directly combat the high percentage of norovirus outbreaks in long-term care facilities and places with similar environments. 

The study, which has funding for three years, will be done in partnership with the Centers for Disease Control and Prevention, Emory University and the University of Illinois-Chicago.

In past studies on proper vomit cleanup, Fraser and Jiang learned that there were gaps in the research, particularly when it came to the proper disinfectant to use on soft services to prevent the spread of diseases.

Chlorine bleach, the most commonly used disinfectant, mainly worked on hard surfaces and could rarely be used on soft surfaces like carpets and couches. One of the areas they realized could benefit the most from this information was long-term care facilities. 

“Long-term facilities want to create a very homelike environment, so they have lots of carpet around in comparison to hospitals and other environments,” Jiang said.

They also, of course, tend to have a high number of older adults.

“That’s people’s living environment,” Fraser said. “Do you really want people to be living where everything is just cinder block or smooth walls?”

She said because older patients are more likely to have chronic diseases, their immune systems are typically weakened as well. This means that when these older adults get infected with diseases like the norovirus, there can be a more severe expression of the disease compared to someone younger. Because of all of these factors, some view the study as even more imperative.

 

Multiple modes of transmission during a Thanksgiving Day Norovirus outbreak, 2017

The U.S. Centers for Disease Control reports on November 28, 2017, the manager of restaurant A in Tennessee reported receiving 18 complaints from patrons with gastrointestinal illness who had dined there on Thanksgiving Day, November 23, 2017. Tennessee Department of Health officials conducted an investigation to confirm the outbreak, assess exposures, and recommend measures to prevent continued spread.

On November 23, one patron vomited in a private dining room, and an employee immediately used disinfectant spray labeled as effective against norovirus* to clean the vomitus. After handwashing, the employee served family-style platters of food and cut pecan pie. For the November 23 Thanksgiving Day, restaurant A served 676 patrons a limited menu from 11 a.m. to 8 p.m. The manager provided contact information, seating times, and seating locations for 114 patrons with reservations. All patrons with contact information were telephoned, and a questionnaire was used to assess illness and exposures for anyone living in the household who ate at restaurant A on November 23. Stool specimens were requested from ill patrons. Among the 676 patrons, 137 (20%) were enrolled in a case-control study.

A probable case was defined as diarrhea (three or more loose stools in 24 hours) or vomiting within 72 hours of eating at restaurant A on November 23; probable cases with norovirus RNA detected in a stool specimen by real-time reverse transcription–polymerase-chain reaction (RT-PCR) were considered confirmed. On November 30, environmental swabs for norovirus testing were collected in the restaurant. Patient and environmental samples were tested by real-time RT-PCR and sequenced at the Tennessee State Public Health Laboratory.

Thirty-six (26%) case-patients (two confirmed and 34 probable) and 101 (74%) controls were enrolled in the case-control study. Illness onsets occurred during November 23–25, with 17 of 35 (49%) cases occurring on November 24. The mean incubation period was 31 hours (range = 2.5–54.5 hours), and the mean illness duration was 3 days (range = 0–6 days). Only one case-patient sought medical care. Diarrhea was reported by 33 (94%) case-patients, fatigue by 29 (83%), nausea and abdominal cramps by 28 (80%), vomiting by 24 (69%), and fever by six (17%).

Among menu items, only pecan pie was significantly associated with illness (odds ratio [OR] = 2.6; 95% confidence interval [CI] = 1.1–5.8); however, it was eaten by only 16 (47%) of 34 case-patients. The vomiting event occurred around noon; patrons seated during 11 a.m.–1 p.m. were significantly more likely to become ill than were patrons seated during other times (OR = 6.0; 95% CI = 2.6–15.3). No significant differences between dining locations (i.e., private dining room versus general seating) were identified (OR = 1.4; 95% CI = 0.4–4.3). Logistic regression was used to evaluate the effects of eating pecan pie, seating time, and seating location; only seating time during 11 a.m.–1 p.m. remained statistically significant (OR = 6.0; 95% CI = 2.2–16.5).

Stool specimens from two case-patients identified Norovirus GII.P16-GII.4 Sydney. Norovirus GII was identified in one environmental swab collected from the underside of a table leg adjacent to the vomitus.

A point-source norovirus outbreak occurred after an infected patron vomited in a restaurant. Transmission near the vomiting event likely occurred by aerosol or fomite. Norovirus spread throughout the restaurant could have occurred by aerosol, person-to-person, fomite, or foodborne routes. Inadequate employee handwashing likely facilitated foodborne transmission through servings of pecan pie.

In hospital settings, CDC and the Tennessee Department of Health recommend contact precautions (e.g., gloves and gowns) when personnel have contact with vomitus (1). Similarly, the Food and Drug Administration’s 2017 Food Code recommends restaurants have a written plan detailing when and how employees should use personal protective equipment for cleaning vomitus (2). Reinforcing the need for proper handwashing and performing thorough environmental cleaning with appropriate personal protective equipment in food service establishments can prevent or mitigate future outbreaks.

Acknowledgments

Teresa Vantrease, Jana Tolleson, Tiffany Rugless, Lee Wood, Anita Bryant-Winton, Heather Mendez, Jeannette Dill, Alan Pugh, Jason Pepper, Katie Nixon, Marcy McMillian, Jane Yackley; FoodCORE Interview Team; staff members from restaurant A.

Corresponding author: Julia Brennan, JBrennan@cdc.gov, 615-253-9971.

1Epidemic Intelligence Service, CDC; 2Division of Scientific Education and Professional Development, CDC; 3Communicable and Environmental Diseases and Emergency Preparedness, Tennessee Department of Health; 4Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee.

All authors have completed and submitted the ICMJE form for disclosure of potential conflicts of interest. William Schaffner reports personal fees from Pfizer, Merck, Dynavax, Seqirus, SutroVax, and Shionogi, outside the submitted work. No other potential conflicts of interest were disclosed.

* Active ingredients = n-Alkyl dimethyl benzyl ammonium chlorides and n-Alkyl dimethyl ethylbenzyl ammonium chlorides.

The cost of Norovirus in Germany

We estimated numbers of hospitalizations for norovirus gastroenteritis (NGE) and associated medical costs in Germany, where norovirus testing is high because reimbursement is affected. We extracted aggregate data for patients hospitalized with a primary or secondary code from the International Classification of Diseases, 10th Revision (ICD-10), NGE diagnosis during 2007–2012 from the German Federal Statistics Office.

We assessed reliability of the coding system in patient records from a large academic hospital. Approximately 53,000–90,000 NGE hospitalizations occurred annually in Germany (21,000–33,000 with primary and 32,000–57,000 with secondary ICD-10–coded NGE diagnoses). Rates of hospitalization with NGE as primary diagnosis were highest in children <2 years of age; rates of hospitalization with NGE as secondary diagnosis were highest in adults >85 years of age. The average annual reimbursed direct medical cost of NGE hospitalizations was €31–43 million. Among patients with a NGE ICD-10 code, 87.6% had positive norovirus laboratory results.

Norovirus Gastroenteritis among Hospitalized Patients, Germany, 2007–2012

Kowalzik, F., Binder, H., Zöller, D., Riera-Montes, M., Clemens, R., Verstraeten, T….Zepp, F. (2018). Norovirus Gastroenteritis among Hospitalized Patients, Germany, 2007–2012. Emerging Infectious Diseases, 24(11), 2021-2028. https://dx.doi.org/10.3201/eid2411.170820.

https://wwwnc.cdc.gov/eid/article/24/11/17-0820_article

Food Safety Talk 166: Surprising lack of cannibalism questions

Don and Ben traveled to SUNY Geneseo for a live version of the podcast sponsored by the Center for Integrative Learning, and hosted by the amazing Beth McCoy. The episode title comes from an unrecorded after dark which may or may not have taken place in a bar in Geneseo.

Episode 166 is available on iTunes and here.

Show notes so you can follow along at home.

Travel-related foodborne illness

A few years ago, my family and I embarked on a trip an all-inclusive resort in Mexico, a little get away from the hectic day to day musings in our lives. First day I decided to go for a jog  and was bitten by a wild dog travelling in a pack. I was shipped off to Cancun to start rabies postexposure prophylaxis. Second day, contracted norovirus. Third day almost left.

Colette Crampsey of the The Daily Record reports:

Reece Russell and John English both fell ill after eating at all-inclusive resorts in Cancun.
Two holidaymakers have told of their ordeals after being crippled by food poisoning bugs in Mexico.
Reece Russell, 28, was infected with salmonella, which led to inflammation around his heart.
And John English, 51, ended up in hospital with bacterial gastritis. He has been left with long-term health problems and has had to give up being a football coach.
Both men fell ill after travelling to all-inclusive resorts in Cancun.
Reece, from Dunfermline, went to the resort with his parents and sister in June.
He said: “About a week after I came home, I started falling very ill. I woke up at 1am with chest pains. In hospital, a blood test showed I had a high level of protein in my blood caused by possible heart attacks.”
Reece was diagnosed with myopericarditis –inflammation of the membrane and muscle around the heart. Tests showed salmonella was to blame.
He said: “The doctors implied that if I hadn’t gone to hospital when I did, it would have been significantly worse.” 
Engineer Reece, who stayed at the Bahia Principe, had to miss two weeks of work. He is seeking compensation from travel firm TUI.
John stayed at Moon Palace hotel with wife Janice and their two children in July.
After eating at a Brazilian restaurant, the Scottish Gas worker was violently sick and was whisked to hospital.
John said: “They told me my magnesium levels were very low. If that happens, your organs can shut down and you can die. It was quite frightening.”
The couple had to fork out £4000 for treatment and a further £1500 on John’s release the next day.
He said: “I’ve lost 2st and doctors have told me my blood pressure is through the roof. I could be on tablets for the rest of my life.
“I’m having to give up football coaching, which is very hard for me.”
A Thomas Cook spokesman said: “We are sorry to hear Mr English became ill. We advise customers to tell their rep or hotel staff immediately if they are unwell so they can get the right support.”
A spokesman for TUI said: “We will be contacting Mr Russell directly to review the matter.
“We regularly audit all of the hotels we feature in respect of health and safety, including hygiene.”

‘We’re trying to stay healthy and look good on stage and everyone’s throwing up around us’ (Probably) Norovirus spreads at Miss Nevada pageant

Faith Tanner of Fox 5 reports that health officials have been investigating a suspected norovirus outbreak at Westgate Las Vegas Resort and Casino.

At the end of June, families from across the state stayed at Westgate for the Miss Nevada pageant. 

Contestants said several people got sick during and after the competition. 

“It’s terrifying, because we’re all trying to stay healthy and look good on stage and everyone’s throwing up around us,” Macie Tuell said. 

It was a week Miss Lake Tahoe, Macie Tuell, prepared all year for, to compete in Miss Nevada at the Westgate in Las Vegas. 

But Tuell and the other contestants weren’t prepared for so many people to get sick. 

“The first girl in our group that got sick, it happened Wednesday night and then each day a couple more girls got sick and a couple more got sick the day after that. I know one girl actually got sick while she was on stage and had to run off,” Tuell said. 

She said the show went on and contestants pulled through. Tuell ended up getting first runner up. It wasn’t until the end of the pageant that most contestants learned how widespread the illness was. 

“A couple of the employees were getting sick, so that’s when we stared to figure out it wasn’t just our group. Even our family members who we had not seen at that point they were getting sick.”

The Southern Nevada Health District has been investigating. 

Their information so far suggested a gastrointestinal illness. Consistent with norovirus or the stomach flu. Health officials couldn’t confirm how many people got sick. 

Officials said they’ve surveyed the Westgate’s kitchens and on July 4, the resort agreed to close the buffet for an additional health assessment. 

‘Hellish’ gastro outbreak sends more than 1,000 people to emergency in Australia

The Sunshine Coast is an idyllic spot on the Pacific Ocean, about an hour north of Brisbane.

But according to Shri Rajen of the Daily Mail a huge, and unidentified gastro outbreak has left more than 1,000 people in hospital. 

Emergency departments in the Sunshine Coast, Queensland, were flooded with 1142 patients with gastroenteritis.

Around 600 cases were treated at the Sunshine Coast University Hospital.

Gastroenteritis can be either infectious or non-infectious, public health physician said, Dr Andrew Langley, reported The Sunshine Coast Daily.

He said, usually bacteria, parasites and viruses are the cause of infectious cases.

‘Noroviruses are a very common cases of viral gastroenteritis. Causes of norovirus are not routinely reported to Queensland Health,’ Dr Langley said.

‘If you have gastroenteritis, you should not return to work until diarrhoea has ceased. Children should not return to childcare or school until diarrhoea has ceased for 24 hours,’ said Dr Langley.

Last month, a gastro outbreak has forced Mt Maria College in Brisbane to close after 20 students and two teachers were sent to hospital with vomiting and diarrhoea.

Last year nearly 2000 people admitted themselves to hospitals across Sydney.

Gastroenteritis can be easily passed from person to person due to its highly infectious nature.