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| __NOTOC__
| | #REDIRECT [[Norovirus outbreak resident survival guide]] |
| {{WikiDoc CMG}}; {{AE}} {{TS}}
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| ==Definition==
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| [[Norovirus]] is one of the extremely [[contagious]] viruses leading to 50% of the [[gastroenteritis]] outbreaks worldwide.<ref name="pmid19084472">{{cite journal| author=Patel MM, Hall AJ, Vinjé J, Parashar UD| title=Noroviruses: a comprehensive review. | journal=J Clin Virol | year= 2009 | volume= 44 | issue= 1 | pages= 1-8 | pmid=19084472 | doi=10.1016/j.jcv.2008.10.009 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19084472 }} </ref> An outbreak of norovirus is defined as an occurrence of 2 or more similar illnesses resulting from a common exposure that is either suspected or laboratory-confirmed to be caused by norovirus.<ref name="www.cdc.gov">{{Cite web | last = | first = | title = CDC - Norovirus - Reporting and Surveillance for Norovirus | url = http://www.cdc.gov/norovirus/php/reporting.html | publisher = | date = | accessdate = 10 February 2014 }}</ref> | |
| ==Causes==
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| ===Life Threatening Causes===
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| Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Severe dehydration can be a life threatening without medical attention.
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| ===Common Causes===
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| * [[Norovirus infection]]
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| ==Prevention of Norovirus Outbreak==
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| Shown below is an algorithm summarizing the approach to prevention and control of a [[norovirus]] infection outbreak according to recommendations by CDC.<ref name="pmid21368741">{{cite journal| author=Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention| title=Updated norovirus outbreak management and disease prevention guidelines. | journal=MMWR Recomm Rep | year= 2011 | volume= 60 | issue= RR-3 | pages= 1-18 | pmid=21368741 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21368741 }} </ref>
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| ===Tips for Healthy Cruising===
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| ====Before Cruising====
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| {{Family tree/start}}
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| {{Family tree |border=2|boxstyle=background: WhiteSmoke;|A1|A1=<div style="float: left; text-align: left; height: 4em; width: 45em; padding:1em;">❑ If you are sick before starting your cruise, consider alternative cruising options.</div>}}
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| {{familytree/end}}
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| ====On the Cruise====
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| {{Family tree/start}}
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| {{Family tree |border=2|boxstyle=background: WhiteSmoke;|A1|A1=<div style="float: left; text-align: left; height: 18em; width: 45em; padding:1em;">'''Hand Hygiene'''<br>
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| ----
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| ❑ Wash hands with soap and running water for 20 seconds.<br>
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| ❑ Hand sanitizers (with at least 60% alcohol) can be used as an adjunct to soap.<br>
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| ❑ Wash your hands:<br>
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| : ❑ Before eating, drinking and smoking<br>
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| : ❑ After visiting bathroom<br>
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| : ❑ After changing diapers<br>
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| : ❑ After touching things that other people might have touched<br>
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| ❑ Avoid touching your face.<br>
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| ❑ Do not touch any ready to eat foods with bare hands.</div>}}
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| {{Family tree |!| }}
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| {{Family tree |border=2|boxstyle=background: WhiteSmoke;|B1|B1=<div style="float: left; text-align: left; height: 18em; width: 45em; padding:1em;"> '''Food and water precautions:''' <br>
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| ----
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| ❑ Avoid eating raw fruits and vegetables unless they are washed and peeled by yourself.<br>
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| ❑ Avoid eating improperly cooked shellfish, oysters and clams.<br>
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| ❑ Prefer food which is cooked properly and served hot.<br>
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| ❑ Avoid ice<br>
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| ❑ Safe beverages include :<br>
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| : ❑ '''Bottled''' or canned water<br>
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| : ❑ Bottled carbonated soda<br>
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| : ❑ '''Hot''' tea, coffee, beer and wine<br>
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| : ❑ Boiled water, or water which has been treated appropriately with chlorine.<br>
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| : ❑ Beverages from sealed containers are safe</div>}}
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| {{Family tree |!| }}
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| {{Family tree |border=2|boxstyle=background: WhiteSmoke;|B1|B1=<div style="float: left; text-align: left; height: 9em; width: 45em; padding:1em;">'''Isolation of infected people'''<br>
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| ----
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| ❑ If you see someone getting sick, move away from the area and report to the cruise staff.<br>
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| ❑ Infected patients should be isolated during period of illness and up to 48-72 hours following recovery.<br>
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| ❑ Asymptomatic but norovirus positive food handlers should also be isolated.</div>}}
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| {{Family tree |!| }}
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| {{Family tree |border=2|boxstyle=background: WhiteSmoke;|C2| C2=<div style="float: left; text-align: left; height: 15em; width: 45em; padding:1em;">'''Disinfect environment'''<br>
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| ----
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| ❑ Clean contaminated surfaces to remove organic loads.<br>
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| ❑ Use freshly prepared 5000 ppm chlorine bleach solution.<br>
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| ❑ Apply disinfecting agent for up to 4 min on fecally soiled surfaces.<br>
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| ❑ Other disinfecting agents include:
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| : ❑ Ozone<br>
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| : ❑ Hydrozen peroxide<br>
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| ❑ A list of disinfecting agents approved by EPA is available.<ref>{{Cite web | last = | first = | title = http://www.epa.gov/oppad001/list_g_norovirus.pdf | url = http://www.epa.gov/oppad001/list_g_norovirus.pdf | publisher = | date = | accessdate = 10 February 2014 }}</ref></div>}}
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| {{familytree/end}}
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| ==Approach to Norovirus Outbreak==
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| Shown below is an algorithm summarizing the approach to [[norovirus]] infection outbreak according to recommendations by CDC.<ref name="pmid21368741">{{cite journal| author=Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention| title=Updated norovirus outbreak management and disease prevention guidelines. | journal=MMWR Recomm Rep | year= 2011 | volume= 60 | issue= RR-3 | pages= 1-18 | pmid=21368741 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21368741 }} </ref>
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| {{familytree/start |summary=PE diagnosis Algorithm.}}
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| {{familytree | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | | | | | |A01=<div style="float: left; text-align: left; height: 18em; width: 20em; padding:1em;">'''Characterize the symptoms'''<br>
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| ----
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| ❑ Non bloody [[diarrhea]]<br>❑ [[Vomiting]]<br>❑ [[Nausea]]<br>❑ [[Abdominal cramps]]<br>❑ [[Low grade fever]]<br>❑ Body aches <br>❑ [[Necrotising enterocolitis]] (in [[neonates]])<br>❑ Chronic diarrhea (in [[immunosuppressed]])<br> ❑ [[Irritable bowel syndrome]]</div>}}
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| {{familytree | | | | | |,|-|^|-|.| | | | | | | | | | | | | | | | | | | | | | | | }}
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| {{familytree | | | | | Z01 | | Z02 | | | | | | | | | | | | | | | | | | | | | | |Z01=Laboratory tests can be done|Z02=Laboratory tests cannot be done}}
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| {{familytree | | | | | |!| | | |!| | | | | | | | | | | | | | | | | | | | | | }}
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| {{familytree | | | | | C01 | | C02 | | | | | | | | | | | | | | | | | | | | |C01='''Collect samples'''|C02='''Assess The Kaplan Criteria'''}}
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| {{familytree | | | | | |!| | | |!| | | | | | | | | | | | | | | | | | | | | | }}
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| {{familytree | | | | | B01 | | B02 | | | | | | | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: left; height: em; width: 20em; padding:1em;">
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| ❑ '''Whole [[stool]] sample'''<br>
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| '''Collection:'''<br>
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| : ❑ Within 48 to 72 hrs after onset<br>
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| : ❑ From at least 5 ill patients<br>
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| : ❑ 10-50 ml of whole stool sample in a stool cup is preferred.<br>
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| '''Storage:'''<br>
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| : ❑ If testing done < 3 weeks
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| :: ❑ Refrigerate samples at 39 F<br>
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| : ❑ If testing done > 3 weeks<br>
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| :: ❑ Refrigerate samples at - 4 F<br>
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| '''Transportation:'''<br>
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| : ❑ Bagged, sealed and transported on ice packs in an insulated and waterproof container.
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| ❑ '''Vomitus sample''' <br>
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| ❑ '''Environmental samples:'''<br>
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| : ❑ Water sample <br>
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| : ❑ Shellfish samples <br>
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| : ❑ Environmental surface swabs<br>
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| (Pursued in consultation with CDC)</div>|B02=<div style="float: left; text-align: left; height: 8em; width: 20em; padding:1em;">'''Kaplan Criteria'''<br>
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| ----
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| ❑ Mean duration of illness is 12-60 hours.<br>
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| ❑ Mean incubation period is 24-48 hours.<br>
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| ❑ Vomiting is present in more than 50% of ill people.<br>
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| ❑ No bacterial agent found.
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| </div>}}
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| {{familytree | | | | | |!| | | |!| | | | | | | | | | | | | | | | | | | | | | }}
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| {{familytree | | | | | D01 | | D02 | | | | | | | | | | | | | | | | | | | | |D01=<div style="float: left; text-align: left; height: 8em; width: 20em; padding:1em;"> '''Diagnostic tests''':<br>
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| ----
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| ❑ Enzyme immunoassays (RIDASCREEN)<br>
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| ❑ Real time RT-PCR<br>
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| ❑ Geno-typing<br>
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| ❑ Electron microscopy</div>|D02=All 4 criteria present?}}
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| {{familytree | |,|-|-|-|(| | | |)|-|-|-|.| | | | | | | | | | | | | | | | | | }}
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| {{familytree | |!| | | |!| | | |!| | | |!| | | | | | | | | | | | | | | | | }}
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| {{familytree | E02 | | E01 | | E03 | | E04 | | | | | | | | | | | | | | | | |E01='''[[Norovirus]]''' '''positive'''|E02='''[[Norovirus]]''' '''negative'''|E03='''Yes'''|E04='''No'''}}
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| {{familytree | |!| | | |!| | | |!| | | |!| | | | | | | | | | | | | | | | | | }}
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| {{familytree | F02 | | F01 | | F03 | | F04 | | | | | | | | | | | | | | | | | F01=<div style="float: left; text-align: left; height: 5em; width: 15em; padding:1em;">❑ '''Take measures to prevent and contain an outbreak''' <br>❑ Treat [[acute gastroenteritis]]</div>|F02=<div style="float: left; text-align: left; height: 2em; width: 15em; padding:1em;">❑ Treat as [[Acute diarrhea resident survival guide|acute gastroenteritis]]</div>|F03=Norovirus outbreak highly likely|F04=<div style="float: left; text-align: left; height: 5em; width: 15em; padding:1em;">Norovirus outbreak cannot be ruled out</div>}}
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| {{familytree | | | | | |!| | | |!| | | | | | | | | | }}
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| {{familytree | | | | | |`| G01 |'| | | | | | | | | | | | | | | | | | | | | |G01=<div style="float: left; text-align: left; height: 28em; width: 19em; padding:1em;">
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| ❑ '''Measures to Contain an Outbreak'''<br>
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| ----
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| : ❑ Isolate the infected patients and food handlers for a minimum period of 48 hours after recovery from symptoms.<br>
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| : ❑ Disinfect routinely touched surfaces.<br>
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| : ❑ Promote hand hygiene among people during an outbreak.<br>
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| : ❑ Avoid any group activities.<br>
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| : ❑ Notify local and state health departments.<br>
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| : ❑ Activate outbreak prevention and response plan (OPRP) on cruise ships.</div>}}
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| {{familytree/end}}
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| ==Initial Management of Acute Gastroenteritis==
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| Shown below is an algorithm summarizing the approach to initial management of acute gastroenteritis.
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| {{familytree/start |summary=PE diagnosis Algorithm.}}
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| {{familytree | | | | | | | C01 | | |C01 = '''Assess volume status'''<br>
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| <table class="wikitable">
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| <tr class="v-firstrow"><th>'''General condition'''</th><th>Normal</th><th>Irritable/less active*</th><th>Lethargic/comatose<sup>§</sup></th></tr>
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| <tr><td>'''Eyes'''</td><td>Normal</td><td>Sunken</td><td> - </td></tr>
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| <tr><td>'''Mucosa'''</td><td>Normal</td><td>Dry</td><td> - </td></tr>
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| <tr><td>'''Thirst'''</td><td>Normal</td><td>Thirsty</td><td>Unable to drink<sup>§</sup></td></tr>
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| <tr><td>'''Radial pulse'''</td><td>Normal</td><td>Low volume*</td><td>Absent/ uncountable<sup>§</sup></td></tr>
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| <tr><td>'''Skin turgor'''</td><td>Normal</td><td>Reduced</td><td> - </td></tr>
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| </table>
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| † Some dehydration = At least two signs, including at least one key sign (*) are present. <BR>
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| ‡ Severe dehydration = Signs of “some dehydration” plus at least one key sign (§) are present.
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| }}
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| {{familytree | | | |,|-|-|-|+|-|-|-|.| |}}
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| {{familytree | | | D01 | | D02 | | D03 | D01 = '''No dehydration''' | D02 = '''Some dehydration''' | D03 = '''Severe dehydration'''}}
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| {{familytree | | | |!| | | |!| | | |!| |}}
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| {{familytree | | | E01 | | E02 | | E03 | E01 =<div style="float: left; text-align: left; height: 25em; width: 15em; padding:1em;"> '''Start altered diet'''
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| ❑ Stop lactose products <br> ❑ Avoid [[alcohol]] and high osmolar supplements <br> ❑ Drink 8-10 large glasses of clear fluids (Fruit juices, soft drinks etc) <br> ❑ Eat frequent small meals (Rice, potato, banana, pastas etc) <br>
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| ----
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| Can start [[oral rehydration therapy]] (ORT) for replacement of stool losses </div> | E02 = <div style="float: left; text-align: left; height: 25em; width: 15em; padding:1em;">❑ Start [[ORT]] at a volume of 50-100 mL/kg <br> ❑ Start altered diet <br> ❑ Reassess status every 4 hr </div>| E03 = <div style="float: left; text-align: left; height: 25em; width: 15em; padding:1em;">❑ Start IV fluids: Ringer lactate at 30ml/kg in the first 1/2hr and 70ml/kg for the next 2 1/2 hr, if unavailable use normal saline <br> ❑ [[CBC]]<br> ❑ [[Electrolytes]] <br> ❑ Assess status every 15 mins until strong pulse felt and then every 1 hr </div>}}
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| {{familytree | | | | | | | | | | | |!| |}}
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| {{familytree | | | | | | | | | | | F01 | | F01 = <div style="float: left; text-align: left; height: 25em; width: 15em; padding:1em;"> '''Patient stable and able to drink'''<br>❑ Start ORT at a volume of 100 mL/kg over 4 hour <br> ❑ Calculate the continuing stool and emesis losses every hour for additional maintenance ORT therapy<br> ❑ Reassess status every 4 hr</div>}}
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| {{familytree/end}}
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| ==Do's==
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| * Settings prone to outbreaks are:<br>
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| : ❑ Health care settings<br>
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| : ❑ Restaurants<br>
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| : ❑ Cruise ships<br>
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| : ❑ Schools and other institutional settings
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| * Symptoms of norovirus gastroenteritis typically resolve in 3 days.
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| * Outbreak is considered as norovirus positive if stool or vomitus specimens from 2 or more patients are found to be positive for norovirus by RT-PCR, EIA or electron microcopy.
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| * Outbreaks are reported to CDC by local and state health departments through NORS (National Outbreak Reporting System).
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| ==Dont's==
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| * Serum samples are not recommended for routine norovirus detection.
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| * Do not use hand sanitizers as a substitute for washing hands with soap and water.
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| ==References==
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