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JUNE 2008
Main Article:
Control of Viral Gastroenteritis within Jails and Prisons
Joseph Bick, MD Chief Deputy, Clinical Services California Medical Facility, California Department of Corrections and Rehabilitation Disclosures: Nothing to disclose Introduction The noroviruses are a group of related viruses in the Caliciviridae family. The name “norovirus” comes from the first identified member of this group, which was isolated from diarrheal stools in 1972 during an outbreak of gastroenteritis in an elementary school in Norwalk, Ohio. Subsequently, noroviruses have been identified as the most common cause of gastroenteritis in the U.S. Noroviruses cause an estimated 23 million cases of gastroenteritis each year in the U.S., more cases than are caused by all other viral, bacterial, and parasitic agents combined. Although noroviruses circulate year-round, epidemics are most commonly recognized in the winter and early spring. Outbreaks of gastroenteritis due to noroviruses are especially common in congregate living environments such as hospitals, long term care facilities, military barracks, summer camps, and cruise ships. More recently, noroviruses have been identified as the cause of gastroenteritis outbreaks in jails, prisons, and detention facilities. Norovirus outbreaks have the potential for significant morbidity, occasional mortality, and disruption in the routine operation of correctional facilities. This article provides recommendations to assist medical and custody personnel in the diagnosis, treatment, and containment of gastroenteritis outbreaks in the correctional setting. Epidemiology There are approximately 267,000,000 episodes of diarrhea among adults in the U.S. each year, resulting in an estimated 612,000 hospitalizations and 3,000 deaths.1 An etiologic agent is identified in less than 10% of these cases of diarrhea, and most persons with acute diarrhea do not seek medical care as a result of their illness. The very young, the elderly, and the immunocompromised are most affected by these illnesses. Little has been published on the frequency and etiology of diarrheal illness among the incarcerated. Inmates often store food in their cells or dorms for later consumption, and do not usually have access to refrigeration or cooking appliances. Perishable food stuffs can be a source of viral and bacterial gastroenteritis. In non-incarcerated institutional settings, toxins and over 200 different bacteria, viruses, fungi, and parasites have been identified as the source of diarrheal outbreaks. Contaminated foods that have been linked to diarrheal illness include pork2, chicken3, ground beef4, milk5, unpasteurized apple cider6-7, spinach8, eggs9, raspberries10, onions11, raw nuts12, cantaloupe13, tomatoes14, soft cheeses15, and shellfish.16 Table 1 details the estimated total number of cases, frequency of food-borne transmission, and hospitalizations for the most common causes of infectious organisms that can cause diarrhea in the U.S.. Signs and symptoms of noroviruses The incubation period for norovirus following infection is 12-48 hours. In healthy adults, clinical signs and symptoms are generally mild and of short duration, usually 12-60 hours. The illness can be more severe in the elderly and others who have compromised immunity. Rarely, severe dehydration due to norovirus can be fatal. There are no known long-term sequelae that result from norovirus infection. Most of those who become ill experience the sudden onset of nausea, vomiting, abdominal cramps, and diarrhea. Constitutional symptoms including low-grade fever, headache, chills, and myalgias are common. Patients may experience only vomiting, commonly referred to as winter vomiting disease.17 Diarrhea due to norovirus is usually watery, and less severe than that caused by bacteria. After recovery from illness due to norovirus, individuals generally experience short-lived immunity from recurrent illness and are therefore susceptible to repeated infection and disease within 6 months. Transmission Viral gastroenteritis can be introduced into a jail or prison by employees, visitors, volunteers, or inmates who are transferred into the facility. Less frequently, the virus can enter a facility in contaminated food or water. Norovirus is excreted in the stool of infected persons, and can be shed from those who do not become clinically ill. Excretion of virus precedes clinical illness and can persist for more than a week after symptoms resolve.18-20 Noroviruses are readily spread from person to person, by fomites, and from contaminated environmental surfaces. The major route of transmission is person to person (fecal-oral) via hands contaminated with feces or emesis. Norovirus is characterized by both a low infectious dose (100 viral particles) and a high attack rate among exposed persons.21 The prolonged shedding of virus in the stool of asymptomatic persons increases the likelihood of transmission by infected food handlers. Noroviruses can survive temperature extremes from freezing to 140 F, and resists killing by numerous disinfectants including relatively high levels of chlorine.22 Diagnosis The first and most important step in the diagnosis of gastroenteritis is to remain vigilant, especially when norovirus is known to be circulating in the outside community. Once viral gastroenteritis is suspected, a rapid definitive diagnosis of the causative agent will help guide strategies for infection control and containment. An outbreak should be suspected if > 2 inmates and/or employees concurrently develop nausea, vomiting, and diarrhea. The coexistence of vomiting and diarrhea is a useful clue to the presence of norovirus. During a suspected outbreak, fresh stool should be collected from six to twelve persons. In addition to testing specimens for norovirus, stool should be cultured for campylobacter, salmonella, and shigella. If the stool is bloody, it should also be tested for E. coli 0157:H7. Noroviruses cannot be cultured. Options for diagnosis include direct visualization of viruses by electron microscopy (EM), enzyme-linked immunosorbent assays (EIA) for detection of virus in stool, the serologic detection of a fourfold increase of specific antibodies in acute- and convalescent-phase blood samples, and the use of reverse-transcription polymerase reaction (RT-PCR).22-25 Because most adults have been infected with norovirus at some point, the simple presence of IgG antibody to norovirus is not useful in terms of making a diagnosis. Serologic diagnosis, therefore, requires detecting either virus-specific IgM antibodies or rising antibody titers in paired acute and convalescent blood samples. The time lag involved in the development of antibodies further limits the usefulness of serological diagnosis. Currently available EIAs are insufficiently sensitive and specific to justify more widespread use at this time. RT-PCR has significantly improved the ability to rapidly and accurately diagnose norovirus as the cause of gastroenteritis outbreaks. Most state public health laboratories can test stool, emesis, rectal swabs, and environmental swabs for noroviruses utilizing RT-PCR. Norovirus can be identified from stool specimens taken between 2 and 7 days after onset of symptoms. Once the presence of norovirus has been confirmed within a facility, additional cases can be diagnosed with sufficient accuracy utilizing clinical criteria. One such definition, the Kaplan criteria, is quite specific for viral gastroenteritis (see Table 2).26 Treatment There are no specific antiviral therapies for norovirus, and in most cases, oral re-hydration is sufficient. Occasionally, anti-emetics, intravenous fluids, and/or electrolyte replacement therapy is necessary. Infection control and containment In the absence of prompt, thorough infection control measures, norovirus can circulate within an institution for an extended period of time. Managing an institutional outbreak of any contagious illness requires close collaboration between medical and custody staff. During an outbreak of gastroenteritis, movement of inmates should be restricted as much as possible. Even those who are not symptomatic may be incubating the virus, and can spread the illness to others. Movement in and out of the impacted housing units should be limited. Viral gastroenteritis is more likely to be spread in congregate settings. For this reason, strong consideration should be given to temporarily suspending indoor group activities such as visitation, school, and religious services. Inmates who are experiencing nausea and/or vomiting should be confined to quarters until they have been asymptomatic for at least 48 hours. Likewise, employees who are ill should be encouraged to stay away from the worksite until they have been without symptoms for at least 48 hours. Sick inmates should be fed in their cell, dorm, or housing unit. If possible, well inmates should eat in groups by unit. The placement of alcohol-based hand cleansers at the beginning of feeding lines should be considered. Dining areas should be cleaned and then wiped with bleach solutionbetween seatings. Local operating procedures (LOPs) should facilitate the closing of dormitories, yards, or entire facilities to incoming inmates during outbreaks of gastroenteritis and other communicable infectious disease such as varicella, tuberculosis, or scabies. Movement within the institution should also be limited as much as possible. This includes bed moves, visiting, religious meetings, mental health groups, art and music programs, hobby shop, and inmate canteen. All non-essential inmate work should be temporarily suspended. The only inmates who should be allowed to work are those who have been symptom free for at least 48 hours. Food handlers should be monitored to ensure that they perform frequent hand hygiene and appropriately use gloves. LOPs should also provide for the rapid screening and clearance of critical inmate workers. Plans should be in place to allow for the identification on short notice of alternate workers for food handling, laundry, and essential functions. Housecleaning and hand hygiene During outbreaks of gastroenteritis, employees and inmates should be regularly reminded about the importance of frequent hand washing. Routine housecleaning efforts should be intensified, including the cleaning of walls, floors, table tops, handrails, sinks, toilets, and door knobs in day rooms, communal restrooms, dining facilities, and showers. In addition to environmental surfaces, medical and custodial equipment such as blood pressure cuffs, stethoscopes, and restraint gear should be routinely sanitized. Rapid response teams should be created to remove and disinfect spills of body fluids such as feces or vomit, especially in common areas. The body fluid should be removed, and the area disinfected by the application of a bleach solution for a minimum of ten minutes. After ten minutes, the excess solution should be wiped up. Mop buckets should be disinfected and mop heads cleaned or discarded after each episode of cleaning up a contaminated spill. Mops and other cleaning materials that are used for cleaning up spills should not be reused for routine cleaning in other areas. All mop heads should be changed and either laundered or discarded at least once daily. Housecleaners should utilize wear personal protective equipment to include masks, disposable gowns, and gloves. Based upon studies of viral killing with other related calciviruses, chlorine bleach is the only disinfectant that is fully endorsed by the CDC for use against norovirus (see 101). Therefore, bleach-containing solutions should be used for surface cleaning and mopping. The solution should be mixed fresh each day utilizing 1 cup of bleach to 3 gallons of water. This disinfectant solution must be changed frequently to prevent dirt and organic materials from inactivating the activate disinfectants. The 101 Section provides directions for mixing bleach solutions. Unfortunately, bleach is caustic and could potentially be used in an assault. Additionally, bleach can be used to change the color of inmate clothing and/or alter personal appearance by dying hair. For these reasons, it is important to work in advance with custody to develop procedures that allow for the safe use of bleach when it is legitimately necessary. Inmates and employees should be encouraged to frequently wash their hands with soap and water, or an alcohol-based hand rub. Healthy inmates should be allowed access to the showers first, followed by those inmates who are ill. Showers should be cleaned and disinfected with bleach solution after being used by sick inmates. Education and communication Educational efforts should be directed at inmates, employees, visitors, volunteers, and the public. The use of multiple teaching methods including handouts, overheads, in-house cable television channels, and posters is encouraged. Inmate peer educators can be a valuable resource, as can inmate advisory counsels, inmate family groups, and labor unions. Educational materials should be provided in multiple languages, and be written to accommodate those with low levels of literacy. Daily briefings should be provided to key medical and custody stakeholders. The public information officer should be prepared to communicate with the media and the surrounding community if called upon to do so. Tracking the outbreak Tracking of all individuals (inmates and employees) greatly facilitates the management of outbreaks of viral gastroenteritis and other communicable conditions. Each day, a list should be updated with essential information to include at least the inmate name, number, housing, date symptoms began and ended, date of confinement to quarters and release, date specimens collected, and results of specimens. This information should be collated each day into a new updated report that can be shared with key outbreak managers (see Table 3). Each day, a nursing team should conduct face-to-face evaluations of any inmates who are experiencing symptoms consistent with gastroenteritis. This is to include new cases and those who are confined to quarters. Nursing staff should carefully monitor these individuals, and rapidly bring them to medical attention if they require additional medical intervention such as intravenous fluid replacement. Conclusions Outbreaks of gastroenteritis commonly occur in congregate living environments such as jails and prisons. Most of these outbreaks are due to viruses, with noroviruses being the most common etiology. Gastroenteritis outbreaks can result in a large number of sick inmates and employees, significant morbidity, and major disruption to normal programming. A coordinated response involving on-site medical and custody staff, augmented as needed by local, county, and state public health resources, can be quite effective in mitigating the impacts of gastroenteritis outbreaks. Jail and prison administrators would be prudent to establish policies and procedures in advance of these outbreaks to help facilitate the best possible outcome. References: 1. Mounts AW, Holman RC, Clarke MJ, et al. Trends in hospitalizations associated with gastroenteritis among adults in the United States, 1979–1995. Epidemiol Infect 1999; 123:1–8. 2. Tauxe RW, Wauters G, Goossens V, et al. Yersinia enterocolitica infections and pork: the missing link. Lancet 1987; 1: 1129-32 3. Istre GR, Blaser MJ, Shillam P, et al. Campylobacter enteritis associated with undercooked barbequed chicken. Am J Public Health 1984; 74: 1265-7 4. Escherischia coli O157:H7 infections associated with eating a nationally distributed commercial brand of ground beef patties and burgers- Colorado, 1997. MMWR 1997; 46: 777-8 5. Headrick ML, Korangy S, Bean, N. The epidemiology of raw milk-associated food-borne disease outbreaks in the United States, 1973 through 1992. Am J Public Health 1998; 88: 1219-21 6. Hilborn ED, Mshar PA, Fiorentino TR, et al. An outbreak of Escherischia Coli O157:H7 infections and haemolytic uremic syndrome associated with consumption of unpasteurized apple cider. Epidemiol Infect 2000124: 31-6 7. Outbreaks of Escherichia coli O157:H7 infection and cryptosporidiosis associated with drinking unpasteurized apple cider-Connecticut and New York, October 1996. MMWR 1997; 46:4-8 8. Ongoing Multistate Outbreak of Escherichia coli serotype O157:H7 Infections associated with consumption of fresh spinach - United States. MMWR 2006; 55: 1-2 9. Outbreaks of Salmonella serotype enteriditis infection associated with eating raw or undercooked shell eggs- United States 1996-1998. MMWR 2000; 49: 73-9 10. Herwaldt BL, Ackers ML. An outbreak in 1996 of cyclosporiasis associated with imported raspberries. The Cyclospora Working Group [see comments]. N Engl J Med 1997; 336:1548-56 11. Hepatitis A outbreak associated with green onions at a restaurant, Monaca, Pennsylvania, 2003. MMWR 2003; 52:115-7 12. Outbreak of Salmonella serotype Enteritidis infections associated with raw almonds-United States and Canada, 2003-2004. MMWR Morb Mortal Wkly Rep. 2004 Jun 11; 53(22): 484-7 13. Multistate outbreaks of Salmonella serotype Poona infections associated with eating cantaloupe from Mexico-United States and Canada, 2000-2002. MMWR Morb Mortal Wkly Rep. 2002 Nov 22; 51(46): 1044-7 14. A multistate outbreak of Salmonella enterica serotype Baildon associated with domestic raw tomatoes. Emerg Infect Dis. 2001 Nov-Dec; 7(6): 1046-8 15. Outbreak of listeriosis associated with homemade Mexican-style cheese-North Carolina, October 2000-January 2001. MMWR Morb Mortal Wkly Rep. 2001 Jul 6; 50(26): 560-2 16. Desenclos J, Klontz KC, Wilder MH, et al. A multistate outbreak of hepatitis A caused by the consumption of raw oysters. Am J Public Health 1991; 81: 1268-72 17. Adler JL, Zickl R. Winter vomiting disease. J Infect Dis 1969; 119:668–73 18. Thornhill TS, Kalica AR, Wyatt RG, et al. Pattern of shedding of the Norwalk particles in stools during experimentally induced gastroenteritis in volunteers as determined by immune electron microscopy. J Infect Dis 1975; 132:28–34 19. Graham DY, Jiang X, Tanaka T, et al. Norwalk virus infection of volunteers: new insights based on improved assays. J Infect Dis 1994; 170:34–43 20. Okhuysen PC, Jiang Xi, Ye L, Johnson PC, et al. Viral shedding and fecal IgA response after Norwalk virus infection. J Infect Dis 1995; 171:566–9 21. Kapikian AZ, Estes MK, Chanock RM. Norwalk group of viruses. In: Fields BN, Knipe DM, Howley PM, eds. Fields virology. 3rd ed. Philadelphia, PA: Lippincott-Raven, 1996; 783–810 22. Keswick BH, Satterwhite TK, Johnson PC, et al. Inactivation of Norwalk virus in drinking water bychlorine. Appl Environ Microbiol 1985; 50:261–4 23. Atmar RL, Estes MK. Diagnosis of noncultivatable gastroenteritis viruses, the human caliciviruses. Clin Micro Rev. 2001; 14(1):15-37 24. Brinker JP, Blacklow NR, Estes MK, et al. Detection of Norwalk virus and other genogroup 1 human caliciviruses by a monoclonal antibody, recombinant antigen-based immuno globulin M capture enzyme immunoassay. J Clin Micro. 1998; 36(4):1064-1069 25. Yuen LKW, Catton MG, Cox BJ, et al. Heminested multiplex reverse transcription-PCR for detection and differentiation of Norwalk-like virus genogroups 1 and 2 in fecal samples. J Clin Microbiol. 2001; 39(7):2690-2694. 26. Kaplan JE, Feldman R, Campbell DS, et al. The frequency of a Norwalk-like pattern of illness in outbreaks of acute gastroenteritis Am J Public Health. 1982; 72(12):1329-32 Additional Resources 1. CDC MMWR: Norwalk-Like Viruses” Public Consequences and Outbreak Management. June 1, 2001. Vol. 50, No RR-9. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5009a1.htm 2. Recommendations for the Prevention and Control of Viral Gastroenteritis Outbreaks in California Long-Term Care Facilities (CDHS, October 2006) http://www.dhs.ca.gov/ps/dcdc/disb/pdf/PCofGE0900_ms.pdf 3. CDC: Viral Gastroenteritis (Fact sheet in English and Spanish) http://www.cdc.gov/ncidod/dvrd/revb/gastro/faq.html 4. CDC: Norovirus: Q&A http://www.cdc.gov/ncidod/dvrd/revb/gastro/norovirus-qa.htm 5. Norovirus: Food handlers. http://www.cdc.gov/ncidod/dvrd/revb/gastro/norovirus-foodhandlers.htm 6. Diagnosis and Management of Food-borne Illnesses: A Primer for Physicians and Other Health Care Professionals. MMWR 2004; 53 (No. RR-4) |
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