WHATS FLU TO YOU? STOMACH FLU VERSUS INFLUENZA Jill Baber and Alicia Lepp North Dakota Department of Health Division of Disease Control 6/25/2015 Lunch and Learn Presentation I HAD THE FLU I HAD THE FLU INFLUENZA = FLU

INFLUENZA STOMACH FLU STOMACH FLU = NOROVIRUS Stomach flu = Winter Vomiting Disease Stomach flu = 24-hour bug Stomach flu Influenza A FLU BY ANY OTHER NAME Influenza = flu

Seasonal flu Pandemic Flu Swine Flu Avian Flu INFLUENZA INFLUENZA A common seasonal respiratory disease associated with high levels of morbidity and mortality each

winter. Common symptoms: Fever Cough Sore throat Headache Body aches

Chills Less common: vomiting (mostly in children) INFLUENZA-LIKE ILLNESS Influenza-like illness is a phrase used to describe respiratory illness fitting the case profile of influenza, but that may or may not be laboratory confirmed. Important for tracking influenza because influenza may not always be confirmed with a laboratory test. Official definition: fever (100F) AND cough AND/OR sore throat

CLINICAL DISEASE Abrupt onset of respiratory disease typically lasting 3-7 days, with related malaise and cough lasting up to two weeks. Common complications include: pneumonia, bronchitis, sinus and ear infections and exacerbation of existing respiratory issues. High risk groups: children, the elderly, pregnant woman and immunocompromised individuals. Incubation period: 2 days.

TRANSMISSION Infected persons can spread influenza about one day prior to symptom onset, and 5 to 7 days after symptom development. Children may be able to spread the virus for longer than 7 days. Influenza is mainly transmitted via respiratory secretions in droplet form. Contact within contaminated surfaces is a secondary source of transmission. General prevention efforts include:

Vaccination Hand washing Disinfection of surfaces Not touching face with unwashed hands Staying home when ill and avoiding others who are ill Treatment with influenza antivirals has not been shown to shorten the transmission period. LABORATORY CONFIRMATION Po s i t i v e i n fl u e n z a l a b t e s t s a re re p o r t a b l e t o t h e N o r t h D a ko t a D e p a r t m e n t o f H e a l t h . Rapid D FA

PCR N e g a t i v e r a p i d o r D FA t e s t s s h o u l d n o t b e u s e d t o r u l e o u t i n fl u e n z a . Te s t i n g i s a l s o a v a i l a b l e t h r o u g h t h e Pu b l i c H e a l t h L a b . PCR (free!) Respiratory Viral Panel (RVP) I n l o n g t e r m c a re s e t t i n g s , t e s t i n g i s re c o m m e n d e d y e a r ro u n d w h e n t w o o r m o re re s i d e n t s p re s e n t w i t h I L I w i t h i n 7 2 hours. Te s t k i t s c a n b e p ro v i d e d d u r i n g o u t b re a k

f o r i n fl u e n z a t y p i n g . INFLUENZA SURVEILLANCE Laboratory-confirmed influenza is reportable in North Da kota. Hospitalizations and adult deaths are not reportable in North Dakota but are still tracked. (And are appreciated!) Hospitalizations obtained ad hoc from complete reports Death information from individual reports and Vital Records data Pediatric deaths are nationally notifiable Sentinel site reporting. Outpatient ILI reports Laboratory reports School absenteeism reports

Syndromic Surveillance (hospital ILI). Long Term Care outbreaks (not just Long Term Care). Information available weekly during the flu season at www.ndflu.com. INFLUENZA AND INFLUENZA-LIKE ILLNESS IN HEALTH CARE FACILITIES Influenza and other respiratory clusters are common in health care facilities. Influenza is common wherever people congregate. Communities with large numbers of elderly residents are especially susceptible to outbreaks. Recommendations specific to health care facilities exist for:

vaccination antiviral treatment Infection prevention infection control Reporting Special considerations for Long term care. CDC toolkit for long term care providers: http://www.cdc.gov/flu/toolkit/longterm-care/

INFLUENZA ANTIVIRALS Oseltamivir (Tamiflu) Zanamivir (Relenza) Treatment with influenza antivirals is recommended in a hospital setting for all confirmed and suspected cases of influenza when the patient is in a high-risk category. The CDC recommendation is to

NOT WAIT for a positive test to begin antiviral treatment. INFLUENZA ANTIVIRALS In facilities with residents, treatment or prophylaxis with influenza antivirals are recommended for: A l l c onfi rmed a nd suspec te d ca ses of i nfl uenz a when the pa ti e nt i s i n a hi gh ri sk c a tegory ( trea tm ent dose) . A l l resi de nt c onta cts o f c onfi rme d a nd suspe c te d ca ses of i nfl ue nz a when the c o nta ct i s i n a hi gh-ri sk c atego ry ( prophy l ac ti c do se) : Roommates Activity partners Residents on the same floor/wing/pod/etc.

A l l resi de nts a t a l ong term ca re fac i l i ty duri ng a c onfi rm ed outbrea k. N EW ! A l l l o ng term c are sta ff co nta c ts of co nfirm ed and suspec ted c ase s dur i ng H 3 N 2 sea sons whe n the va c ci ne i s poorl y m atc hed to the c i rcul a ti ng stra i n ( l i ke 2 0 14 -1 5 , pro phy l ac ti c dose ). INFECTION PREVENTION: VACCINATION Yearly seasonal influenza vaccination is recommended for patients, residents, family members and health care workers. Different kinds of seasonal influenza vaccines are available.

No current recommendations for particular vaccine types over others. INFECTION CONTROL: ACTIVE SURVEILLANCE Daily active surveillance of residents, staff and visitors for ILI in a health care facility should be initiated during outbreaks. Active surveillance should continue for one week after the most recent case is identified. Active surveillance provides

situational awareness and can guide other infection control measures. INFECTION CONTROL: DROPLET PRECAUTIONS In addition to following the standard precautions always recommended for health care settings, droplet precautions should be implemented for all residents with ILI. Examples: Placing ill patients/residents in a private room. OR place residents suspected of having influenza together ( cohorting). Masking of staff and visitors when entering the room of an ILL patient/resident (dispose of mask upon exit).

Masking of the patient/resident during transport. Share ILI status information with staff receiving patients/residents being transferred to another area. Duration: 7 days after onset OR 24 hours after the resolution of fever and respiratory symptoms (or longer). INFECTION CONTROL: EMPLOYEE/VISITOR SCREENING Screen employees and visitors for respiratory illness: Employees:

Track employee health Have ill employees stay home Visitors: Discourage ill visitors from entering facility Require masking of visitor Restrict all visitors or young visitors during active outbreaks (facility discretion) Post signs! INFECTION CONTROL: CLEANING AND DISINFECTION

Proper cleaning in infection are important to controlling influenza and other respiratory viruses that can live on surfaces for several hours. Routine cleaning is typically sufficient: Clean and disinfect surfaces and objects that are touched often Use cleaning/disinfecting products approved by the EPA for effectiveness against influenza A viruses (alternative: solution of one tablespoon of bleach to 4 cups water) For visibly dirty surfaces, clean with a general cleaner, rinse with water, and follow with an EPA-approved disinfectant. Consider disinfecting wipes for often used electronic items, such as phones and computers An outbreak of ILI presents a good opportunity to review

cleaning procedures! ILI REPORTING Influenza-like illness outbreaks in health care institutional settings are reportable. ILI REPORTING: WHAT? CDC definition of a long term care outbreak of influenza-like illness: Two or more cases of ILI in residents (or residents and staff) that occur within 48 to 72 hours of each other, OR One resident with a positive laboratory result for influenza Laboratory confirmation is not necessary for an

outbreak in a long term care facility to be reportable. ILI REPORTING: WHY? Required as part of reportable disease law for reporting nosocomial outbreaks. Long term care outbreaks are tracked by CDC as an influenza indicator. Reporting in aggregate 40 reported outbreaks in North Dakota for the 2014-15 season Non-influenza ILI is important, as other respiratory diseases can cause outbreaks and even deaths. Rhinovirus

Respiratory Syncytial Virus (RSV) Human metapneumovirus ILI REPORTING: WHERE? Web-based reporting form: http://www.ndflu.com/Reporting/FluOutbreak.htm ILI REPORTING WHERE? ILI REPORTING: WHERE Following the path of: www.NDFlu.com Outbreak

Reporting Long Term Care Outbreaks this form will appear. ILI REPORTING: WHAT? NDDoH reporting form asks for: Facility name, type, address and phone number Reporter name and email Total number of residents, staff, residents with illness and staff with illness Date of onset for first case

Symptoms associated with the outbreak If and where specimens were collected for laboratory confirmation Vaccination status for ill residents If antivirals have been given to residents affected or potentially affected by the outbreak Any prevention measures taken by facility ILI REPORTING Information from the report will be recorded by NDDoH influenza staff. Follow-up often occurs

in order to: Provide CDC recommendations Obtain any necessary additional information Arrange for influenza test kits to be delivered We are always happy to answer questions! NOROVIRUS NOROVIRUS

No ro v ir us i s v e r y c o n t a g io us . Is the most common cause of a c ut e ga s t ro e n t e r i t i s i n t he U S. Causes 19-21 million illnesses Contributes to 56,000-71,000 hospitalizations 570-800 deaths C an s pre ad qu ic k l y i n c l os e d pl a c e s , s uc h a s d a y c a re c e n te rs , nur s i ng ho m e s , s c ho o l s a nd c r ui s e s h i ps . C au s e s ac ut e bu t s e l f- l i mi t e d di a rrh ea , o ft e n w i t h v o mi t in g,

a bdo m i n al c ra m pi ng , f e ve r a n d fa t i gu e. Most individuals recover from acute symptoms with 2-3 days, but can be more severe in vulnerable populations. NOROVIRUS Norovirus was first identified as the cause of a gastroenteritis outbreak in Norwalk, Ohio, in 1968 Noroviruses are a group of nonenveloped, singlestranded RNA viruses classified into the genus Norovirus (previously referred to as Norwalklike viruses or small round-structured viruses) of the family Caliciviridae. Noroviruses can be divided into at least five

genogroups, designated GI-- GV, based on amino acid identity in the major structural protein. The strains that infect humans are found in GI, GII, and GIV, whereas the strains infecting cows and mice are found in GIII and GV, respectively NOROVIRUS OUTBREAKS Since 2001, GII.4 viruses have been associated with the majority of viral gastroenteritis outbreaks worldwide. Recent studies have demonstrated that these viruses evolve over time through serial changes in the VP1 sequence, which allow evasion of immunity in the human population Periodic increases in norovirus outbreaks tend to

occur in association with the emergence of new GII.4 strains that evade population immunity. These emergent GII.4 strains rapidly replace existing strains predominating in circulation and can sometimes cause seasons with unusually high norovirus activity NOROVIRUS IN HEALTHCARE FACILITIES Norovirus is a recognized cause of gastroenteritis outbreaks in healthcare facilities. Healthcare facilities are the most commonly reported settings of norovirus

gastroenteritis outbreaks in the US. Outbreaks of gastroenteritis in healthcare settings pose a risk to patients, healthcare personnel, and to the efficient provision of healthcare services. CLINICAL DISEASE I n fect i ou s do se: 18 -10 00 vir a l pa r t ic les I n cu ba t i on per io d: 12 - 4 8 h o u r s Ac u t e- o ns et vo m it ing an d/o r di arrh ea

Watery, non-bloody stools Abdominal cramps, nausea, low-grade fever 30% infections asymptomatic Mo st reco ver a ft er 1 2- 7 2 h o u r s Up to 10% seek medical attention; some require hospitalization and fluid therapy More severe illness and death possible in elderly and those with other illnesses VIRAL SHEDDING

Primarily in stool, but can also be present in vomitus Shedding peaks 4 days after exposure In some individuals, shedding may occur for at least 2-3 weeks May occur after resolution of symptoms TRANSMISSION OF DISEASE Person to p erson Direct fecal-oral Ingestion of aerosolized vomitus Indirect via fomites or contaminated environment Food Contamination by infected food handlers

Point of service or source (e.g., raspberries, oysters) Recreational an d Drinking Water Well contamination from septic tank Chlorination system breakdown In healthcare, the most likely and comm on modes of transmission are through direct contact with infected persons or contaminated equipment IMMUNITY TO NOROVIRUS Short-term immunity after infection There is little cross protective immunity (against different genotypes)

No long-term immunity Protection believed to last less than one year, and in some studies, protection may only last a few months Genetic susceptibility A portion of the population may be genetically resistant to norovirus infection Currently no commercially available test to identify those who might carry genes conferring resistance to norovirus infection LABORATORY CONFIRMATION OF NOROVIRUS Reverse transcription polymerase chain reaction (RTPCR) confirmation is the

preferred diagnostic for norovirus Differentiate genogroup I and genogroup II norovirus Rapid commercial assays have recently been cleared by FDA for preliminary identification of norovirus when testing multiple specimens during outbreaks Poor sensitivity (50%) Samples that test negative should be confirmed by second technique

SUBMITTING CLINICAL SAMPLES FOR NOROVIRUS TESTING Consult with NDDoH prior to submitting samples for norovirus identification Need multiple suspect cases before specimen testing can be performed Stool specimens should be collected from individuals during acute phase of illness Virus may be able to be detected in specimens taken later in the course of illness, but sensitivity is reduced Submit stool specimens as early as possible during a potential outbreak or cluster Both staff and patient cases can be tested

WHAT SHOULD STAFF DO IF THEY SUSPECT NOROVIRUS? Key Infection Control Activities Rapid identification and isolation of suspected cases of norovirus gastroenteritis Communicating the presence of suspected cases to Infection Preventionists Promoting increased adherence to hand hygiene, particularly the use of soap and water after contact with symptomatic patients Enhanced environmental cleaning and disinfection Promptly initiate investigations

Collection of clinical and epidemiological information Obtain clinical samples INFECTION CONTROL: PATIENT ISOLATION OR COHORTING In healthcare settings where risk of transmission is high, use of isolation precautions is often the most effective means of interrupting transmission CONTACT PRECAUTIONS single occupancy room with a dedicated bathroom, strict adherence to hand hygiene, wear gloves and gown upon room entry Use Contact Precautions for a minimum of 48 hours after the resolution of symptoms Symptomatic patients may be cohorted together

Exclude ill staff members and food handlers in healthcare facilities for a minimum of 48 hours following resolution of their symptoms Exclude non-essential personnel and visitors INFECTION CONTROL: HAND HYGIENE Wash hands with soap and water after contact with symptomatic patients Alcohol-based hand sanitizers Currently available

products appear to be relatively ineffective against norovirus Consider using FDAcompliant alcohol-based hand sanitizers for other indications (e.g., before contact with norovirus patient) INFECTION CONTROL: ENVIRONMENTAL CLEANING AND DISINFECTION The use of chemical cleaning and disinfecting agents are key in interrupting norovirus spread from contaminated environmental

surfaces Increase the frequency of cleaning and disinfection of patient care areas and frequently touched surfaces e.g., increase ward/unit level cleaning to twice daily, with frequently touched surfaces cleaned and disinfected three times daily Use commercial cleaning and disinfection products registered with the U.S. EPA [e.g., sodium hypochlorite (bleach) solution, hydrogen peroxide products, etc.). http://www.epa.gov/pesticides/antimicrobials/list_g_norovirus.pdf It is critical to follow manufacturer instructions for methods of application, amount, dilution and contact time.

INFECTION CONTROL: OTHER CONSIDERATIONS To reduce transmission, and depending on the magnitude of the outbreak, cohort staff to care for patients who are Asymptomatic unexposed Asymptomatic, potentially exposed Symptomatic Remove communal or shared food items for staff or patients for the duration of the outbreak Group activities for patients may need to be suspended; minimize patient movements within a patient care area to help control transmission

SURVEILLANCE FOR NOROVIRUS CASES Units can use a line list to track symptomatic staff and patients During an outbreak, collect key information to assist with controlling the outbreak and to inform NDDoH on outbreak details Suggested line list elements

Case (staff/patient) identifier Case location Symptoms Outcome/Date of Resolution Diagnostics submitted http://www.epa.gov/pesticides/antimicrobials/list_g_norovirus.pdf REPORTING OUTBREAKS Internal Communication Report gastroenteritis outbreaks (e.g., 2 or more suspected or confirmed cases among staff or patients) to infection control units Outbreaks should also be reported to clinical management

Important to include communications, laboratory, environmental services, admitting, occupational health departments http://www.cdc.gov/hai/pdfs/norovirus/216887-A-GICommFramewk5 08.pdf External Communication Report norovirus outbreaks to NDDoH NDDoH enter norovirus outbreak data (among other pathogens) into CDCs National Outbreak Reporting System (NORS) https://www.ndhealth.gov/disease/Gastroenteritis/Gastroenteritis.as px QUESTIONS?

Contact info: North Dakota Department of Health Division of Disease Control 701.328.2378 Jill Baber: [email protected] (influenza, other respiratory) Laura Cronquist: [email protected] (norovirus, other enterics)

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