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AL1003NRV-51a - Alabama Department of Public Health

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					               Outbreak of Norovirus Among Residents at a Specialty Care Assisted Living
                    Facility Montgomery County, Alabama 2010 (AL1003NRV-51a)



Introduction

On March 19, 2010, the Public Health Area (PHA) 8 Surveillance nurse contacted the Alabama
Department of Public Health (ADPH), Surveillance Branch, concerning a gastrointestinal outbreak of
unknown origin at an assisted living facility in Montgomery County housing 68 beds, 15 assigned to
Specialty Care Assisted Living. At the time of the outbreak, the facility employed 57 staff and cared
for 53 patients.

Methods

On March 19, the medical director of the facility reported residents and employees were ill with
symptoms of nausea, vomiting, and diarrhea that began March 17; symptom onset continued
through March 21.

The case definition included residents and employees who experienced gastrointestinal symptoms
between March 17 and 21. The Surveillance nurse adapted a Gastrointestinal Case Log to obtain
information about the sick patients (Appendix 1). Three stool specimens were submitted for
norovirus testing at the state lab (BCL) based on the symptoms exhibited. Unfortunately, only the
number of employees reporting illness is known as demographic and disease-specific data was not
collected for this group.

Results

Between March 17 and 21, a total of
                                          Table 1. Characteristics of Cases Involved in a Norovirus
18 (34.0%) residents and 8 (14.0%)
                                          Outbreak Among Residents of an Assisted Living Facility in
employees reported gastrointestinal       Montgomery County, Alabama – March 2010 (AL1003NRV-51a).
symptoms. The mean age of ill
residents was 86.8 years (range 75-96        Characteristics                                  Ill (N=18)
years), and 14 (77.8%) were female.          Age, years
                                                      Mean (SD)                               86.8 (6.6)
Disease duration ranged from 24 to
                                                      Median                                  87.0
48 hours. Reported symptoms                           Range                                   75.0-96.0
included nausea and diarrhea (Table          Gender, female (%)                               14 (77.8)
1). Unfortunately, disease-specific          Disease onset, hours
                                                      Range                                   24.0-48.0
data are limited to patients; only the       Nausea, %                                        18 (100.0)
number of employees reporting                Diarrhea, %                                      18 (100.0)
illness was collected. Norovirus was
hypothesized as the causative agent based on the symptom complex and disease duration. BCL
isolated norovirus from three patient stool specimens submitted during this outbreak (Appendix 2).
Discussion/Conclusion

Norovirus is a major cause of gastrointestinal outbreaks in the United States. An estimated 90% of
community outbreaks associated with viral gastroenteritis is attributed to norovirus. The usual
incubation period is 12 to 48 hours followed by the abrupt onset of diarrhea, vomiting, nausea and
abdominal cramps. Norovirus is highly contagious and is transmitted primarily through the fecal-
oral route or by direct person-to-person contact.

The PHA 8 Surveillance nurse consulted central office staff and provided the following norovirus
specific recommendations to the facility:

        Distribute the Centers for Disease Control and Prevention norovirus fact sheet and
        emphasized hand washing (Appendix 2).
        Discourage usage of hand sanitizers until outbreak resolves as it is not effective against
        norovirus.
        Record the names, illness onset dates, symptoms, and room locations of ill and/or
        hospitalized residents and employees on Gastrointestinal Case Log (Appendix 3).
        Cancel all group activities and avoid transporting any patients until outbreak resolves,
        unless due to an emergency.
        Assign employees to specific work areas.
        Send symptomatic staff members home immediately and require staff be symptom free for
        two days prior to returning to work (three days if preparing food).
        Request stool specimens for symptomatic residents be sent to BCL for testing.
        Provide information, specimen containers, and lab forms for specimen collection and
        shipping.
        Contact the local nurse to report any additional illness.

In addition, the following control measures were already implemented by the facility prior to
ADPH’s investigation:

        Disinfected all common areas, doorknobs and bathrooms with Clorox® and Lysol®. All
        common linens (e.g., table cloths) sanitized.
        Sanitized all dishes, serving utensils, and condiment containers daily.
        All freezer and refrigerator items checked to insure proper dates.
        Notified family members of an outgoing outbreak.
        Posted restricted visitor signs and limited visits.
        Advised staff to use gloves and good hand washing.
        Closed the central dining area and delivered meals via tray to rooms.
        Served meals using paper products.

During the analysis of the data, several limitations were observed. The facility did not collect
specific information about disease onset for each patient. In addition, the Gastrointestinal Case Log



AL1003NRV-51a- Outbreak of Norovirus Among Residents at a Specialty Care Assisted Living Facility, Montgomery
County, AL-March 2010 (MLS/ARS)                                                                               2
did not contain information on symptoms other than nausea and diarrhea. Importantly, the facility
did not collect disease-specific information about the ill staff.

In conclusion, a norovirus outbreak occurred among residents and employees of an assisted living
facility in Montgomery County. There were 26 ill subjects, of whom information was available for 18
patients. In addition, three clinical specimens tested positive for norovirus.

Appendices

        Appendix 1. Gastrointestinal Case Log
        Appendix 2. Centers for Disease Control and Prevention Norovirus Fact Sheet
        Appendix 3. Laboratory Report




AL1003NRV-51a- Outbreak of Norovirus Among Residents at a Specialty Care Assisted Living Facility, Montgomery
County, AL-March 2010 (MLS/ARS)                                                                               3
Appendix 1. Gastrointestinal Case Log Used to Assess a Norovirus Outbreak Among Residents of an
Assisted Living Facility in Montgomery County, Alabama – March 2010 (AL1003NRV-51a).




AL1003NRV-51a- Outbreak of Norovirus Among Residents at a Specialty Care Assisted Living Facility, Montgomery
County, AL-March 2010 (MLS/ARS)                                                                               4
Appendix 2. Centers for Disease Control and Prevention Norovirus Fact Sheet Provided During a
Norovirus Outbreak Among Residents of an Assisted Living Facility in Montgomery County, Alabama
– March 2010 (AL1003NRV-51a).




AL1003NRV-51a- Outbreak of Norovirus Among Residents at a Specialty Care Assisted Living Facility, Montgomery
County, AL-March 2010 (MLS/ARS)                                                                               5
Appendix 3. Laboratory Report of a Clinical Specimen Obtained During a Norovirus Outbreak
Among Residents of an Assisted Living Facility in Montgomery County, Alabama – March 2010
(AL1003NRV-51a).




AL1003NRV-51a- Outbreak of Norovirus Among Residents at a Specialty Care Assisted Living Facility, Montgomery
County, AL-March 2010 (MLS/ARS)                                                                               6

				
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