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Guideline for the Prevention and Control of Norovirus Gastroenteritis Outbreaks in Healthcare Settings, 2011

II. Summary of Recommendations

Table 1. HICPAC Categorization Scheme for Recommendations
Category IA A strong recommendation supported by high to moderate quality evidence suggesting net clinical benefits or harms.
Category IB A strong recommendation supported by low-quality evidence suggesting net clinical benefits or harms, or an accepted practice (e.g., aseptic technique) supported by low to very low-quality evidence.
Category IC A strong recommendation required by state or federal regulation.
Category II A weak recommendation supported by any quality evidence suggesting a tradeoff between clinical benefits and harms.
Recommendation for further research An unresolved issue for which there is low to very low-quality evidence with uncertain tradeoffs between benefits and harms.

*Please refer to Methods Section and Umscheid et al. Updating the Guideline Methodology of the Healthcare Infection Control Practices Advisory Committee (HICPAC) for the process used to grade quality of evidence and implications of category designation
**Key questions are described within the Evidence Review Section

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Patient Cohorting And Isolation Precautions

  1. Avoid exposure to vomitus or diarrhea.  Place patients on Contact Precautions in a single occupancy room if they have symptoms consistent with norovirus gastroenteritis.   (Category IB)(Key Question 1.A.1)
    1. When patients with norovirus gastroenteritis cannot be accommodated in single occupancy rooms, efforts should be made to separate them from asymptomatic patients. Dependent upon facility characteristics, approaches for cohorting patients during outbreaks may include placing patients in multi-occupancy rooms, or designating patient care areas or contiguous sections within a facility for patient cohorts. (Category IB) (Key Question 3C.4.b)
  2. During outbreaks, place patients with norovirus gastroenteritis on Contact Precautions for a minimum of 48 hours after the resolution of symptoms to prevent further exposure of susceptible patients (Category IB) (Key Question 3.C.4.a)
    1. Consider longer periods of isolation or cohorting precautions for complex medical patients (e.g., those with cardiovascular, autoimmune, immunosuppressive, or renal disorders)  as they can experience protracted episodes of diarrhea and prolonged viral shedding.  Patients with these or other comorbidities have the potential to relapse, and facilities may choose longer periods of isolation based on clinical judgment.(Category II) (Key Question 1.A.2.a)
    2. Consider extending the duration of isolation or cohorting precautions for outbreaks among infants and young children (e.g., under 2 years), even after resolution of symptoms, as there is a potential for prolonged viral shedding and environmental contamination. Among infants, there is evidence to consider extending contact precautions for up to 5 days after the resolution of symptoms.(Category II) (Key Question 3.A.1)
  3. Further research is needed to understand the correlation between prolonged shedding of norovirus and the risk of infection to susceptible patients (No recommendation/unresolved issue) (Key Question 3.A.2)
  4. Consider minimizing patient movements within a ward or unit during norovirus gastroenteritis outbreaks.(Category II) (Key Question 3.C.4.c)   
    1. Consider restricting symptomatic and recovering patients from leaving the patient-care area unless it is for essential care or treatment to reduce the likelihood of environmental contamination and transmission of norovirus in unaffected clinical areas. (Category II) (Key Question 3.C.4.c.1) 
  5. Consider suspending group activities (e.g., dining events) for the duration of a norovirus outbreak. (Category II) (Key Question 3.C.4.d)      
  6. Staff who have recovered from recent suspected norovirus infection associated with an outbreak may be best suited to care for symptomatic patients until the outbreak resolves.(Category II) (Key Question 3.C.5.b)

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Hand Hygiene

  1. Actively promote adherence to hand hygiene among healthcare personnel, patients, and visitors in patient care areas affected by outbreaks of norovirus gastroenteritis. (Category IB)(Key Question 3.C.1.a)
  2. During outbreaks, use soap and water for hand hygiene after providing care or having contact with patients suspected or confirmed with norovirus gastroenteritis. (Category IB)(Key Question 3.C.1.b)
    1. For all other hand hygiene indications (e.g., before having contact with norovirus patients) refer to the 2002 HICPAC Guideline for Hand Hygiene in Health-Care Settings, which includes the indications for use of FDA-compliant alcohol-based hand sanitizer. (Category IB)(Key Question 3.C.1.b.1)
      1. Consider ethanol-based hand sanitizers (60-95%) as the preferred active agent compared to other alcohol or non-alcohol based hand sanitizer products during outbreaks of norovirus gastroenteritis. (Category II) (Key Question 3.C.1.b.2)
    2. Further research is required to directly evaluate the efficacy of alcohol-based hand sanitizers against human strains of norovirus, or against a surrogate virus with properties convergent with human strains of norovirus. (No recommendation/unresolved issue) (Key Question 3.C.1.b.3)
  3. More research is required to evaluate the virucidal capabilities of alcohol-based as well as non-alcohol based hand sanitizers against norovirus.   (No recommendation/unresolved issue) (Key Question 3.C.12.e.4)  

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Patient Transfer and Ward Closure

  1. Consider the closure of wards to new admissions or transfers as a measure to attenuate the magnitude of an outbreak of norovirus gastroenteritis.  The threshold for ward closure varies and depends on risk assessments by infection prevention personnel and facility leadership. (Category II) (Key Question 3.C.6)
  2. Consider limiting transfers to those for which the receiving facility is able to maintain Contact Precautions; otherwise, it may be prudent to postpone transfers until patients no longer require Contact Precautions.  During outbreaks, medically suitable individuals recovering from norovirus gastroenteritis can be discharged to their place of residence.(Category II) (Key Question 3.C.11)
  3. Implement systems to designate patients with symptomatic norovirus and to notify receiving healthcare facilities or personnel prior to transfer of such patients within or between facilities. (Category IC)
  4. To prevent food-related outbreaks of norovirus gastroenteritis in healthcare settings, food handlers must perform hand hygiene prior to contact with or the preparation of food items and beverages. For more information visit the FDA Food Code website. (Category IC) (Key Question 1.C.3.a)
  5. Personnel who work with, prepare or distribute food must be excluded from duty if they develop symptoms of acute gastroenteritis.  Personnel should not return to these activities until a minimum of 48 hours after the resolution of symptoms or longer as required by local health regulations. For more information visit FDA Food Code website. (Category IC) (Key Question 1.C.3.b)
  6. Remove all shared or communal food items for patients or staff from clinical areas for the duration of the outbreak. (Category IB) (Key Question 3.B.2)

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Diagnostics

  1. Consider the development and adoption of facility policies to enable rapid clinical and virological confirmation of suspected cases of symptomatic norovirus infection while implementing prompt control measures to reduce the magnitude of a potential norovirus outbreak.(Category II) (Key Question 1.C.1)
  2. In the absence of clinical laboratory diagnostics or in the case of delay in obtaining laboratory results, use Kaplan’s clinical and epidemiologic criteria to identify a norovirus gastroenteritis outbreak (see Table 4 for Kaplan’s criteria).  (Category IA)  (Key Question 2.A.1) 
  3. Further research is needed to compare the Kaplan criteria with other early detection criteria for outbreaks of norovirus gastroenteritis in healthcare settings, and to assess whether additional clinical or epidemiologic criteria can be applied to detect norovirus clusters or outbreaks in healthcare settings.  (No recommendation/unresolved issue) (Key Question 2.A.1) 
  4. Consider submitting stool specimens as early as possible during a suspected norovirus gastroenteritis outbreak and ideally from individuals during the acute phase of illness (within 2-3 days of onset).  It is suggested that healthcare facilities consult with state or local public health authorities regarding the types of and number of specimens to obtain for testing.(Category II) (Key Question 2.B) 
  5. Use effective laboratory diagnostic protocols for testing of suspected cases of viral gastroenteritis (e.g., refer to the Centers for Disease Control and Prevention (CDC)'s most current recommendations for norovirus diagnostic testing (Category IB)(Key Question 2.C)
  6. Routine collecting and processing of environmental swabs during a norovirus outbreak is not required.  When supported by epidemiologic evidence, environmental sampling can be considered useful to confirm specific sources of contamination during investigations. (Category II)
  7. Specimens obtained from vomitus can be submitted for laboratory identification of norovirus when fecal specimens are unavailable.  Testing of vomitus as compared to fecal specimens can be less sensitive due to lower detectable viral concentrations. (Category II)

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Personal Protective Equipment

  1. If norovirus infection is suspected, adherence to PPE use according to Contact and Standard Precautions is recommended for individuals entering the patient care area (i.e., gowns and gloves upon entry) to reduce the likelihood of exposure to infectious vomitus or fecal material.    (Category IB)(Key Question 1.C.4) 
  2. Use a surgical or procedure mask and eye protection or a full face shield if there is an anticipated risk of splashes to the face during the care of patients, particularly among those who are vomiting. (Category IB)(Key Question 3.C.2.a)
  3. More research is needed to evaluate the utility of implementing Universal Gloving (e.g., routine use of gloves for all patient care) during norovirus outbreaks. (No recommendation/unresolved issue)

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Environmental Cleaning

  1. Perform routine cleaning and disinfection of frequently touched environmental surfaces and equipment in isolation and cohorted areas, as well as high-traffic clinical areas.   Frequently touched surfaces include, but are not limited to, commodes, toilets, faucets, hand/bedrailing, telephones, door handles, computer equipment, and kitchen preparation surfaces. (Category IB)(Key Question 3.B.1)
  2. Clean and disinfect shared equipment between patients using EPA-registered products with label claims for use in healthcare.  Follow the manufacturer’s recommendations for application and contact times.  The EPA lists products with activity against norovirus on their website. (Category IC) (Key Question 3.C.12.a)   
  3. Increase the frequency of cleaning and disinfection of patient care areas and frequently touched surfaces during outbreaks of norovirus gastroenteritis (e.g., increase ward/unit level cleaning to twice daily to maintain cleanliness, with frequently touched surfaces cleaned and disinfected three times daily using EPA-approved products for healthcare settings).  (Category IB)(Key Question 3.C.12.b.1)     
  4. Clean and disinfect surfaces starting from the areas with a lower likelihood of norovirus contamination (e.g.,tray tables, counter tops) to areas with highly contaminated surfaces (e.g., toilets, bathroom fixtures).  Change mop heads when a new bucket of cleaning solution is prepared, or after cleaning large spills of emesis or fecal material. (Category IB)(Key Question 3.C.12.b.2)
  5. Consider discarding all disposable patient-care items and laundering unused linens from patient rooms after patients on isolation for norovirus gastroenteritis are discharged or transferred.   Facilities can minimize waste by limiting the number of disposable items brought into rooms/areas on Contact Precautions.(Category II) (Key Question 3.C.12.c.1)
  6. No additional provisions for using disposable patient service items such as utensils or dishware are suggested for patients with symptoms of norovirus infection. Silverware and dishware may undergo normal processing and cleaning using standard procedures. (Category II) (Key Question 3.C.12.c.2)
  7. Use Standard Precautions for handling soiled patient-service items or linens, including the use of appropriate PPE. (Category IB)(Key Question 3.C.12.c.3)
  8. Consider avoiding the use of upholstered furniture and rugs or carpets in patient care areas, as these objects are difficult to clean and disinfect completely.  If this option is not possible, immediately clean soilage, such as emesis or fecal material, from upholstery, using a manufacturer-approved cleaning agent or detergent.  Opt for seating in patient-care areas that can withstand routine cleaning and disinfection. (Category II) (Key Question 3.C.12.d.1)
  9. Consider steam cleaning of upholstered furniture in patient rooms upon discharge.  Consult with manufacturer's recommendations for cleaning and disinfection of these items.  Consider discarding items that cannot be appropriately cleaned/disinfected. (Category II) (Key Question 3.C.12.d.2)     
  10. During outbreaks, change privacy curtains when they are visibly soiled and upon patient discharge or transfer. (Category IB)(Key Question 3.C.12.d.3)
  11. Handle soiled linens carefully, without agitating them, to avoid dispersal of virus.  Use Standard Precautions, including the use of appropriate PPE (e.g., gloves and gowns), to minimize the likelihood of cross-contamination. (Category IB) (Key Question 3.C.12.d.4) 
  12. Double bagging, incineration, or modifications for laundering are not indicated for handling or processing soiled linen. (Category II) (Key Question 3.C.12.d.5)
  13. Clean surfaces and patient equipment prior to the application of a disinfectant.   Follow the manufacturer’s recommendations for optimal disinfectant dilution, application, and surface contact time with an EPA-approved product with claims against norovirus.  (Category IC) (Key Question 3.C.12.e.1)    
  14. More research is required to clarify the effectiveness of cleaning and disinfecting agents against norovirus, either through the use of surrogate viruses or the development of human norovirus culture system.  (No recommendation/unresolved issue) (Key Question 3.C.12.e.2)
  15. More research is required to clarify the effectiveness and reliability of fogging, UV irradiation, and ozone mists to reduce norovirus environmental contamination.  (No recommendation/unresolved issue) (Key Question 3.C.12.e.3)  
  16. Further research is required to evaluate the utility of medications that might attenuate the duration and severity of norovirus illness.  (No recommendation/unresolved issue ) (Key Question 3.D)

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Staff Leave and Policy

  1. Develop and adhere to sick leave policies for healthcare personnel who have symptoms consistent with norovirus infection.  (Category IB)(Key Question 3.C.3)
    1. Exclude ill personnel from work for a minimum of 48 hours after the resolution of symptoms. Once personnel return to work, the importance of performing frequent hand hygiene should be reinforced, especially before and after each patient contact. (Category IB)(Key Question 3.C.3.a) 
  2. Establish protocols for staff cohorting in the event of an outbreak of norovirus gastroenteritis.  Ensure staff care for one patient cohort on their ward and do not move between patient cohorts (e.g., patient cohorts may include symptomatic, asymptomatic exposed, or asymptomatic unexposed patient groups).   (Category IB) (Key Question 3.C.5.a)   
  3. Exclude non-essential staff, students, and volunteers from working in areas experiencing outbreaks of norovirus gastroenteritis. (Category IB) (Key Question 3.C.5.c)

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Visitors

  1. Establish visitor policies for acute gastroenteritis (e.g., norovirus) outbreaks.   (Category IB)(Key Question 3.C.7.a) 
  2. Restrict non-essential visitors from affected areas of the facility during outbreaks of norovirus gastroenteritis. (Category IB)(Key Question 3.C.7.b) 
    1. For those affected areas where it is necessary to have continued visitor privileges during outbreaks, screen and exclude visitors with symptoms consistent with norovirus infection and ensure that they comply with hand hygiene and Contact Precautions. (Category IB)(Key Question 3.C.7.b.1)

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Education

  1. Provide education to staff, patients, and visitors, including recognition of norovirus symptoms, preventing infection, and modes of transmission upon the recognition and throughout the duration of a norovirus gastroenteritis outbreak. (Category IB)(Key Question 3.C.8.a)    
  2. Consider providing educational sessions and making resources available on the prevention and management of norovirus before outbreaks occur, as part of annual trainings, and when sporadic cases are detected. (Category II) (Key Question 3.C.8.b)

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Active Case-Finding

  1. Begin active case-finding when a cluster of acute gastroenteritis cases is detected in the healthcare facility.  Use a specified case definition, and implement line lists to track both exposed and symptomatic patients and staff.  Collect relevant epidemiological, clinical, and demographic data as well as information on patient location and outcomes. (Category IB) (Key Question 3.C.9.a) 

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Communication and Notification

  1. Develop written policies that specify the chains of communication needed to manage and report outbreaks of norovirus gastroenteritis.  Key stakeholders such as clinical staff, environmental services, laboratory administration, healthcare facility administration and public affairs, as well as state or local public health authorities, should be included in the framework. (Category IB) (Key Question 3.C.10)
  2. 50a.Provide timely communication to personnel and visitors when an outbreak of norovirus gastroenteritis is suspected and outline what policies and provisions need to be followed to prevent further transmission (Category IB) (Key Question 3.C.10.a)
  3.  As with all outbreaks, notify appropriate local and state health departments, as required by state and local public health regulations, if an outbreak of norovirus gastroenteritis is suspected.    (Category IC) (Key Question 3.C.9.b)

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