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

GRADE Table Q3 What Patient Interventions Best Prevent Or Contain Norovirus Outbreaks In The Healthcare Setting?

Components of an Outbreak Prevention/Containment Program

Visitor policies

Comparison Outcome Quantity and type of evidence Findings Starting grade Decrease GRADE Increase GRADE GRADE of Evidence for Outcome Overall GRADE of Evidence Base
S
t
u
d
y
 
Q
u
a
l
i
t
y
**
C
o
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s
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t
e
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c
y
**
D
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e
c
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n
e
s
s
**
P
r
e
c
i
s
i
o
n
**
P
u
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l
i
c
a
t
i
o
n
 
B
i
a
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**
L
a
r
g
e
 
M
a
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n
i
t
u
d
e
**
D
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p
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C
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Visitor policies

Symptomatic norovirus infection*

5 DES 168, 170, 182, 183, 205

Restriction of visitors was emphasized as an intervention in 5 DES 168, 170, 182, 183, 205

Nurse managers screened all visitors for gastroenteritis, and if symptomatic, prohibited them from visiting patients in the units for 72 hours in 1 DES 168

Visitors were restricted to the immediate family and children were restricted from visiting in 1 DES 183

Visitors were restricted to two for each patient in 1 DES. All visitors were registered and records were kept for 14 days. All visitors were screened by a standard questionnaire for symptoms and signs of gastroenteritis 170

Visitors were restricted to one unit per visit in 1 DES 182

Very Low

0

0

0

0

0

0

0

0

Very Low

Very Low

Education

Comparison Outcome Quantity and type of evidence Findings Starting grade Decrease GRADE Increase GRADE GRADE of Evidence for Outcome Overall GRADE of Evidence Base
S
t
u
d
y
 
Q
u
a
l
i
t
y
**
C
o
n
s
i
s
t
e
n
c
y
**
D
i
r
e
c
t
n
e
s
s
**
P
r
e
c
i
s
i
o
n
**
P
u
b
l
i
c
a
t
i
o
n
 
B
i
a
s
**
L
a
r
g
e
 
M
a
g
n
i
t
u
d
e
**
D
o
s
e
-
r
e
s
p
o
n
s
e
C
o
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f
o
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d
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r
s

Education

Symptomatic norovirus infection*

6 DES 166, 168, 169, 172, 182, 205

Education of healthcare workers was emphasized as an intervention in 5 DES 166, 168, 169, 182, 205

Possible topics included identification of norovirus, spread of gastroenteritis, cleaning and disinfection procedures, isolation, transfers, discharge.

Education was provided to family members in 1 DES 172

Very Low

0

0

0

0

0

0

0

0

Very Low

Very Low

Surveillance

Comparison Outcome Quantity and type of evidence Findings Starting grade Decrease GRADE Increase GRADE GRADE of Evidence for Outcome Overall GRADE of Evidence Base
S
t
u
d
y
 
Q
u
a
l
i
t
y
**
C
o
n
s
i
s
t
e
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c
y
**
D
i
r
e
c
t
n
e
s
s
**
P
r
e
c
i
s
i
o
n
**
P
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l
i
c
a
t
i
o
n
 
B
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**
L
a
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g
e
 
M
a
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n
i
t
u
d
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**
D
o
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-
r
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s
p
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s
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C
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f
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s

Surveillance

Symptomatic norovirus infection*

4 DES 58, 84, 166, 170

Emphasized as an intervention in 4 DES 58, 84, 166, 170

Active surveillance and case finding after defining the surveillance period and establishing a case definition was recommended in 1 DES. Contact tracing among staff was done and admission records of patients were reviewed170

Active surveillance was promoted using a two-tiered definition of cases and outbreaks in 1 DES 58

Very Low

0

0

0

0

0

0

0

0

Very Low

Very Low

Policy Development and Communication

Comparison Outcome Quantity and type of evidence Findings Starting grade Decrease GRADE Increase GRADE GRADE of Evidence for Outcome Overall GRADE of Evidence Base
S
t
u
d
y
 
Q
u
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l
i
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y
**
C
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t
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c
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**
D
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t
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**
P
r
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c
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i
o
n
**
P
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l
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c
a
t
i
o
n
 
B
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L
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M
a
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D
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C
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Policy development and communication

Symptomatic norovirus infection*

6 DES 63, 84, 172, 182-184

Emphasized as an intervention in 6 DES 63, 84, 172, 182-184

Very Low

0

0

0

0

0

0

0

0

Very Low

Very Low

Patient Transfers and Discharges

Comparison Outcome Quantity and type of evidence Findings Starting grade Decrease GRADE Increase GRADE GRADE of Evidence for Outcome Overall GRADE of Evidence Base
S
t
u
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y
 
Q
u
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C
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t
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D
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P
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**
P
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B
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L
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M
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D
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Patient discharges

Symptomatic norovirus infection*

4 DES 172, 179, 183, 184

Transfer of patients after symptom resolution was supported in 1 DES 172, but discouraged in 3 DES 179, 183, 184 unless medically necessary. 

Very Low

0

0

0

0

0

0

0

0

Very Low

Very Low

Environmental Disinfection

Comparison Outcome Quantity and type of evidence Findings Starting grade Decrease GRADE Increase GRADE GRADE of Evidence for Outcome Overall GRADE of Evidence Base
S
t
u
d
y
 
Q
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C
o
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**
D
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P
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**
P
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B
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M
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C
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Targeted surface disinfection

Symptomatic norovirus infection*

1 SR 153 of DES
3 DES 79, 168, 183

Emphasized as an intervention in 1 SR 153 and 3 DES 79, 168, 183
for high touch surfaces (eg. patient and staff bathrooms and clean/dirty utility rooms, tables, chairs, commodes, computer keyboards/mice, and items in close proximity to symptomatic patients) and carpets

Very Low

0

0

0

0

0

0

0

0

Very Low

Very Low

Process of environmental disinfection

Symptomatic norovirus infection*

4 DES 168, 170, 177, 179

The frequency of routine ward, bathroom and toilet cleaning was increased to hourly and hypochlorite was used to disinfect hard surfaces after cleaning in 1 DES 179

Diluted sodium hypochlorite was used for all horizontal surfaces and toilets were cleaned three times daily in 1 DES 177

The routine cleansing of ward was increased to twice daily in 1 DES 170

Mop heads were changed every 3 rooms in 1 study 168

Very Low

0

0

0

0

0

0

0

0

Very Low

Very Low

Cleaning/ disinfection of patient service items

Symptomatic norovirus infection*

3 DES 168, 172, 177

Emphasized as an intervention in 3 DES 168, 172, 177

Very Low

0

0

0

0

0

0

0

0

Very Low

Very Low

Cleaning/ disinfection of fabrics

Symptomatic norovirus infection*

1 SR 153 of DES
3 DES 168, 177, 183

Changing patient curtains if visibly soiled in 1 SR 153 and 2 DES 168, 177

One DES suggested that soiled, upholstered patient equipment should be steam cleaned.  If this was not possible, these items were discarded 168

Careful handling of soiled linen to minimize re-aerosolization of virus in 2 DES 177, 183

Very Low

0

0

0

0

0

0

0

0

Very Low

Very Low

Cleaning and disinfection agents

Symptomatic norovirus infection*

1 SR 153
of 14 DES 63, 83, 87, 89, 167, 168, 170, 174, 176-179, 182, 184

Emphasized as an intervention in 1 SR 153 and 12 DES 63, 83, 167, 168, 170, 174, 176-179, 182, 184

In one DES, concentrated hypochlorite (1000 ppm) was used for disinfection. The frequency of routine cleaning of the ward was increased and the cleansing area was widened to one square meter surrounding the infected area 170

Hypochlorite was used to disinfect hard surfaces after cleaning in 1 DES 179

1% sodium hypochlorite was used to wipe down surfaces for spills of vomitus and feces, thorough facility wide cleaning was performed, all continence pads treated as infectious waste and additional mop heads allocated to all the units in 1 DES 182

Diluted sodium hypochlorite was used for all horizontal surfaces in 1 DES 177

Rooms were disinfected with 0.5% hypochlorite after patient discharge in 1 DES 167

Rooms were cleaned with 1% aldehyde or 0.1% chlorine-free bleach in 1 DES 174

Unit was disinfected several times with 1:10 diluted hypochlorite (household bleach) in 1 DES 176

Hypochlorite was used to disinfect hard surfaces in 1 DES 178

2% hypochlorite solution used in 2 DES 87, 89

Cleaning regimen used hypochlorite solution and alcohol wipes in 1 DES 184

An outbreak resulted when vomiting was cleaned with an ordinary vacuum cleaner without hypochlorite 83

Very Low

0

0

0

0

0

0

0

0

Very Low

Very Low

Inactivation of norovirus*

3 BAS 187, 194, 201

5% organic acid, 1% peroxide, not less than 2% aldehyde with a contact time of 1 h or  a 1% halogen compound with 6, 000 ppm of free chlorine and a contact time of 15 minutes were required for safe disinfection in 1 BAS 187

Cleaning a contaminated surface with a cloth soaked in anionic detergent followed by cleaning with a combination of hypochlorite/detergent was found to the best cleaning regimen in 1 BAS. Cleaning with the detergent alone or the hypochlorite/detergent combination without prior cleaning failed to eliminate norovirus contamination 194

Treatment of water with monochloramine produced negligible reduction in norovirus titer in 1 BAS 201

High

0

0

−1

0

0

0

0

0

Moderate

Inactivation of FCV

9 BAS 185, 187, 188, 190−192, 198-200

An activated aldehyde based product was found to be the most effective disinfectant on all types of fabric and carpet in 1 BAS 190, although statistical differences were not reported

A quarternary ammonium compound exhibited similar efficacy to hypochlorite 1000 ppm in 1 DES 188

Ethanol at 70% and 90% and isopropranol at 40-60% were effective at killing 99% of FCV within 1 min in 1 BAS 191

Sodium bicarbonate at concentrations of 5% and above was found to achieve 99% reduction in FCV titers, both alone and in combination with aldehyde or hydrogen peroxide in 1 BAS 192

FCV was more resistant to UV light when compared with hepatitis A virus, polio virus and round coliphages although statistical differences were not reported in 1 BAS 198

0.5% glutaraldehyde, hypochlorite and 0.8% iodine completely inactivated FCV, but a quarternary ammonium compound, ethanol and a 1% anionic detergent did not in 1 BAS 200

4% organic acid, 1% peroxide, not less than 2% aldehyde with a contact time of 1 h or  a 1% halogen compound with 6, 000 ppm of free chlorine and a contact time of 15 minutes were required for safe disinfection in 1 BAS 187

1 BAS demonstrated that ozone from a portable commercial generator could inactivate norovirus and FCV 185

Phenolic compounds, peroxyacetic acid + hydrogen peroxide,   and quarternary ammonium compound + sodium bicarbonate were effective at concentrations 2-4 times that recommended by the manufacturers in 1 BAS 199

High

0

0

−1

0

0

0

0

0

Moderate

Medications

Comparison Outcome Quantity and type of evidence Findings Starting grade Decrease GRADE Increase GRADE GRADE of Evidence for Outcome Overall GRADE of Evidence Base
S
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P
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B
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M
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Medications

Symptomatic norovirus infection*

1 OBS 203

Psychiatric patients who received trihexyphenidyl or benztropine in addition to antipsychotic drugs had a significantly decreased risk compared to those who received antipsychotic drugs alone

Patients who received psyllium had a significantly decreased risk compared with those who did not.

Low

0

0

0

−1

0

0

0

0

Very Low

Very Low

Time to symptom resolution*

1 RCT 202

Significantly decreased in patients who received nitazoxanide when compared to those who did not.

High

0

0

−1

−1

0

0

0

0

Low

RCT – randomized controlled trial; OBS – observational study (prospective or retrospective controlled); DES – descriptive study (case series, case report, uncontrolled data in an observational study); BAS – basic science study
* These outcomes are considered the most critical by the guideline developers.
** These modifiers can impact the GRADE by 1 or 2 points

 

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