Society of Chief Officers of Environmental Health in Scotland Outbreak Control Viral Gastro-enteritis INFECTION CONTROL PROCEDURES FOR COACHES, HOTELS, EXHIBITION CENTRES AND SIMILAR PREMISES 1
Introduction Reports of outbreaks of gastro-intestinal illness, whose cause is known or attributed to a Small Structured Round Virus (SSRV) or Norwalk-like Agent, have risen markedly over the last decade. SSRVs are a cause of both institutional outbreaks involving person-to-person transmission and food-borne gastro-enteritis. Outbreaks due to person-to-person spread tend to be of particular importance in hotels and similar premises. This document has been produced for your guidance in the event of illness arising within your premises. Further advice and assistance may be obtained by contacting your local Environmental Health Office. Virus Survival Viruses only multiply in certain living tissues. When outside this medium, then can survive for varying time periods depending on the type of organism and environmental conditions. Viruses do not grow on foods. However, illness may be associated with food where contamination can be attributed to infected food handlers or foods, which have come into contact with an infected environment. Symptoms SSRVs are generally associated with short-lived illness sometimes referred to as winter vomiting disease which rarely results in the victims obtaining medical attention unless in a high-risk group. Vomiting, often projectile, is normally the most prominent symptom with diarrhoea tending to last for only a short time, being less severe than with other causes of gastroenteritis. Other features such as fever and headache occur in a minority of those affected. The incubation period is from 24 to 48 hours and gastro-intestinal symptoms resolve spontaneously within a further 24 to 48 hours. Persons not exhibiting symptoms of illness can excrete the virus for considerable periods of time. Spread Person-to-person spread via the faecal-oral route or via aerosols, which are released by projectile vomiting, are the most common. It is also understood that airborne transmission can occur in the absence of vomiting. Whilst the duration of illness is normally limited within individuals, outbreaks can be perpetuated for several weeks amongst newly exposed groups of people, where a reservoir of infection remains either in staff or within the environment. 2
Role of Environmental Health The local Environmental Health Officer, in conjunction with the area Health Board, has a responsibility for the control of communicable disease. This is achieved in a number of ways: investigate the cause of the illness take samples for analysis advise on good hygiene practices advise on control strategies implement outbreak control measures co-ordinate control plans prepare after the event reports for discussion and implementation of the lessons learned advise on preventative measures 3
Being Prepared In order that an outbreak of illness may be rapidly brought under control, it is imperative that management and staff are fully prepared for an incident at all times. The responsibilities of staff members should be clearly defined and the person/persons who will co-ordinate an outbreak investigation and implement control measures must be identified. It is recommended that a specialist Clean--Up Team be appointed who can deal with gross contamination in the event of an outbreak of illness. This team may comprise of existing staff members. All staff which would be involved with an outbreak, either directly as part of a Clean-Up Team, or indirectly, should be aware of the guidelines for the management of an outbreak and have undertaken suitable training. Where appropriate, staff should be supervised. Equipment, staffing and resources identified for the control of an outbreak should be accessible at all times. It is recommended that contacts are identified both within the local Environmental Services and G.P s Practice. This will mean that in the event of an outbreak, advice and assistance for staff and guests will be readily available. 4
Initial Investigation Notification of Illness Where it is apparent that a person within a hotel or similar premises is suffering from the symptoms of gastro-intestinal illness, an investigation should be undertaken. Where possible, the investigation should commence immediately. The following information must be obtained: Name, Address and Telephone Number of the affected person Name and Address of the affected person s own G.P. Room Number Details of transport arrangements and accompanying persons Description of symptoms and date and time of onset Any indication that a food may be implicated If necessary, the local G.P. should be contacted for medical assistance and where a food source may be implicated the Environmental health Officer should be contacted for advice. Where the symptoms indicate that the illness is likely to be viral in origin, i.e. vomiting being the most common symptom and the duration of the illness being generally shortlived (12 to 48 hours), outbreak control procedures should be initiated. When two or more cases are identified the Environmental Health Officer should be notified. 5
Control Measures Control measures aim to prevent person-to-person transmission between existing groups of residents and staff, prevent the spread of illness to other premises via infected persons or transport and prevent the infection of newly-exposed residents or staff to a contaminated environment or food. Therefore: Where possible, infected persons should be isolated within their accommodation for the duration of their illness and meals provided therein. Plenty of fresh drinking water should be made available and the affected person should be given the option of seeing a G.P. Provide suitable receptacles for vomit, e.g. buckets or tubs. Assemble the Clean-Up Team and undertake checks to ensure that sufficient cleaning supplies are available. Towels must be changed at least daily and soiled bed linen removed and replaced as required following the guidelines detailed below. Contaminated laundry should be placed in plastic bags, which are identifiable. Thorough cleaning and disinfection of rooms of infected persons and communal facilities must be undertaken in accordance with the cleansing procedures included in this document. After cleaning, ensure that rooms are well ventilated. Transport operators must be made aware of the occurrence of illness and have the knowledge and facilities available to clean their vehicles as described within this document. Where persons associated with an outbreak of illness are transferring to other accommodation, the management of the intended destination should be advised of the outbreak situation. On the departure of affected persons, the room occupied should be thoroughly cleansed as described below. Note: If staff that handle food are affected, they must be immediately excluded from work until they have been free of symptoms for at least 48 hours. All control procedures should be implemented for staff as for other persons affected. The Clean-Up Team The Clean-Up Team should be available on request to clean up occurrences of gross contamination and vomit in accommodation and communal facilities. The team must routinely clean public areas, as necessary and shared facilities should be cleaned at least hourly during an outbreak. Arrangements for the Clean-Up Team should aim to limit the number of staff having contact with infected cases. 6
Facilities and Equipment The Clean-Up Team should be provided with the following equipment, kept in a lockable cupboard and solely for the purposes of the Team: Rubber gloves Disposable aprons Disposable facemask Dustbin bags in a distinctive colour Soiled linen bags Disinfectant/virucidal agent Multi-purpose detergent cleaner Wet/dry vacuum cleaner Absorbent granules Virucidal air freshener Disposable cloths Mop, bucket and dustpan and brush In addition, the following facilities must be made available: A cleaning sink with hot and cold water Refuse storage receptacles Changing and washing facilities supplied with hot and cold water and bactericidal soap and a nailbrush Cleaning Procedures Hard Surfaces: (For example, wash basins, work surfaces, toilets and washable floors) Gross contamination should be treated with absorbent granules, which can then be removed for proper disposal. All surfaces should be cleaned with detergent to remove debris and dirt. Apply disinfectant/virucidal agent after cleaning. 7
Soft furnishings: Carpets should be cleansed using a wet clean vacuum containing a detergent and disinfectant solution. The area to be cleaned should extend to at least three metres around the contaminated area. Other soft furnishings should have gross contamination removed using the wet vacuum and/or disposable cloths, and then the contaminated area and its surrounds should be sprayed with a virucidal agent/disinfectant. Laundry: If an external laundry service is used, inform the operators of the likelihood of contaminated bedding, etc and identify any special requirements, which they may have for the receipt of such articles. Where there is gross contamination of laundry it should be disposed of. Disposal advice is available from Environmental Health, see below for contact details. Washing temperatures should exceed 60 C on a full wash cycle. Air borne contamination: Virucidal air freshener can be used for dealing with air borne viruses in public places and occupied rooms. Fogging of public rooms and bedrooms may be of particular value. Fogging must be carried out when rooms are unoccupied. Adequate ventilation of rooms after spraying is essential. Cleaning of Premises Gross Contamination: All contaminated material should be removed and cleaned or properly disposed of in accordance with the procedures detailed above. Please note this is a job for the clean up team. A routine clean may also be required see below. Routine cleaning: Remove any contaminated material and clean the room as normal. Clean and disinfect bathroom surfaces and fittings. Clean and disinfect all hand contact surfaces (including door handles). Wash cup and glasses and disinfect. Replenish drinking water supplies. When cleaning is complete replace towels and linen as necessary. Where possible ventilate the room. 8
Cleaning of vacated rooms: Remove bedding and towels for laundering. If possible duvets and pillows should be removed for cleaning. Where this is not practicable they should be treated with a virucidal agent. All other soft furnishings should be treated with virucidal agent. All hard surfaces including internal and external surfaces of furniture, waste bins, handles, window frames and bathroom fittings, should be cleaned and disinfected. Cups, glasses, teapots and other crockery should be cleaned and disinfected. Such crockery should not be taken to the kitchen unless it has been sterilised first. Cleaning of Transport The responsibility for cleaning transport must be defined prior to any outbreak, as there may be an overlap between the transport operator and the accommodation management. Environmental Health would advocate that gross contamination of transport be dealt with a soon as practicable by the driver. This means the driver must be equipped with appropriate personal protective kit and cleaning materials. Further cleaning and disinfection will be required on arrival and the Clean Up Team may carry this out. Gross contamination: Incidents of sickness and diarrhoea should be cleaned up as soon as possible using absorbent granules or disposable cloths and placed in a suitable receptacle for disposal. The contaminated area should then be treated with a virucidal agent or virucidal air freshener. Routine cleaning: On arriving at the destination the transport operator should notify the person in charge of the occurrence of illness on board his/her vehicle and the action taken. The transport operator or Clean Up Team should then carry out a full routine clean. Remove any contaminated material for proper disposal. Remove seat head rest covers, cushions, etc and launder at 60 C. Clean and disinfect hard and soft furnishings with the appropriate cleaner/disinfectant. Include toilets, washbasins, handles, floors and windows. Clean accessible carpeted areas with a wet and dry vacuum cleaner containing detergent and disinfecting solution or clean and treat with virucidal agent. 9
Where fogging is to be used on board transport, cleaning should be carried out first and then the disinfectant allowed to permeate the vehicle, including the air conditioning system, if fitted. The vehicle should be well vented after cleaning and disinfection is complete. Cleaning agents Disinfectants: For the destruction of viruses, a disinfecting agent delivering at least 1000 parts per million (ppm) or 0.001% of available chlorine is required. Examples of such agents are included below but you should contact your supplier for details of products that will be suitable for your premises and the surfaces/furnishings therein. (a domestic bleach solution at a dilution of 1:10 or a Milton Fluid solution at a dilution of 1:10 will satisfy the above requirement). Virucidal agents: Some products are specifically designed for killing or de-activating viruses in addition to having a bactericidal effect. Please contact your supplier. Detergents: Suitable detergents should be selected to remove dirt and debris from the item or surface being cleaned prior to disinfection. Please consult your supplier. Fogging agents: The fogging of disinfectants gives more complete control of viruses that may be present on air borne particles. A fogging machine is required to deploy with method of disinfection and you should consult your supplier for advice. For further information and advice contact your local Environmental Health Service: - East Lothian Council, John Muir House, Haddington. TEL: 01620 827365 FAX: 01620 827918 July 2002 10