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Norovirus
Evonne Curran
Nurse Consultant
Health Protection Scotland
In this presentation
• Norovirus GI infection
• Why it causes us problems
• Results of a survey of norovirus
experience 2009/10
• Plans for 2010/11
• Plans for after 2011
Why is norovirus such a problem
in hospitals?
Airborne
dissemination
SICPs
not enough
Odd
presentations –
is it a case?
Voluminous
diarrhoea &
vomiting
Immunity
short lasting
Infectious before
symptoms
Martin et al. Eurosurveillance 2004 Age sex distribution norovirus
‘The diarrhoea in norovirus infection is
driven by both a leak flux and a
secretory component.’
Schulzke, et al GUT 2008
It’s not always mild and there is an associated mortality
•Nothing can be
done
•Nothing works
•We just go
through rituals
•Should not bother
•No one comes
into hospital to
get an infection
•By being
prepared we
can reduce the
impact of
norovirus
Reduction in outbreaks on cruises
• Changing their ways of working
– Surveillance (real time data)
– Look for cases
– Action when cases
• Serve buffet, laundry services,
isolation, cabin with window, hand
hygiene facilities, check you are doing
what you are supposed to be doing,
remind people what to do, non buffet
but restaurant.
Norovirus season evaluation 2009/10
• How was it for you?
Not so bad
A pain: the worst ever
12
60
10
40
8
30
6
20
4
10
2
0
0
28
Wk 7
2
Wk 6
2
Wk 5
2
Wk 4
2
Wk 3
2
Wk 2
2
Wk 1
2
Wk 0
2
Wk 9
1
Wk 8
1
Wk 7
1
Wk 6
1
Wk 5
1
Wk 4
1
Wk 3
1
Wk 2
1
Wk 1
1
Wk 0
1
Wk
9
Wk
8
Wk
7
Wk
6
Wk
5
Wk
4
Wk
3
Wk
2
Wk
1
Wk 2
5
Wk 1
5
Wk 0
5
Wk 9
4
Wk 8
4
Wk 7
4
Wk 6
4
Wk 5
4
Wk 4
4
Wk 3
4
Wk 2
4
Wk 1
4
Wk 0
4
Wk 9
3
Wk 8
3
Wk 7
3
Wk 6
3
Wk 5
3
Wk 4
3
Wk 3
3
Wk 2
3
Wk 1
3
Wk 0
3
Wk 9
2
Wk
Weeks 2009-10
NHS Ayrshire and Arran Ward Closures
50
NHS Scotland Ward Closures
NHS Scotland Norovirus Ward Closures NHS board 1
week 29 (2009) - week 28 (2010) n = 85
Scotland
Board 1
12
60
10
40
8
30
6
20
4
10
2
0
0
28
Wk
27
Wk 6
2
Wk
25
Wk 4
2
Wk
23
Wk 2
2
Wk
21
Wk 0
2
Wk 9
1
Wk 8
1
Wk 7
1
Wk 6
1
Wk 5
1
Wk 4
1
Wk 3
1
Wk 2
1
Wk
11
Wk 0
1
Wk
9
Wk
8
Wk
7
Wk
6
Wk
5
Wk
4
Wk
3
Wk
2
Wk
1
Wk
52
Wk 1
5
Wk
50
Wk 9
4
Wk
48
Wk 7
4
Wk 6
4
Wk 5
4
Wk 4
4
Wk 3
4
Wk 2
4
Wk 1
4
Wk 0
4
Wk 9
3
Wk
38
Wk 7
3
Wk
36
Wk 5
3
Wk
34
Wk 3
3
Wk
32
Wk 1
3
Wk
30
Wk 9
2
Wk
Weeks 2009 - 10
NHS Fife Ward Closures
50
NHS Scotland Ward Closures
NHS Scotland Norovirus Ward Closures & Board 4
Week 29 (2009) - Week 28 (2010) n = 55
Scotland
Board 4
12
60
10
40
8
30
6
20
4
10
2
0
0
28
Wk 7
2
Wk 6
2
Wk 5
2
Wk 4
2
Wk 3
2
Wk 2
2
Wk
21
Wk 0
2
Wk
19
Wk 8
1
Wk
17
Wk 6
1
Wk
15
Wk 4
1
Wk
13
Wk 2
1
Wk 1
1
Wk 0
1
Wk
9
Wk
8
Wk
7
Wk
6
Wk
5
Wk
4
Wk
3
Wk
2
Wk
1
Wk 2
5
Wk 1
5
Wk 0
5
Wk 9
4
Wk 8
4
Wk 7
4
Wk 6
4
Wk 5
4
Wk
44
Wk 3
4
Wk
42
Wk 1
4
Wk
40
Wk 9
3
Wk
38
Wk 7
3
Wk
36
Wk 5
3
Wk
34
Wk 3
3
Wk 2
3
Wk 1
3
Wk 0
3
Wk 9
2
Wk
Weeks 2009 - 10
NHS Highland Ward Closures
50
NHS Scotland Ward Closures
NHS Scotland Norovirus Ward Closures Board 8
Week 29 (2009) - Week 28 (2010) n = 48
Scotland
Board 8
10
Board 9
50
12
60
8
30
6
20
4
10
2
0
0
28
Wk 7
2
Wk 6
2
Wk 5
2
Wk 4
2
Wk 3
2
Wk 2
2
Wk 1
2
Wk 0
2
Wk 9
1
Wk 8
1
Wk 7
1
Wk 6
1
Wk 5
1
Wk 4
1
Wk 3
1
Wk 2
1
Wk 1
1
Wk 0
1
Wk
9
Wk
8
Wk
7
Wk
6
Wk
5
Wk
4
Wk
3
Wk
2
Wk
1
Wk 2
5
Wk 1
5
Wk 0
5
Wk 9
4
Wk 8
4
Wk 7
4
Wk 6
4
Wk 5
4
Wk 4
4
Wk 3
4
Wk 2
4
Wk 1
4
Wk 0
4
Wk 9
3
Wk 8
3
Wk 7
3
Wk 6
3
Wk 5
3
Wk 4
3
Wk 3
3
Wk 2
3
Wk 1
3
Wk 0
3
Wk 9
2
Wk
Weeks 2009 - 10
NHS Lanarkshire Ward Closures
40
NHS Scotland Ward Closures
NHS Scotland Norovirus Ward Closures Board 9
Week 29 (2009) - Week 28 (2010) n = 47
Scotland
Key comments
Lots of small fires starting at once
When it came it came quickly
Lots of relapses
NB The ward reopening is not the point
when its no longer a problem it’s the
point when its manageable
The perfect norovirus storm
• Increased referrals by out of hours
GPs
• Fewer coping services
• Fewer experts to say ‘no’
• Weekends – no full ICN service
What we do
• Let everyone know its started 5/11
• Let key HCWs know its started 6/11
• Keep everyone updated once its
started 8/11
Good Practice Points
•
•
•
•
•
•
Run workshops (doctors)
The CE puts a letter out
Note in the pay slips
Point prevalence data to bed management
Whole hospital on alert once it starts
Attend daily bed management
Do you remind staff to
• Check referring GP if diarrhoea or
diarrhoea in care home 4/11
• Provide GPs with advice managing
noro in the community 6/11
• Require docs to ask about diarrhoea
when taking a history 6/11
• Avoid unnecessary moves 11/0
Do you have
• Policy to avoid unnecessary admissions
3/11
• Advice that patients with DV to isolation
11/0
• Advice to minimise CI in home 8/11
• A&E algorithm 5/5
• A&E procedure when Noro + MI 5/11
• Contingency plans 3/11
Do you think that recognising patients
with possible norovirus symptoms as
an infection risk is a problem in your
hospitals ?
• Yes 8/11
• Failure to recognise risk
Biggest problem when risk
recognised
• Insufficient isolation facilities
• Competing priorities (A&E targets)
• Isolation requirement not passed on
Recognition of outbreak
• Early 9/11 established 2/11
• Transfer pre closure 3/11 never
• Speed of closure – excellent ‘except
at weekends’
• Ward staff are quick sometimes
started precautions before I get there
‘How leaky is your bucket?’
Are you able to continuously apply
norovirus guidelines?
• Yes 7 / 11
Other Key issues
• No data on exactly when each
outbreak occurs
• Visitors
Lots of good testing ideas
• Quarantined not closed
• Management of paired wards
• Norovirus diaries
Lets plug the holes in the bucket!
•
•
•
•
•
•
•
Contingency planning
Start date
A&E algorithm
Admission avoidance at weekends
Nursing home admission avoidance
Visitors
RCA
Contingency planning
Pre-start of season:
• There is a plan for a norovirus outbreak includes who
does what!
• A contingency plan to reduce norovirus impact and the
likelihood of norovirus outbreaks getting out of control
(includes comms and single ward option)
• Who at board level CPHM will help
• Agreed norovirus activity locally:
– Green: single wards in single hospitals
– Amber: more than single wards in single hospitals
– no pressure on routine services
– Red: more than single wards closed – routine
services being stopped
– Black: One or more hospital closed due to multiple
ward closures
Season has started nationally:
•
•
•
•
•
•
•
•
•
•
•
•
Confirm Norovirus contingency plan still valid
Any changes needed to noro email groups
Visit A&E / bed management – remind of algorithm inform of
national situation
Remind of how noro presents
Remind what to ask / what to do
Powerpoint for all new staff since last season
Collective ID of the weakest links and mitigate
Confirm / remind all wards of norovirus (e)folder of what to
do
Email who to contact for noro – at weekends or after 5
Get board public comms ready – Get top level co-operation
Liaise with board re any N home outbreaks
Weekend cover of ICN?
Ward X and Y
are closed to
due to
norovirus.
Visitor restrictions
apply
Season has started locally:
•
•
•
•
•
•
Tell everyone – including the media
Tell the visitors at the front door
All meet and greet
Daily meetings with bed-management
Daily sit rep with local norovirus assessment
Id how did the index case cause the
outbreak – feedback
• Assess all outbreaks for lessons learned
• Share lessons learned locally and with HPS
Season over
• Season debrief management and ICT
– What worked well?
– What could have worked better?
– What will make it work better next
time?
– Share findings
– Share with HPS
If we fail to prepare, we prepare to fail
B Franklin
Norovirus will continue to be
• A severe winter challenge to
NHSScotland
• Better preparation and execution of
preparation plans will reduce its
impact on ourselves and our services
but more importantly….