Tackling the threat of norovirus head on

Prepared by the Health Protection Agency (HPA), together with other professional bodies from the norovirus working group.

Norovirus outbreaks in hospitals are estimated to cost the NHS in excess of £100 million each year, in years of high incidence. The norovirus working group includes members from the British Infection Association, Healthcare Infection Society, Infection Prevention Society, NHS Confederation, Sowerby Centre for Health Informatics and the National Concern for Healthcare. There are two primary reasons driving need for new guidance: the large burden of norovirus disease experienced by the NHS and other organisations recently; and the organisational and operational systems in the modern NHS and the need for efficient and safe care of patients within a safe environment.

Norovirus symptoms include a sudden onset of vomiting and/or diarrhoea. Some people may also have a temperature, headache and stomach cramps. It usually resolves in one to two days and there are no long-term effects. Unless someone is severely dehydrated there is no need to attend hospital for treatment.

Though outbreak management guidance has been in place for a number of years the latest document draws on current practice that shows how cases should be managed in single rooms and bays in the first instance if possible. This will allow some flexibility in the response and also for cleaning to take place allowing smaller wards to be able to re-open more quickly.

If managing the cases at the single room or bay level fails to control the outbreak then the outbreak control team (OCT) can consider closing the whole ward. This approach would not work in ‘Nightingale’ style wards where all the beds are in one room and segregation of those who have the virus would not be possible. In these cases the ward would need to be closed.

The guidance also includes recommendations that include closing affected bays to admissions and transfers and closing doors to side rooms and bays. Other measures are to have signage on doors informing all visitors that the ward is closed and restricting staff and essential social visitors only to the affected area and planning a deep clean at the earliest possible date.

Building Awareness
There are separate recommendations for healthcare workers who are integral to the response. This covers the need for all staff to be aware of the norovirus outbreak and how the virus is transmitted. They also need to ensure that all staff are aware of the work exclusion policy and the need to go off duty at the first sign of symptoms and to allocate staff to duties in either affected or non-affected areas, but not both.

Dr Bharat Patel, the HPA’s lead consultant medical microbiologist, and one of the authors on the report, said: “Managing norovirus outbreaks is very hard owing to the nature of the virus and how quickly it spreads. Any outbreak causes widespread disruption and it is very important that appropriate control measures are implemented quickly.

“This guidance gives very clear recommendations on how to manage outbreaks within the hospital and community setting. It will be greatly beneficial to staff to know that there is now the option of trying to manage the outbreak at the single room and bay level which will reduce the pressure that closing wards has on both staff and patients.”

Striking a balance
The guidance is based on a principle of minimising disruption to important and essential services and maximising the ability of organisations to deliver appropriate care to patients safely and effectively. There is, it says, a shift of focus towards a balance between the prevention of the spread of infection, and maintaining organisational activity. This means, in effect, a move away from the traditional approach of complete ward closure and an adoption of a pragmatic, escalatory system of isolation using single rooms and cohort nursing without compromising patient care both for norovirus itself and other essential healthcare.

Approximately 3000 people a year are admitted to hospital with norovirus in England and the incidence in the community is thought to be about 16.5 per cent of the 17 million cases of Infectious Intestinal Disease in England per year, according to the guidelines. There is, it goes on to say, evidence that this burden has increased over the past decade.

Within the guidance there are recommendations on the management of outbreaks of vomiting and/or diarrhoea in hospitals and community health and social care settings, including nursing and residential homes. There are other causes of vomiting and/or diarrhoea outbreaks and the guidance will apply to all viral gastroenteritides. However, the principal and most common causes of such outbreaks is norovirus which is one of the most infective agents seen in health and social care establishments and the title reflects this. Food borne norovirus outbreaks require investigation and management according to other appropriate guidance and procedures.

Organisational Preparedness
Norovirus impacts the health and social care systems differently every year. This can include outbreaks within schools and communities, hospital ward closures or admission restrictions, closure of nursing and residential homes, or delays in patient transfers. Because such outbreaks can cause severe patient service disruption, the new guidelines address the importance of organisational preparedness for such incidents.

Even the closure of schools, in addition to the implications for local authorities, impacts on the ability for health and social service delivery because many staff may need to take time off work for emergency childcare.

All services registered under the Health and Social Care Act 2008 are expected to have a policy for the control of outbreaks of communicable infections (governed in England by the Care Quality Commission) and these are often developed through the Infection Prevention and Control Team (IPCT). In today’s health and social care settings there is a need to ensure minimal disruption to services and maximise the ability of organisations to deliver safe and effective services based on local risk assessment.

Business Continuity
Organisations must develop systematic business continuity plans for use in outbreak situations. The plan should include actions for safe environments, staffing, information, surveillance, communications and leadership.

Clear plans should be in place as to the policy for segregation and protection of patients. Before an outbreak occurs, organisations need to be clear about what escalation system will be used at the onset and throughout the course of the outbreak. The policy on the movement of patients and staff needs to be fully understood by the workforce.

Business continuity plans will already contain actions for staff arrangements. During an outbreak organisations will need to have a clear policy for the management of staff who are affected by the virus and their return to work. Consideration will need to be given to those who can’t work due to family care needs. Escalation measures for the redeployment of staff from other departments to deliver front line services should also be included. These plans should consider arrangements with other organisations for potential staff movement (e.g. acute to community and vice versa, use of voluntary sector).

Organisations will need to have in place information systems for the dissemination of information to staff, patients and the public as the outbreak escalates and then returns to normal status. A suite of information material should be part of the continuity plan and be ready for use on day 1 of the outbreak (e.g. laminated signs for use at ward or department entrances, signs at entrances of organisations to inform the public, guidance signs at any on-site food outlets).

Staff information needs to include infection prevention practice, occupational health support and processes, and health messages to patients and visitors. Patient information needs to include protection of their own wellbeing and environment, advice to their family and friends who visit, and the organisational policy for movement around the environment. Public information should include general advice on the prevention and spread of the infection, avoiding visiting patients if they, their family or other contacts have been unwell, and the restriction of food items being brought in during an outbreak.

A key element of information in an outbreak is accurate data around both patient and staff incidence. Organisations need to have systems in place, preferably electronic, to aid decision making for patient and staff placement and movement. Information needs to be timely and accurate.

Information availability and needs change rapidly during an outbreak especially in the early phases of escalation. Increased awareness through effective communication may favourably alter the dynamics of an outbreak. Plans must include clear systems of two way communication between outbreak meetings and the rest of an organisation and communication with other health and social care organisations, says the guidelines.

Strong and visible leadership is essential during times of duress in any organisation. During an outbreak, effective business continuity planning provides staff with assurance of a clear plan of action. Senior leadership involvement should include the Director of Infection Prevention and Control (DIPC) in England to ensure that both Infection Prevention and Control and service provision are integral to the plan. The participation of the chief executive in outbreak management within an organisation sends out a clear message to staff. Part of the business continuity plan and outbreak policy will include clarification of roles including the authority to make decisions. For smaller, community-based organisations such as some nursing and residential homes, this management model may not apply. In such situations, appropriate operational director involvement will be required.

Whilst plans need to be clear, succinct, and have lines of accountability and decision making stated, every outbreak is different and an element of flexibility will be required to enable an organisation and health and social care economy to manage the outbreak effectively to enable a return to normal business as soon as possible.

Evaluation
Following each outbreak a multidisciplinary or organisational evaluation should take place to review the outbreak and learn lessons in order to strengthen future plans. These lessons need to be shared across organisations in order to improve future outbreak management.

Norovirus epidemiology changes over time and geography and the emergence of new strains will continue to challenge us as populations at risk, including employees of affected organisations, also changes. Meeting these challenges will require robust surveillance of outbreaks and sentinel surveillance of norovirus activity in organisations and the wider community.

Laboratory work also remains vital to those involved in the investigation and management of outbreaks and guidance is included on the appropriate use of norovirus testing.

Further information
The guidelines are available on the HPA website at: www.hpa.org.uk/Publications/InfectiousDiseases