1. Introduction - Amazon S3 · Web viewClean-up and control measures should be implemented for all gastrointestinal outbreaks as soon as possible after an outbreak is suspected, and

A guide for the management and control of gastroenteritis outbreaks in care facilities

Consultation draft

A guide for the management and control of gastroenteritis outbreaks in care facilities

To receive this publication in an accessible format phone 1300 651 160 using the National Relay Service 13 36 77 if required, or email Communicable Disease Prevention and Control at [email protected]

Authorised and published by the Victorian Government, 1 Treasury Place, Melbourne.

© State of Victoria, Department of Health and Human Services September 2018.

ISBN/ISSN <number>

Available at www2.health.vic.gov.au/public-health

https://www2.health.vic.gov.au/public-health/infectious-diseases/infection-control-guidelines/gastrointestinal-illness-investigation-guidelines

Contents

1. Introduction........................................................................................................................................... 71.1 Gastroenteritis...................................................................................................................................... 7

1.2 Viral gastroenteritis............................................................................................................................... 7

1.3 Foodborne illness................................................................................................................................. 8

1.4 Waterborne illness................................................................................................................................ 9

1.5 Antibiotic-related diarrhoea...................................................................................................................9

1.6 Animal-to-person infection.................................................................................................................... 9

Table 1. High risk foods for the elderly or immunocompromised.........................................................10

2. What should happen in the event of a gastroenteritis outbreak?..................................................112.1 Notify the outbreak.............................................................................................................................. 11

2.1.1 Is a gastro outbreak occurring?..................................................................................................11

2.1.2 How do you notify a gastro outbreak?........................................................................................11

2.1.3 What if someone dies during a gastro outbreak?........................................................................12

2.1.4 What can be done to control the spread of illness?....................................................................12

Figure 1. Gastro outbreak management summary flowchart...............................................................13

3. Infection prevention and control measures.....................................................................................143.1 Standard precautions.......................................................................................................................... 14

3.2 Transmission-based precautions (contact precautions)......................................................................14

3.2.1 Personal protective equipment (PPE).........................................................................................14

3.2.1.1 Gloves................................................................................................................................ 15

3.2.1.2 Gowns................................................................................................................................ 15

3.2.1.3 Masks................................................................................................................................. 15

3.2.1.4 Eyewear.............................................................................................................................. 15

3.2.1.5 Staff training........................................................................................................................ 15

3.2.2 Hand hygiene.............................................................................................................................. 15

3.2.2.1 Hand washing..................................................................................................................... 15

3.2.2.2 Alcohol-based hand rubs....................................................................................................16

3.2.2.3 Hand hygiene for residents/patients...................................................................................16

3.2.3 Environmental cleaning and disinfection.....................................................................................16

3.2.3.1 Kitchen cleaning................................................................................................................. 17

3.2.3.2 Eating utensils.................................................................................................................... 17

3.2.3.3 Carpets............................................................................................................................... 17

3.2.3.4 Cleaning up vomit of faeces................................................................................................17

3.2.3.5 Shared equipment and instruments/devices.......................................................................18

3.2.3.6 Cleaning equipment............................................................................................................18

3.2.3.7 Linen and laundry items......................................................................................................18

Table 2. Cleaning and disinfection recommendations.........................................................................18

3.2.4 Staff............................................................................................................................................ 19

3.2.5 Residents and patients in the facility...........................................................................................20

3.2.5.1 Placement........................................................................................................................... 20

3.2.5.2 Movement........................................................................................................................... 20

3.2.6 Admissions and transfers............................................................................................................20

3.2.6.1 New admissions.................................................................................................................. 20

3.2.6.2 Re-admissions (excludes health care settings)...................................................................21

3.2.6.3 Transfers............................................................................................................................ 21

3.2.7 Signage...................................................................................................................................... 21

3.2.8 Visitors and communal activities.................................................................................................21

3.2.8.1 Non-infected residents........................................................................................................22

3.2.9 Waste management.................................................................................................................... 22

3.3. Case lists........................................................................................................................................... 22

3.4. Faecal specimen collection................................................................................................................23

3.5. Declaring an outbreak over................................................................................................................23

3.6 Additional control measures for suspected food or water borne outbreaks.........................................24

3.6.1 Food........................................................................................................................................... 24

3.6.2 Water.......................................................................................................................................... 24

3.6.3 Additional information to assist the outbreak investigation.........................................................24

4. Communication................................................................................................................................... 25

5. Staff education and training..............................................................................................................255.1 Adequate stock levels......................................................................................................................... 26

6. Privacy................................................................................................................................................. 26

7. Media.................................................................................................................................................... 26

Appendix 1. Guidance for the dilution of chlorine-based solutions required for disinfection........27

Appendix 2. Exclusion guidelines for food handlers, health care workers and child care workers.................................................................................................................................................... 29

Appendix 3. Outbreak management checklist for gastroenteritis outbreaks in care facilities........30

Appendix 4. Instructions for the collection of faecal (poo) specimens.............................................32

Appendix 5 – Outbreak case list: Care facilities..................................................................................33

Appendix 6: Signage – Care facilities...................................................................................................35

Appendix 7. Blenders and mixing equipment in care facility kitchens..............................................39

Acronyms and abbreviations................................................................................................................. 40

Glossary.................................................................................................................................................. 41

1. Introduction

This guide has been produced to assist in the management and control of outbreaks of gastroenteritis (gastro) in aged care, special accommodation, hospitals and other residential care facilities. Owners, managers, directors of nursing, infection control practitioners and all clinical and allied health staff should follow these guidelines to manage and control gastroenteritis outbreaks. They may also need to liaise with council environmental health officers (EHOs), and the Department of Health and Human Services (the department) if an outbreak investigation is conducted.

1.1 GastroenteritisGastroenteritis may be caused by a variety of different bacteria, viruses or parasites. Symptoms of diarrhoea, nausea, vomiting and abdominal pains may be experienced over several hours, days or weeks, and may also be accompanied by fever, headache and lethargy. Generally, gastrointestinal pathogens are spread by direct person-to–person transmission (viruses), via aerosols of vomit, from contact with contaminated surfaces, or by consuming contaminated food or water (bacteria, viruses or parasites). The time from becoming infected to the commencement of symptoms (the incubation period) can vary from a few hours to several days.

In recent years, the number of gastroenteritis outbreaks in aged care facilities, hospitals and residential facilities has increased. Residents and patients of many of these facilities represent populations at high risk for gastroenteritis, who tend to experience greater severity and longer duration of illness. In these settings, transmission of disease may be complicated by close living conditions, shared bathroom facilities, low mobility and incontinence.

Gastroenteritis is generally self-limiting and no treatment is required, however, this is a decision for the treating doctor. Given the highly susceptible populations in aged care and health care facilities, it is essential that outbreaks of gastroenteritis are contained (keeping the number of patients, residents and staff infected to a minimum) as quickly as possible by implementing the infection control procedures outlined in these guidelines.

Elderly residents may also have symptoms that can mimic gastroenteritis which are due to chronic bowel disease or problems or certain medicines, but are not the result of an infection. These non-infectious illnesses do not usually occur in several residents at the same time.

1.2 Viral gastroenteritisGastroenteritis outbreaks in aged care, hospitals and residential facilities are largely due to the highly infectious virus called norovirus. Norovirus is transmitted from person to person by faecal-oral spread, via aerosolised vomit by contact with contaminated surfaces, or by consuming food contaminated by an infected person. It is a very hardy virus that can survive in the environment for weeks and withstand freezing, heating to 60°C and weak chlorine solutions. The incubation period is generally accepted to be 12–48 hours, and symptoms, predominantly vomiting, diarrhoea and abdominal pain, usually last for only 24–48 hours. As the virus passes from one person to the next, onset of illness in cases tends to occur over several days, rather than all at the same time.

Where a facility is affected by an outbreak of suspected viral gastroenteritis the main focus should be on enhancing infection control. For further information on viral gastroenteritis, please refer to the department’s fact sheet here

< https://www2.health.vic.gov.au/about/publications/ResearchAndReports/Gastroenteritis%20-%20viral%20pamphlet>

Page 8 A guide for the management and control of gastroenteritis outbreaks in care facilities

https://www2.health.vic.gov.au/about/publications/ResearchAndReports/Gastroenteritis%20-%20viral%20pamphlet

1.3 Foodborne illnessGastroenteritis can also be caused by eating contaminated food. Most foodborne illness is caused by bacteria which, given the right conditions, can grow in the food to numbers sufficient to infect the consumer – this is called the infective dose. If there is no further cooking, or if the cooking process is inadequate, the bacteria may survive and infect those who eat the food.

Certain foods are considered to be high risk for susceptible populations such as the elderly, very young children and those who are already ill. These foods should not be served to residents of aged care facilities or patients in hospital (table 1). Eggs can be high risk as they may be contaminated with Salmonella bacteria, so should not be eaten raw or undercooked. Eggs should always be kept in the fridge in the original carton and used before the best-before date. Cracked and/or dirty eggs should be discarded. When storing, handling and preparing eggs, always take the same precautions as you would for raw chicken, meat, seafood and dairy products. Cooking these foods well ensures that the bacteria are destroyed, however during food preparation, kitchen equipment (such as the whisk or blades of an appliance) may become contaminated when raw eggs or foods containing raw eggs, such as cake batter, are processed in mixers or blenders. If the mixing equipment is then not washed and sanitized correctly, any ready-to-eat foods processed in this equipment may become contaminated and cause serious illness. It is recommended that separate pieces of mixing equipment are allocated to raw food and ready-to-eat foods. (See Appendix 7)

Soft cheeses, deli meats, uncooked or smoked fish, pre-prepared salads and sandwiches containing any of these ingredients may sometimes be contaminated with Listeria bacteria, which can cause serious illness and death in the elderly and anyone whose immune system has been weakened by disease, illness or medications. All of these foods should be avoided, or only served in cooked, hot dishes for vulnerable people1.

Bacteria called Clostridium perfringens can survive the cooking process in a spore state. The spores may germinate to live bacteria that can then grow to large numbers in the food and produce a toxin (poison) in the gut of the consumer. This bacteria may be found in meat-based foods such as soups, gravies, casseroles and roasts, so if these foods are prepared ahead of serving time, they must be cooled quickly in small quantities, and stored in the fridge, and then re-heated quickly to a temperature of 60C or above and served hot. It is not safe practice to repeatedly cool and reheat the same food over several meals or days. Food should be re-heated only once.

Bacteria called Staphylococcus aureus can also produce toxins in food if allowed to grow to high numbers. As food can be contaminated with Staphylococcus aureus from a food handler’s hands it is essential that ready-to-eat food is not handled with bare hands. It is also important to store food at less than 5°C or above 60°C and minimize the amount of time food is kept between these temperatures during preparation to reduce the risk of any bacterial growth.

Care should always be taken to follow all aspects of the Food Safety Program (FSP), especially with regard to personal hygiene of food handlers, temperature control, cross-contamination and cleaning and disinfection procedures. Food safety records should be constantly maintained to show that food is being stored, prepared and served safely and that food handling staff are well trained in all aspects of food hygiene.

1 State Government Victoria. (2018). Food poisoning - listeria. Available: https://www.betterhealth.vic.gov.au/health/healthyliving/food-poisoning-listeria.

A guide for the management and control of gastroenteritis outbreaks in care facilities Page 9

1.4 Waterborne illnessGastroenteritis can be caused by drinking contaminated water. Waterborne illness may be caused by parasites such as Giardia and Cryptosporidium, by bacteria or by viruses. It is therefore essential that all facilities provide safe water for their residents, patients and staff at all times.

All water used for drinking and food preparation must be potable (safe to drink). The water quality standards for potable water are described in the drinking water legislation, available here <https://www2.health.vic.gov.au/public-health/water/drinking-water-in-victoria/drinking-water-legislation>

Private water supplies, such as dams, rivers, bores and rainwater tanks, cannot be guaranteed to be free of pathogens. For this reason, private water supplies that need to be potable should be treated to prevent the risk of waterborne illness. As the level of treatment is dependent upon the quality of the source water, proprietors should seek advice from a water quality specialist to ensure the treatment system is appropriate for their circumstances.

If water used at a facility, at the time of an outbreak, is non-mains water (such as from a bore, rainwater tank or dam), the proprietor must provide the council EHO with documentation proving potability of the water, that the water is safe to drink (e.g. a water supply management plan). If the cause of an outbreak is suspected to be waterborne (for example, from contaminated rainwater tanks, bore water or other private water supplies), the EHO will collect samples of water for laboratory testing.

1.5 Antibiotic-related diarrhoeaDiarrhoea in residents of care facilities, particularly aged care, can be caused by a bacteria called Clostridium difficile. This diarrhoeal illness generally lasts longer than two days. The bacteria is present in less than 3 per cent of healthy adults, but diarrhoea can result when changes to the normal gut bacteria allow the Clostridium difficile bacteria to grow in numbers and produce a toxin. The use of antibiotics is the key factor affecting the normal gut bacteria. Outbreaks of antibiotic-related diarrhoea are most likely to occur in patients/residents who are taking, or have recently taken, antibiotics. Other risk factors include being older than 60 years, and spending time in health care or residential care settings. For this reason it is important when notifying an outbreak to indicate any antibiotic treatment of symptomatic patients/residents.

1.6 Animal-to-person infectionMany animals carry bacteria even if they have no signs of illness and these bacteria can contaminate the animal environment. After touching animals and their surroundings bacteria that is present on hands can easily be taken into the mouth when eating or drinking. Puppies and young dogs as well as kittens should not be considered or permitted as companion animals in care facilities due to their high rates of Campylobacter carriage, their social immaturity, the susceptibility of elderly residents to infection and poor outcomes2.

Care facilities need to be aware of the risk posed from the transmission of bacteria from animals to humans and the potential for adverse outcomes among a vulnerable population such as frail, elderly persons living in an aged-care environment. Care facilities need to adopt and enforce policies that recognize this infection risk and restrict inappropriate animal access.

2 Moffatt C et al. An assessment of risk posed by a Campylobacter-positive puppy living in an Australian residential aged-care facility. Western Pacific Surveillance and Response Journal, 2014, 5(3). doi:10.5365/wpsar.2014.5.2.009


https://www2.health.vic.gov.au/public-health/water/drinking-water-in-victoria/drinking-water-legislation

Table 1. High risk foods for the elderly or immunocompromised

Food Advice Safer Alternative

Eggs Do not add raw eggs to food (e.g. custard) or drinks (e.g. milkshakes, protein shakes) unless the food or drink is then cooked/reheated to 75C

Do not make sauces, salad dressings or desserts (e.g. mayonnaise, hollandaise sauce, trifle, tiramisu) using raw eggs.

Do not serve undercooked (sloppy/runny) eggs

Use pasteurised egg pulp or powdered eggs for foods that are not cooked.

Purchase commercial brands of sauces and salad dressings.

Cook eggs, and food containing raw eggs, well, so that all parts of the egg are firm.

Soft Cheese Do not serve cheeses such as brie, camembert, ricotta or fetta (unless they are in a dish that is cooked and served hot).

Serve hard cheeses (e.g. cheddar) or processed cream cheese or cheese spreads.

Retailed pre-cooked meat (such as pate and deli meats)

Do not serve these products uncooked, as part of a meal or in sandwiches.

Only serve in cooked, hot dishes (eg. pizzas, pasta)

Ready to eat seafood (eg. smoked fish, mussels, oysters, raw seafood)

Do not serve uncooked or smoked fish or seafood.

Only serve cooked, hot fish and seafood, or canned fish.

Pre-prepared or stored salads (e.g. coleslaw, fruit salad)

Do not prepare salads too far ahead of serving, even if they are stored in the fridge.

Do not serve leftover salads for subsequent meals.

Always wash salad ingredients thoroughly and prepare then as close to serving as possible.

Leftover roast meats to be used in salads or sandwiches

Slice, cover and cool roast meats quickly and store refrigerated. Serve in sandwiches and salads within 24 hours.

Use processed fillings for sandwiches (e.g. vegemite, cream cheese, canned tuna) and use leftover roast meats in hot dishes (reheat to 75C).

Ready-to-eat foods, including leftovers that have been in the fridge for more than one day

Do not serve these foods cold.

Do not serve leftovers that are more than 24 hours old.

Cool quickly.

Always reheat any leftovers quickly to at least 75C before serving.

Do not re-heat food more than once.

Soups, gravies, casseroles and roasts

If prepared ahead of service, decant or slice into small shallow containers, cover and refrigerate. Reheat quickly to at least 75C.

Prepare as needed and serve hot immediately whenever possible.

Prevention is better than cure.


2. What should happen in the event of a gastroenteritis outbreak?

This section describes the various steps that need to be undertaken if a gastroenteritis outbreak occurs, including notification, control measures and other actions required to assist in the investigation of the outbreak, such as faecal specimen collection. These steps are summarised in figure 1: Gastro outbreak management summary flowchart. An outbreak management checklist has also been designed to assist facilities in managing their gastroenteritis outbreak (see Appendix 3). This checklist identifies the tasks that need to be undertaken and allows individual tasks to be signed off by staff members.

2.1 Notify the outbreakMedical practitioners are legally required to notify the department if they become aware of cases who may have “Food or water borne illness (two or more associated cases)” and particularly for those who reside in the same care facility. Currently there is no legal requirement for facilities to notify the department of an outbreak of gastroenteritis.

However, notification of an outbreak of gastroenteritis by a care facility is strongly recommended as the department can provide advice and support in managing outbreaks to minimise the severity and duration of illness, particularly in vulnerable people.

2.1.1 Is a gastro outbreak occurring?An outbreak may be defined as more than the expected number of cases of illness over a given time period. An outbreak in a care facility is defined as two or more cases of vomiting and/or diarrhoea among residents/patients and/or staff (that cannot be explained by medication or other medical conditions) within 72 hours, in a setting that makes epidemiological sense.

It is important to note that this definition may not always cover all outbreaks. Any concerns regarding gastroenteritis amongst residents/patients should be discussed with the department.

2.1.2 How do you notify a gastro outbreak?

If you suspect you have a gastro outbreak, the first step is to notify the Department of Health and Human Services, Communicable Disease Prevention and Control on 1300 651 160 within 24 hours. The department officer will collect information on the number of cases, symptoms, duration of illness and other details, and can discuss any issues you may have and provide advice if necessary. Based on the information you provide, the officer will assess the probable cause of the outbreak and the way in which it is likely to spread.

Note: Notify outbreaks by telephone on 1300 651 160, and speak directly to a departmental officer as soon as possible. Please do not email and fax notifications of outbreaks, or leave messages regarding outbreaks on answering machines.


2.1.3 What if someone dies during a gastro outbreak?The death of any resident/patient during a gastrointestinal outbreak must be reported to the department within 24 hours on telephone 1300 651 160, giving the cause of death if known and the case list should be updated to reflect the deceased resident/patient.

2.1.4 What can be done to control the spread of illness?Once an outbreak of gastroenteritis has been identified it is essential that cleaning and infection control measures are implemented immediately to reduce the risk of the infection spreading and the number of cases increasing. Clean-up and control measures should be implemented for all gastrointestinal outbreaks as soon as possible after an outbreak is suspected, and should continue until the outbreak has been confirmed as being over (48 hours after symptoms have ceased in the last case - no further cases of illness occurring).

You will be contacted by your council Environmental Health Officer (EHO), who will visit the facility to conduct an inspection, check that infection control measures have been implemented, collect further information and provide advice.

The control measures outlined in this guide have been suggested to reduce the risk of:

• people contracting the illness from contaminated food or water;• infected people passing the infection to others; and• the pathogen remaining in the environment and being able to infect others.

Specific control measures may depend upon:

• the pathogen (bacteria or virus) known or suspected to be responsible for the illness;• the way in which the pathogen spreads to others (known or unknown); and• the setting where the outbreak has occurred.


Figure 1. Gastro outbreak management summary flowchart


Gastro outbreak suspected or identified

Notify the outbreak to CDPC at the department

Inform ALL staff of the outbreak (including casual and agency staff) – keep staff informed as the outbreak

progresses

Start a case list as a record of those who are ill – forward updated list to CDPC and Council at least

twice per week.

Conduct outbreak cleaning and repeat regularly throughout outbreak

Arrange collection of faecal specimens from those who are ill

Provide CDPC and/or council with additional information as

requested

Implement outbreak infection control procedures - note additional infection

control for suspected foodborne outbreaks

Implement hand washing procedures immediately. (Hand hygiene signage)

Limit visitors to facility. Advise visitors/families of the outbreak

(signage)Notify all deaths to CDPC immediately

Continue until outbreak is over (48 hours after symptoms stop in

last case)


3. Infection prevention and control measures

This section describes the various infection prevention and control measures that should be implemented for all outbreaks of gastroenteritis, as well as additional control or investigational measures that should be implemented for food or water borne outbreaks.

3.1 Standard precautionsThe use of standard precautions is an essential infection control strategy for the successful prevention and minimisation of transmission of all infections between residents/patients, staff and visitors. Standard precautions refer to the work practices required to achieve a basic level of infection prevention and control and apply to all residents, regardless of suspected or confirmed infection status. Standard precautions include (but are not limited to):

• hand hygiene;• routine environment cleaning and cleaning and disinfection of shared equipment;• use of personal protective equipment;• waste management; and• appropriate handling of linen.

Consistent application of standard infection control precautions will reduce the risk of transmission of gastrointestinal infections during an outbreak.

3.2 Transmission-based precautions (contact precautions)Transmission based precautions are infection control precautions used in addition to standard precautions to prevent the spread of certain infectious pathogens. Contact precautions are the additional infection control precautions required when caring for residents/patients suspected or confirmed as having a gastrointestinal illness.

Contact precautions (in addition to the standard precautions listed above) include the procedures described below and are discussed in the context of a gastrointestinal outbreak Contact precautions should be continued for ill residents/patients until 48 hours after the last symptoms.

3.2.1 Personal protective equipment (PPE)As per standard precautions, staff should wear appropriate PPE when it is anticipated that there may be contact with a resident’s/patient’s blood or body fluids, mucous membranes, non-intact skin or other potentially infectious material or equipment. The principles as outlined below should also be followed during a gastroenteritis outbreak.

• PPE must be worn when providing care for residents/patients with a gastrointestinal illness.• PPE should be donned before entering an ill resident’s/patient’s room as the whole room is to be

considered potentially contaminated. Always remove PPE before exiting the resident’s/patient’s room to ensure areas outside residents’/patients’ rooms do not become contaminated.

• If patients/residents occupy a shared room staff must ensure they change their PPE and perform hand hygiene when moving between residents/patients in that shared room.

• Always perform hand hygiene before putting on PPE and immediately after removal of PPE.• PPE should be removed in a manner that prevents contamination of the clothing, hands and the

environment (see section 3.2.1.5).


• PPE should be immediately discarded into appropriate waste bins (clinical waste for residents/patients with a gastrointestinal illness).

3.2.1.1 Gloves

Single-use disposable gloves must be worn for all contact with ill residents/patients and when hands are likely to be contaminated with vomit or faeces. Hand hygiene must be performed immediately before and after glove use. If gloves are not worn during contact with an ill resident/patient hands must be washed with soap and water immediately after contact with the resident/patient.

3.2.1.2 Gowns

Single-use disposable impermeable gown or plastic apron must be worn whenever entering the room of a resident/patient in contact precautions.

3.2.1.3 Masks

Norovirus is highly infectious and may become aerosolised, for example, during vomiting. A surgical-style face mask should be worn when there is the potential for generation and dissemination of aerosols, such as when a resident/patient is vomiting or cleaning surfaces visibly contaminated with vomit or faeces.

3.2.1.4 Eyewear

Protective eyewear should be worn when there is the potential for splash or splattering from vomit or faeces. If reusable goggles are worn, they should be cleaned and disinfected between each use.

3.2.1.5 Staff training

Staff should be trained and deemed proficient or experienced in donning and doffing (putting on and removing) PPE before an outbreak occurs. The following resources are highly recommended showing the correct technique for donning and doffing PPE. Tasmanian Infection Prevention and Control Unit’s videos <http://www.dhhs.tas.gov.au/publichealth/tasmanian_infection_prevention_and_control_unit/healthcare_worker_education/proper_use_of_personal_protective_equipment> as a resource for correct PPE use.

3.2.2 Hand hygieneHand hygiene is one of the most effective infection control measures for preventing the spread of infectious pathogens. Emphasis should be placed on the importance of hand hygiene for all staff, residents/patients and visitors.

Hand hygiene is a general term that refers to any action of hand cleansing, such as hand washing with soap and water or hand rubbing with an alcohol-based hand rub (ABHR).

There must be adequate access for staff, residents/patients and visitors to hand hygiene stations (that is, ABHR and hand basins with liquid soap, water and paper towel) that should be adequately stocked and maintained at all times. Hand basins for staff should, wherever possible, be hands-free (for example, elbow operated) to facilitate appropriate hand hygiene practices and prevent recontamination of hands when turning off taps. Staff should be made aware of the proper hand hygiene technique and rationale; when, where and how, known as the “5 moments of hand hygiene”.

The use of gloves should never be considered an alternative to hand hygiene. Hand hygiene is required before putting on gloves and immediately after they have been removed.

3.2.2.1 Hand washing

Hands should be washed using a plain liquid soap for 15-20 seconds, then rinsed under running water and pat dried with disposable paper towel. Hand dryers may be used, but it essential that hands are


http://www.dhhs.tas.gov.au/publichealth/tasmanian_infection_prevention_and_control_unit/healthcare_worker_education/proper_use_of_personal_protective_equipment

http://www.dhhs.tas.gov.au/publichealth/tasmanian_infection_prevention_and_control_unit/healthcare_worker_education/proper_use_of_personal_protective_equipment

completely dried before undertaking any further activities. Multi-use cloth towels must not be used to dry hands.

3.2.2.2 Alcohol-based hand rubs

Generally, using an ABHR is the preferred method for hand cleansing when hands are not visibly dirty. Hands must be washed with plain liquid soap and water when visibly dirty or visibly soiled with blood or body fluids and after using the bathroom.

Because norovirus cannot be cultured, the efficacy of alcohol-based preparations against this virus has been difficult to determine. The Australian guidelines for the prevention and control of infection in health care settings (2010), recommend that:

• if gloves are worn during the care of patients with non-enveloped viruses (for example, norovirus) ABHR remains the agent of choice for hand hygiene; and

• if gloves have not been worn or hands are visibly soiled, they must be washed with soap and water.

Access to hand basins for staff is also often limited in residential care facilities. As such, alcohol-based hand rubs must not be removed from clinical settings or patient care areas during an outbreak.

3.2.2.3 Hand hygiene for residents/patients

Hand hygiene for residents/patients is another important measure to prevent the transmission of infectious organisms. Residents/patients should wash their hands after toileting, after blowing their nose, before eating and when leaving their room. If a resident’s/patient’s cognitive or physical state is impaired, staff caring for them must be responsible for helping residents/patients with this activity. Staff should assist residents/patients to perform hand hygiene whenever they leave their room, after going to the toilet or blowing their nose, prior to communal activities and before eating food.

Remind visitors that they should perform hand hygiene before and after visiting any resident/patient.

Further information and resources about hand hygiene can be found at Hand Hygiene Australia <https://www.hha.org.au/hand-hygiene/hha>.

3.2.3 Environmental cleaning and disinfectionGastroenteritis may be caused by a number of pathogens, but the most common cause of gastroenteritis outbreaks in residential care facilities is norovirus. Norovirus is a very hardy organism that may survive on surfaces for up to 28 days, and as norovirus is highly infectious (approximately 10-100 viruses is all that is needed to cause infection), cleaning and disinfection of the environment is one of the most important measures for limiting the spread of disease.

The frequency of environmental cleaning and disinfection during an outbreak should be at least twice daily, particularly of frequently touched surfaces such as bedside rails, over bed tables, the arms of bedside chairs, call bells and door handles. The frequency of cleaning and disinfection of toilets should also be increased including flush handles or buttons, toilet seats, taps, light switches and door handles. All other areas of the premises, including dining rooms, bathrooms, cases bedrooms, handrails and all communal areas should also be cleaned and disinfected frequently during an outbreak.

The choice of disinfectants that are effective against norovirus is limited. Generally, quaternary ammonia compounds (QATs) and alcohols have not been shown to be effective against norovirus (or feline calicivirus (FCV), the substitute virus used for these studies), but chlorine-based disinfectants at a minimum dilution of 1000 ppm have. When selecting a disinfectant to use during an outbreak consider the following.

• Select a disinfectant or combined cleaning and disinfecting agent that is either “listed” or “registered” with the Therapeutics Goods Administration (TGA). Products can be checked to see if they are on the


https://www.hha.org.au/hand-hygiene/hha

Australian Register of Therapeutic Goods (ARTG) here <https://tga-search.clients.funnelback.com/s/search.html?query=&collection=tga-artg>;

• If not a chlorine-based product then the product must specify that it is effective against norovirus;• Select a disinfectant that is effective against the vast majority of organisms that cause health care

associated infections. The need to use different disinfectants for different organisms could lead to mistakes in dilution and usage of products; and

• For practical purposes, the disinfectant should have a fast kill time (or contact time). This will enable killing of organisms before the solution can dry, be removed or before residents/patients or staff are likely to touch the surface.

Always follow the manufacturer’s instructions for use (and dilution) of detergents and disinfectants. A 2-in-1 cleaning and disinfecting product may be used, allowing for a 1-step cleaning and disinfection process. There are a number of 2-in-1 detergent and disinfectant products available that are simple and effective to use. Ensure the manufacturers’ instructions are followed for correct dilution and use. See also section 4 which is a guide for the dilution of chlorine-based solutions required for disinfecton.

If facilities use an alternative method for cleaning and disinfection, the method must be validated to be equivalent to the above. If using a non-touch method of surface disinfection (for example, ultraviolet [UV-C] or hydrogen peroxide vapour) prior cleaning is required.

A ‘terminal clean and disinfection’ should be conducted when contact precautions have been ceased for a resident and when the outbreak for a unit has been declared over.

If a commercial cleaning company has been engaged by the care facility to undertake the environmental cleaning it is the facility’s responsibility to ensure that the cleaning contractor is conducting the cleaning in accordance with this guide.

3.2.3.1 Kitchen cleaning

All kitchen areas should be cleaned and disinfected at the beginning of every outbreak and then twice daily until the outbreak has been declared over. All work surfaces, benches, shelving, doors, sinks, floors etc., or any other areas that are possibly contaminated should be cleaned and sanitised with 1000ppm of available chlorine. See section 4 for chlorine dilutions or check your supplier/manufacturer’s instructions.

3.2.3.2 Eating utensils

Crockery and cutlery should be washed and sanitised in a dishwasher if the rinse cycle is able to achieve a minimum of 82C for two minutes, or if a dishwasher is not available, items should be washed by hand using hot water and detergent, then immersed in 100ppm of available chlorine for at least three minutes at 50C, rinsed in hot water and dried. The use of disposable cutlery or separation of cutlery and crockery during an outbreak is not required. See section 4 for chlorine dilutions.

3.2.3.3 Carpets

All carpets contaminated by vomit and/or faeces should be cleaned with detergent and hot water and then steam cleaned, as high temperature and moisture are required to kill viruses. Clean all surface soiling thoroughly then use a vapour steam cleaner that boils the water until it turns to steam. True steam cleaners release steam under pressure, which ensures that the temperature is above 100C and the carpet dries quickly. Vacuum cleaning carpets and polishing floors has the potential to recirculate norovirus and is not recommended during an outbreak3.

3 Communicable Diseases Network Australia. (2010). Guidelines for the public health management of gastroenteritis outbreaks due to norovirus or suspected viral agents in Australia. Available: http://www.health.gov.au/internet/main/publishing.nsf/Content/cda-cdna-norovirus.htm.


https://tga-search.clients.funnelback.com/s/search.html?query=&collection=tga-artg

3.2.3.4 Cleaning up vomit of faeces

Vomit can produce aerosols, (a fine mist of virus particles) suspended in the air and fall onto food or surfaces. If a person vomits in a public area, all people should be removed from the vicinity and the area cleaned immediately. Persons cleaning vomit or faeces should wear gloves, apron and a mask. Paper towels should be used to soak up excess vomit and faeces and disposed of into a clinical waste bag. The area can then be cleaned and disinfected.

3.2.3.5 Shared equipment and instruments/devices

Use disposable equipment where possible (for example, blood pressure cuffs) or dedicate use of non-disposable equipment to any residents/patients with a gastrointestinal illness. If equipment must be shared (for example, lifting machine) for multiple residents/patients, ensure the equipment has been cleaned and disinfected before use on another resident/patient. Items such as slings should be dedicated to one resident’s/patient’s use and must be laundered before use on another resident/patient.

Consider cohorting (grouping) equipment to use for residents/patients in contact precautions, or to a wing or unit under isolation. If equipment is cohorted, it must still be cleaned and disinfected between each resident/patient use.

3.2.3.6 Cleaning equipment

Where possible, cleaning equipment such as cloths, mops and brushes should be disposable and discarded immediately after use.

3.2.3.7 Linen and laundry items

Handle, transport, and process used linen or items requiring laundering (for example, clothing) in a manner that avoids contamination of air, surfaces and persons. If linen or resident/patient clothing is laundered onsite compliance with the Australian Standard AS/NZS 4146:2000 Laundry Practice is required. No additional precautions are required for the management of linen for residents/patients with gastroenteritis if compliance with AS/NZS 4146:2000 Laundry Practice is adhered to and linen and clothing items from residents/patients with a gastrointestinal illness do not need to be segregated or laundered separately.

If residents’/patients’ clothing is laundered by their family, families should be advised to wear disposable gloves while handling clothing and to launder clothing from ill residents/patients separately and in the hottest washing machine cycle the clothing can withstand. For temperatures less than 60°C the addition of a laundry sanitiser (for example, Napisan™) is recommended. Clothing should also be dried on the hottest dryer setting following washing.

A summary of cleaning and disinfection recommendations for items in a care setting has been included in Table 2.

Table 2. Cleaning and disinfection recommendations

Item Cleaning RecommendationCarpets contaminated by faeces or vomit

Clean with warm water and detergent then steam clean (True steam cleaners release steam under pressure, above 100C)

DO NOT vacuum carpets during an outbreak

Communal Areas (staff rooms, dining areas, lounge rooms, banisters, hand rails, lockers, telephones, cupboard handles, etc)

Wash with detergent and hot water, then disinfect for 10 minutes with 1000ppm available chlorine. Rinse with cold water then dry.


Item Cleaning RecommendationKitchen – food contact surfaces (utensils, equipment, crockery, cutlery etc)

Immerse in hot water at a minimum of 82C for 2 minutes. This can be done in a dishwasher as long as the rinse cycle reaches this temperature

OR

Wash by hand then immerse in 100ppm of available chlorine for at least 3 minutes at 50C.

For equipment that cannot be completely immersed, 200ppm of available chlorine should be used on all surfaces for 10 minutes

Kitchen – work surfaces, benches, shelving, doors, door and cupboard handles, storage areas, sinks, floors etc.


Mattresses and soft furnishings (pillows, curtains, couches, cushions, doonas, etc)

Clean with warm water and detergent then steam clean (True steam cleaners release steam under pressure, above 100C)

OR

Discard if not able to be effectively cleaned

Soiled clothing and linen (sheets, towels, blankets etc)

Wash in washing machine on the hottest cycle then dry in a dryer on the hot cycle.

The Australian Standard AS/NZS 4146(2000) – guidelines for correct laundry practice.

Toilet/Bathroom Areas (toilet bowls/seats, bedpans, commodes, bath and toilet rails, hand wash basins, tap handles, doors and door handles, flush buttons, floors etc)


3.2.4 StaffStaff with a gastrointestinal illness must be excluded from working at the facility (and cannot work at any other facility) until 48 hours after symptoms have ceased (this includes all food handling staff, kitchen staff, waiting staff, serving staff/volunteers and also includes nursing or personal care staff). See Appendix 2 exclusion guidelines.

During an outbreak, wherever possible, staff should not move between wings or units of the facility to provide care for other residents/patients. This is particularly important if not all wings/units are affected by the outbreak. It is preferable to cohort staff to areas (either in isolation or not in isolation) for the duration of the outbreak.

Management should support the recommendation that staff should not return to work for 48 hours after symptoms have ceased. Staff should not feel compelled to return to work earlier for fear of losing their employment or due to staff shortages4.

4 Communicable Diseases Network Australia. (2010). Guidelines for the public health management of gastroenteritis outbreaks due to norovirus or suspected viral agents in Australia. Available: http://www.health.gov.au/internet/main/publishing.nsf/Content/cda-cdna-norovirus.htm.


3.2.5 Residents and patients in the facility

3.2.5.1 Placement

It is preferable that all residents/patients with a gastrointestinal illness be cared for in a single room with their own ensuite facilities. The resident/patient should be restricted to their room until at least 48 hours after symptoms have ceased.

If single rooms are not available, use the following principles to guide resident/patient placement.

• Give highest priority to single room placement to residents/patients that are incontinent of faeces and/or vomiting;

• Where well and unwell residents/patients share a room/ward it may not be advisable to separate them as those who currently have no symptoms may be incubating the infection. It is also not advisable to move an ill resident/patient out of a shared room and place another non-ill resident/patient into their shared room for the same reason. In these situations, the ill resident/patient should not share the bathroom or toilet with the non-ill resident(s)/patient(s). The affected resident/patient should either have their own dedicated ensuite or be toileted on their own dedicated commode; and

• In shared rooms staff must ensure they change their PPE and perform hand hygiene when moving between residents/patients.

3.2.5.2 Movement

There should be limited movement of ill residents/patients wherever possible. In an outbreak situation, common areas, such as lounge rooms and dining rooms should not be used by unwell residents/patients. Resident/patient movement between affected an unaffected areas should be strictly limited. If this is not possible residents/patients should not use common areas.

• Where possible, residents/patients in contact precautions should be restricted to their room until at least 48 hours after symptoms have ceased.

• Meals should be delivered to unwell residents/patients in their rooms until 48 hours after their symptoms have ceased.

• Medical or procedural appointments of ill residents/patients should be deferred until at least 48 hours after symptoms have ceased. If an appointment is urgent and cannot be deferred the receiving facility should be informed that the resident/patient has gastroenteritis (or is within 48 hours of their last symptoms).

• Medical or procedural appointments of non-symptomatic residents/patients are preferably deferred until the outbreak is declared over. If an appointment cannot be deferred the receiving facility should be informed that the resident/patient has come from a facility that currently has a gastrointestinal illness outbreak.

• Suspend all swimming, hydrotherapy, communal spas and other non-medical appointments or activities during the outbreak.

3.2.6 Admissions and transfers

3.2.6.1 New admissions

An ongoing outbreak does not mean the facility has to go into complete “lock down”. It is preferable that admission of new residents/patients to an affected unit or facility during an outbreak does not take place. However, where new admissions are unavoidable, new residents/patients and their families must be informed of the current outbreak and adequate outbreak control measures must be in place for these new residents/patients. Families may wish to make an informed choice and make alternative arrangements until the outbreak is over.


3.2.6.2 Re-admissions (excludes health care settings)

An aged care or residential care facility is considered the primary residence of the residents of that facility. If a resident has temporarily been transferred to another facility such as a hospital for medical attention and their treatment has been completed, that resident will need to return to the aged care/residential care home, regardless if an outbreak is occurring. Every attempt should be made to place the recovering resident in an area where there is no illness. If this is not possible, the room the resident is returning to should be thoroughly cleaned and disinfected as per the guidelines prior to returning and appropriate precautions undertaken by staff to prevent further transmission of the illness.

The returning resident and their family must be informed if there is an outbreak at the facility. Families may wish to make an informed choice and make alternative arrangements until the outbreak is over.

3.2.6.3 Transfers

If transfer to a hospital or another facility is required during an outbreak, the ambulance service and receiving hospital/facility must be notified of the outbreak, and whether or not the resident being transferred is a confirmed/suspected or recovering case (which is potentially still infectious).

3.2.7 SignageA contact precaution sign must be placed outside symptomatic residents’/patients’ rooms to alert staff and visitors to the requirement for transmission-based precautions.

Contact precautions posters/ signage are available at:

• The Australian Commission for Safety and Quality in Health Care website <https://www.safetyandquality.gov.au/our-work/healthcare-associated-infection/national-infection-control-guidelines/>; and

• The department’s webpage <https://www.safetyandquality.gov.au/wp-content/uploads/2012/02/Portrait-Victoria-Standardised-Infection-Control-and-Prevention-Signs-PDF-5583KB.pdf>.

Signage must also be posted at all external entrances to the facility to alert visitors to the outbreak.

Signage should also be strategically posted to remind visitors to:

• not visit if unwell;• visit only one resident during their visit;• follow signs for the use of PPE as indicated; and• perform hand hygiene before and after their visit.

Care facilities should consider posting permanent signage with the following reminders to visitors:

• do not visit the facility if unwell with gastroenteritis; and• perform hand hygiene before and after visit.

See Appendix 6 for staff and visitor signage.

3.2.8 Visitors and communal activitiesDuring an outbreak, where possible, minimise the movement of visitors into and within the facility. Facilities should consider implementing the following strategies.

• Suspend all group activities, particularly those that involve visitors (for example, musicians).• Postpone visits from non-essential external providers (for example, hairdressers).


https://www.safetyandquality.gov.au/wp-content/uploads/2012/02/Portrait-Victoria-Standardised-Infection-Control-and-Prevention-Signs-PDF-5583KB.pdf

https://www.safetyandquality.gov.au/our-work/healthcare-associated-infection/national-infection-control-guidelines/

• Inform regular visitors and families of residents of the gastroenteritis outbreak and request that they only undertake essential visits. Visitors should also be advised of the need to follow all infection control procedures, and to restrict visits to only one resident during the outbreak.

• Visitors are discouraged from bringing young children to visit during an outbreak as they are highly susceptible to infection.

• Any visitors experiencing symptoms of gastroenteritis are advised not to visit the facility until 48 hours after their symptoms have ceased.

• Visitors are discouraged from bringing food to the facility to share amongst the residents/patients during an outbreak.

• Ask visitors who visit an ill resident/patient to:– visit only the ill resident/patient;– wear PPE as directed by staff;– enter and leave the facility directly without spending time in communal areas; and– perform hand hygiene before entering and after leaving the resident’s room and upon leaving the

facility.

3.2.8.1 Non-infected residents

In some circumstances, it may be feasible to transfer residents who are not symptomatic, to other settings (for example, family care or another facility) for the duration of the outbreak. The family or receiving facility must be made aware that the resident may have been exposed and is at risk of developing gastroenteritis.

3.2.9 Waste managementAll personal protective equipment (for example, gowns and gloves) used whilst caring for a resident/patient with gastroenteritis should be disposed of into clinical waste (yellow bin or bag). Faecally contaminated incontinence aids from residents/patients with gastroenteritis will also need to be disposed of into clinical waste for the duration of their illness.

Ensure waste is appropriately segregated into the different waste streams, for example, general, recyclable, or clinical and related waste. Storage and handling of all waste must meet the Environment Protection Authority (EPA) Victoria legislative requirements. For more information refer to EPA Victoria’s Clinical and Related Waste – Operational Guidance <www.epa.vic.gov.au/business-and-industry/guidelines/waste-guidance/clinical-waste-guidance>.

3.3. Case listsEach facility should prepare a case list of all residents/patients and staff who have been ill (Appendix 6). These case lists must be faxed (or emailed) to the council EHO (details to be provided by your council) and to the department on fax number 1300 651 170 or email cdi&[email protected] .

So that the outbreak can be monitored effectively, you will be requested to update this list daily and send it to the council EHO and the department at least twice per week during an outbreak, or more often as requested, for example during suspected food or water borne outbreaks.

This means that new cases (people who have started to have symptoms since the last case list was completed) should be added to the list, and any additional information on cases already on the list should be added or updated, for example, a case may have been sent to hospital or a case’s symptoms may have stopped since the last time you updated the list. There is no need to re-write the whole list each time it is updated and each ill person is only to be added once.

“Symptoms started” means the date and time the case had the first symptom(s).


mailto:cdi%[email protected]

http://www.epa.vic.gov.au/business-and-industry/guidelines/waste-guidance/clinical-waste-guidance

“Symptoms ended” means the date and time the case had the last symptoms(s) – do not include the 48 hour symptom-free period with the end date.

3.4. Faecal specimen collectionTo identify the pathogen responsible for an outbreak, faecal specimens from ill people should be tested by a laboratory. It is best to obtain faecal specimens as soon as possible after the onset of symptoms. Unless otherwise advised, faecal specimens should be collected from five ill people for each outbreak, and these should be from ill residents/ patients and ill staff.

Ensure that all ill staff/residents/patients, and all staff who are assisting ill residents/ patients, receive a copy of the faecal specimen collection instructions (Appendix 4). It is the responsibility of the premises/facility to ensure that all specimen containers are adequately labelled with the name and date of birth of the case, the date of collection and the name of the outbreak or the name of the facility where the outbreak is occurring. Labelling is best done before the specimen has been collected into the container. Always record the date of faecal specimen collection for each case on the case list.

In outbreak situations, all faecal specimens should be forwarded to the Microbiological Diagnostic Unit (MDU). In most cases during outbreaks, council EHOs can provide faecal specimen collection kits and will arrange to collect the completed specimens and deliver them to the laboratory with the appropriate laboratory request forms for testing.

In certain circumstances some ill food handling staff, may be requested to provide faecal specimens. The council EHO will advise if this is the case.

For any queries concerning faecal specimen collection, contact the department or your council EHO.

3.5. Declaring an outbreak overA gastro outbreak will not be declared to have ended until 48 hours after symptoms have ceased in the last case, that is no ongoing cases and no new cases occurring.

The department can provide final approval when this time frame has occurred to ensure that the outbreak can be declared over.

A final clean-up and disinfection of the facility is required when an outbreak has been declared over. The case list will need to be updated to reflect that there are no further cases occurring, any existing case’s symptoms have ceased and the case list has been marked as ‘final’ and sent through to the council and department, along with any faecal specimen results conducted at a private pathology service (that the department may not have a copy of). A copy of all faecal specimen results, tested at MDU and collected as part of an outbreak are already provided to the council and the department.

If you are unsure whether your outbreak is over, please call the department on tel. 1300 651 160 to discuss.

For unknown or food or water borne outbreaks:

Although cases may have ceased and the outbreak may be declared over, the investigation of the outbreak may not be over. If the investigation is still continuing the council EHO will still be visiting the premises and collecting information to try and determine the cause and transmission of the outbreak. The department may also be analysing information and awaiting laboratory results of samples and specimens to inform the investigaton.

If you are unsure as to whether an investigation is over please ask your council EHO or speak to the public health officer dealing with your outbreak at the department.


3.6 Additional control measures for suspected food or water borne outbreaksIf it is suspected that the outbreak is food or water borne (caused by eating contaminated food or drinking contaminated water), the following tasks will need to be undertaken in addition to those measures described above.

3.6.1 Food• Ensure that any suspect food or drink is not served but do not discard it. Ensure that it is kept in a

suitable place (e.g. storeroom/fridge) and labelled with “do not use”, so it cannot be served by mistake, until the council EHO has collected it.

• Allow the council EHO to collect samples of foods and/or ingredients, and swabs (if indicated) of equipment or the kitchen environment. This should occur before the clean-up has been conducted.

• Store all food in the refrigerator until it is collected by the EHO.• Allow the EHO to take away any equipment that is suspected to be contaminated, such as a blender

used to blend raw ingredients.• After the council EHO has collected samples ensure all potentially contaminated food is disposed of

adequately under supervision by the EHO, who will advise on what food needs to be discarded.

3.6.2 WaterIf the facility uses non-mains water (such as water from rainwater tanks or bore water):

• allow the EHO to collect samples of water;• provide the EHO with the most recent documentation proving potability of the water, that the water is

safe to drink (e.g. a water supply management plan). The EHO may also conduct a risk assessment of the water supply; and

• ensure that all water intended for drinking, food preparation and brushing teeth is boiled before use, until results of laboratory testing are available. Alternatively, water must be brought in from a safe source (e.g. commercially bottled), or existing water supplies must be treated by the most appropriate method, the EHO can advise on this.

3.6.3 Additional information to assist the outbreak investigationAs part of a foodborne disease outbreak investigation, the EHO may also:

• conduct a food safety compliance check/inspection;• request a list of all people who may have consumed the suspect meal(s), (this should include all

patients/residents and staff);• request a copy of the menus for all meals served in the week before onset of illness in the first case;• collect details of the type of meals served to individuals, such as vitamised, soft option, peg fed, as

well as any specific dietary or nutritional needs of individuals;• require details of the methods of service/distribution of meals;• request as much detail as possible regarding the food process steps for preparing any implicated

foods;• request details of three-day food history for all cases (this information will usually be best obtained

from care staff);• require a copy of the suppliers list for the business (this should be easily available as a part of your

FSP);• review your FSP, particularly with regard to processes in place for the preparation of suspect foods

and maintenance of records;


• require a copy of the most recent food safety auditor’s report; and• Conduct interviews with all exposed people, both sick people and well people to try and determine a

source for the outbreak.

4. Communication

It is essential that details of the outbreak and the control measures in place are conveyed to all staff, including casual or agency staff, allied health professionals and visiting medical practitioners/locums, and that staff are updated as the outbreak progresses. Staff briefings should give clear instructions on:

• transmission of gastroenteritis;• infection control procedures;• cleaning and disinfection procedures;• isolation of ill patients;• collection of faecal specimens;• restricted transfer of patients;• infection control measures in place for visitors;• exclusion of ill staff for 48 hours after symptoms cease;• staffing of wards/areas during the outbreak;• details of any agency/contract staff during the outbreak;• the need to liaise closely with council and/or the department during the outbreak investigation; and• names and contact numbers for infection control personnel and the council EHO.Staff should be kept updated as the outbreak progresses and until the outbreak has been declared over.

In a residential/aged care setting, resident’s families need to also be informed when there is an outbreak in the facility.

Once the outbreak has been declared over, all individuals and agencies involved in the investigation should be notified that the outbreak is over.

All staff should be informed that the outbreak will not be declared to have ended until 48 hours after symptoms have ceased in the last case (that is, no ongoing illness, and no new cases occurring).

5. Staff education and training

It is the responsibility of every care facility to ensure that their staff are adequately trained and competent in all aspects of gastrointestinal outbreak management. Workplace education could be incorporated into induction training programs.

Staff should be able to identify the early signs of an outbreak and be prepared to know how to manage the outbreak while minimising the risk of infection to themselves. Equipment, staff and resources must be identified and accessible at all times.

During an outbreak, regular promotion of handwashing is recommended. Where possible, institutions need to have access to PPE and staff need to be trained in how and when to use them. Training on cleaning and disinfection procedures is also important. If a vomiting incident occurs in any public area,


staff members need to know how to clean and disinfect the area correctly to prevent further transmission through environmental contamination and aerosolisation of vomit[1].

5.1 Adequate stock levelsFacilities should ensure that they have adequate stock levels of disposable materials required during an outbreak. This includes:

• personal protective equipment (gloves, gowns, masks, eyewear);• hand hygiene products (liquid soap, paper towels);• faecal specimen collection kits (your council EHO should be able to supply these); and• cleaning supplies (detergent and bleach-based disinfectant)Facilities should have an effective policy in place to ensure that they have access to additional stock from suppliers as required.

6. Privacy

In an outbreak situation, facilities are requested to provide council EHOs and the department with information pertinent to the investigation. Councils and the department are required to adhere to privacy legislation governing the collection, use and dissemination of personal information. This information includes names and illness information for all staff and patients/residents, which will be needed to complete the case lists.

7. Media

The media may become aware of the outbreak at your facility either officially, through a departmental media release, or unofficially through other sources such as staff/relatives or the general public. If a facility receives media enquires directly, in relation to an outbreak, they may wish to consult the department’s media unit before releasing any information. This will ensure accuracy and consistency with any departmental communications. Please call the department on 1300 651 160 for further assistance.


Appendix 1. Guidance for the dilution of chlorine-based solutions required for disinfectionFor surface disinfection, the Australian Guidelines for the Prevention and Control of Infection in Healthcare (2010) recommends the use of either a TGA registered disinfectant with label claims against the specific organism of concern or a chlorine-based product. If not a chlorine-based product then the product must specify that it is effective against norovirus.

Chlorine based sanitisers (like household bleach) should be used in outbreak situations, as other sanitisers and disinfectants (such as quaternary ammonium compounds) are only effective against some bacteria but have very little effect on destroying viruses such as Norovirus.

Sufficient time is required to kill the virus – at least 10 minutes contact time.

Chlorine solutions must be made up just prior to use as the chlorine deteriorates over time. The following tables will assist in making up the required concentration needed for disinfection. Cleaning and disinfection should be conducted at least twice a day until the outbreak is over.

A final clean-up and disinfection of all areas needs to be completed at the end of every outbreak (when there have been no symptomatic cases for at least 48 hours).

The following tables provide a guide to the correct dilution according to the product used.

Dilutions using household bleach (with 4% available chlorine as written on the label)

Household bleach 4% available chlorine

Add the following amounts of bleach to the water to give the required concentration

Volume of cold water to which chlorine is added 100ppm 200ppm 1000ppm

5 litres 12.5ml 25ml 125ml

10 litres 25ml 50ml 250ml


Dilutions using a commercial grade sanitiser (with 12.5% available chlorine as written on the label)Commercial grade sanitiser 12.5% available chlorine

Add the following amounts of bleach to the water to give the required concentration

Volume of cold water to which chlorine is added 100ppm 200ppm 1000ppm

5 litres 4.2ml 8.4ml 42ml

10 litres 8.4ml 16.8ml 84ml


Please Note: This table is to be used as a guide only. For questions about how to dilute specific products please refer to the

relevant Material Safety Data Sheet (MSDS) for the specific product being used, or contact your supplier or manufacturer of the

chemical disinfectant.


Milton tablets are not validated for use as a surface disinfectant and are not recommended for this purpose.

Important safety notes:

• It is safer to add chlorine to water – do not add water to chlorine

• Do not heat water up to make chlorine solutions – cold water is safer.

• Mix in a well ventilated room

• Do not mix with any other chemical.

• Use gloves and wear protective eye wear when preparing chlorine solutions.

• Follow safety, storage and handling instructions on all bleach and chlorine containers.

• Use chlorine carefully as it is corrosive to metals, damages fabrics/textiles and may irritate the skin, nose and lungs.

• Solution should not be used in spray bottles.


Appendix 2. Exclusion guidelines for food handlers, health care workers and child care workers

Gastrointestinal illness/pathogen Exclusion period advisedCholera, Shigella Until 2 successive negative faecal specimens are

taken 24 hours apart, and not less than 48 hours after taking antibiotics. Food handlers, health care workers and childcare workers need to be counselled on personal hygiene before returning to work.

Typhoid and Paratyphoid Until 2 consecutive negative faecal specimens are taken one week apart, and not less than 48 hours after taking antibiotics. Cases who continue to excrete for 90 days or more are not to engage in food handling.

Other bacterial gastroenteritis

(including Campylobacter, Salmonella, Staphylococcus, Clostridium, Helicobacter, Vibrio, Listeria, Entamoeba).

Giardia or Cryptosporidium

Until diarrhoea has ceased. Food handlers, health care workers and childcare workers to be counselled on personal hygiene before returning to work.

Hepatitis A or E Until a medical certificate of recovery is received, but not before 7 days after onset of jaundice or illness.

Food handlers with acute hepatitis illness should be excluded from work until laboratory tests confirm that the infection is not due to either Hepatitis A or E.

STEC/VTEC

Other viral gastroenteritis (including rotavirus and norovirus), or when the pathogen is unknown

Until 48 hours after symptoms have ceased.


Appendix 3. Outbreak management checklist for gastroenteritis outbreaks in care facilities

This checklist has been designed to assist care facilities in managing gastroenteritis outbreaks. The use of this checklist is optional and the Department of Health and Human Services does not require a copy.

Outbreak definitionAn outbreak in a care facility is defined as two or more cases of vomiting and/or diarrhoea among residents/patients and/or staff (that cannot be explained by medication or other medical conditions) within 72 hours, in a setting that makes epidemiological sense.

Checklist Date provided or N/A

Signature of person

responsible

IDENTIFY AND NOTIFY:

Outbreak detected - Identify if your facility has an outbreak using the above definition ___/___/___

Name of outbreak coordinator:

Outbreak notified to the department, Communicable Disease prevention and Control (CDPC) on tel. 1300 651 160 ___/___/___

IMMEDIATELY:

Implement infection prevention and control measures (Section 3)

Implement outbreak hand hygiene (Section 3.2.2)

Exclude ill staff from work – until 48 hours after symptoms have ceased (Section 3.2.4)

Begin environmental cleaning and disinfection (Section 3.2.3)

Complete case list(s) – include details of all ill patients/residents and staff (Appendix 5)

Collect faecal specimens – from ill patients/residents and staff (Section 3.4)

Post signage - at appropriate locations throughout the facility including all entrances (Appendix 6)

Communicate all outbreak information to all staff (Section 4)

PROVIDE THE DEPARTMENT (CDPC) AND/OR COUNCIL WITH:

Initial case list - to the department (CDPC) either by fax: 1300 651 170 or email: cdi&[email protected] and your local council EHO as directed ___/___/___

Faecal specimens to be submitted to laboratory (correctly labelled) ___/___/___

Menus (if requested) ___/___/___

Food suppliers list (if requested) ___/___/___

A copy of the food safety program (if requested) ___/___/___


mailto:cdi%[email protected]

Date provided or N/A

Signature of person

responsible

COMMUNICATION

Communicate all outbreak information to all staff ___/___/___

Inform families of outbreak (residential aged care only) ___/___/___

ON-GOING

Continue outbreak cleaning procedures (minimum twice daily cleaning)

Monitor outbreak progress through increased observation of patients/residents for gastro symptoms

Update the case list daily and fax to the department & council twice weekly

Add positive and negative test results to case list

Continue communication with staff and families of residents

Report any resident/patient deaths to the department on tel. 1300 651 160within 24 hours.

Other:

DECLARE OUBREAK OVER

Declare outbreak over – 48 hours after symptoms have ceased in the last case (patient/resident or staff), so no ongoing cases and no new cases occurring.

___/___/___

Fax final case list to the department and council – include any results if conducted at a private pathology laboratory ___/___/___

Conduct a final clean-up of the facility ___/___/___

Communicate to staff and families of residents that the outbreak is over. ___/___/___

Remove all signage ___/___/___

Return to normal duties ___/___/___

Review Outbreak Management & Recommendations for Improvement(s)


Appendix 4. Instructions for the collection of faecal (poo) specimens

The faecal kit provided to you should contain:• A faecal (poo) collection pot (with or without) a built-in scoop inside the lid;• A wooden spatula or plastic spoon;• A zip-lock (bio hazard) plastic bag and a brown paper bag, if provided;• A laboratory request form (this may or may not be provided to the patient by should be included with

the specimen after collection); and• Instructions for the collection of a faecal (poo) specimen.

Patients should collect a faecal specimen as soon as possible.1. Label the specimen jar carefully, with patient’s name, date of birth or age and date and time of

collection (nothing AM or PM).

2. Include the outbreak name, if known.

3. Place a large clean container (e.g. clean plastic ice cream container), plastic wrap or newspaper in the toilet bowl.

4. Pass faeces (poo) directly into the large container, plastic wrap or newspaper.

5. Do not contaminate the faeces (poo) with urine.

6. Open the sample jar. Using the scoop inside the lid of the jar, scoop enough of the faeces (poo) to fill about half of the jar. If there is no scoop provided inside the lid of the jar, use the wooden spatula or plastic spoon provided to place the sample inside the jar. Take care not to contaminate the outside of the jar.

7. Dispose of left-over faecal matter (poo) from the large container, plastic wrap or newspaper into the toilet, then place the large container, plastic wrap or newspaper into a plastic bag, secure and place directly into the rubbish bin.

8. Make sure you wash your hands after collecting the faecal (poo) specimen.

9. Screw the lid on the sample jar firmly. Put the jar into the plastic zip-lock or bio-hazard bag and include the laboratory request form if provided. Then place into the brown paper bag (if provided).

10. Keep specimen cool (at 2-8C) in the fridge – but DO NOT FREEZE.

11. Telephone the council EHO without delay and request they pick up the specimen.


Appendix 5 – Outbreak case list: Care facilities



Appendix 6: Signage – Care facilities

See suggested signage on the following pages


AttentionOur facility currently has residents and/or staff

with gastroenteritis (vomiting and/or diarrhoea).

To protect yourself and others please washand dry your hands thoroughly and often.

Thank you for your cooperation.


Attention staffOur facility currently has residents and/or staff

with gastroenteritis (vomiting and/or diarrhoea).

If you are ill with vomiting and/or diarrhoea,please let management know, and remain

at home until 48 hours after symptomshave stopped.


Attention visitorsOur facility currently has residents/staff withgastroenteritis (vomiting and/or diarrhoea).

Please see a staff member beforevisiting any residents.

Thank you for your cooperation.


Appendix 7. Blenders and mixing equipment in care facility kitchens

Raw foods such as meat, chicken, fish and eggs may contain bacteria that can cause illness, especially in vulnerable people. Cooking these foods well, ensures that these bacteria are destroyed. However, during food preparation, kitchen equipment can become contaminated with bacteria from these high risk raw foods and it is essential to avoid the risk of bacteria spreading to ready-to-eat foods (foods that are not further cooked).

Eggs may contain Salmonella bacteria and are a common raw ingredient for many foods. When raw eggs are processed in mixers or blenders (for scrambled eggs, or beaten in cake mix or pancake/quiche batter), they may contaminate the whisk or blades which may then contaminate other ready-to-eat foods processed in the same equipment. If the mixing equipment is not washed or sanitised correctly any ready to eat foods processed in this equipment could cause serious illness.

Recommendations(a) Separate blending or mixing equipmentIt is recommended that aged care and health care facility kitchens consider allocating one piece of mixing equipment for mixing raw high risk foods (such as cake/pancake/quiche batter and desserts containing raw egg)and another separate piece of mixing equipment for mixing ready-to-eat foods that will not be cooked further after the mixing step (such as whipped cream, powdered mousses or puddings, and fillings for cold set cheesecakes or other sweet pies). The blending or mixing equipment allocated to process high risk raw foods should not be used to vitamise foods that are ready to serve to residents or patients who require a soft diet.

(b) Cleaning of blending and mixing equipmentIn addition to allocating individual processing equipment for raw and ready-to-eat foods, effective cleaning and sanitising of this equipment is important. Some equipment is very difficult to clean effectively, particularly hand stick mixers that cannot be dismantled and are not suitable for dishwashers.

All blending equipment should be cleaned and sanitised after every use and as soon as possible after use, so that food does not dry onto the blades/whisks making it more difficult to remove. All parts of these pieces of equipment should be washed in hot water and detergent, using a clean scrubbing brush to clean all surfaces thoroughly.

Sanitising is only effective on properly cleaned equipment and should be conducted by:

• immersing in hot water (minimum of 80C) for 2 minutes (in a sink or dishwasher); or• immersing in 50ppm of chlorine solution for 30 seconds at 50C.Rinse in cold water if chlorine solution has been used and dry.

For further information please see your council Environmental Health Officer.


Acronyms and abbreviations

The following acronyms apply throughout this guide

CDPC Communicable Disease Prevention and Control, Department of Health and Human Services

CHO Chief Health Officer, Department of Health and Human Services

the department Department of Health and Human Services

EHO Environmental Health Officer

FSP Food Safety Program

MDU Microbiological Diagnostic Unit (Public health laboratory)

PPE Personal protective equipment

ppm Parts per million (a measure of concentration)


Glossary

The following definitions apply throughout this guide

Aerosols In medical terms means the fine particles that are emitted after coughing or vomiting and that may be a vehicle for transmitting infection

Available chlorine Free chlorine expressed as a percentage of active ingredient in a concentrated liquid or powder

Care setting A care setting includes aged care, special care, health care and other residential care facilities (e.g. disability homes, supported residential services SRS.)

Cleaning The removal of soiled matter (including organic material) and the reduction of the number of microorganisms from the surface of an item by a process such as detergent and water to the extent necessary for further processing or for intended use

Contamination The introduction of microorganisms or foreign matter to sterile or non-sterile materials or tissues

Detergent A substance that enhances the cleansing action of water (preferably warm/hot) or another liquid

Disinfect/disinfection A process that reduces the number of viable organisms on an item to a level specified as appropriate for its intended further handling or use

Disinfectant A chemical agent that is applied to non-living objects to kill micro-organisms

Doffing (to doff) To remove (an item of clothing or PPE)

Donning (to don) To put on (an item if clothing or PPE)

Environmental Health Officer An authorised officer employed by either local or state government

Faecal-oral transmission Transmission of an infection whereby faecal particles pass from one person to the mouth of another person, mainly through poor hygiene practices

Foodborne transmission Transmission of an infection through the ingestion of contaminated food

Food safety program A food safety program is a written document indicating how a food business will control the food safety hazards associated with the food handling activities of the business. Only certain high risk food businesses are required to have food safety programs. (Standard 3.2.1 Safe Food Australia – FSANZ).

Gastroenteritis(Gastrointestinal illness, Gastro)

Inflammation of a membrane of the stomach and intestines, caused by variety of different enteric pathogens. Symptoms may include diarrhoea, nausea, vomiting, abdominal pain, abdominal cramps, fever and sometimes headaches, lethargy, chills and muscular pains


Impermeable Not allowing fluid to pass through (e.g. waterproof, water-resistant)

Incubation period The time interval between initial contact with an infectious agent and the appearance of the first clinical signs and symptoms of the disease

Infection Invasion and multiplication of microorganisms in body tissues

Infection control The process of minimising the risks of spreading infection

Infectious (of a disease causing organism) liable to be transmitted to people, organisms etc., through the environment.

Microorganisms A microscopic organism

Organism An individual animal, plant or single-celled life form.

Outbreak The occurrence of a disease or health event in excess of the expected number of cases for a given time

Person-to-person transmission Transmission of a disease by close and direct personal contact. For example, touching, kissing or sexual intercourse

PPE (personal protective equipment)

Protective clothing, goggles, or other garments or equipment designed to protect the wearer’s body from injury or infection

Sanitise To reduce pathogenic microorganisms to a safe level

Self-limiting (of a condition) ultimately resolving itself without treatment

Transmission In terms of infection, it relates to any mechanism by which an infectious agent is spread from a source or reservoir to a person

Viable Alive, capable of living, developing or reproducing.

Waterborne transmission Transmission of illness through the ingestion of contaminated water


Documents

1. Introduction - Amazon S3 · Web viewClean-up and control measures should be implemented for all gastrointestinal outbreaks as soon as possible after an outbreak is suspected, and