News Archives |
Volume 5 No 47; 25 November 2011
- New guidelines for the management of norovirus outbreaks in acute and community health and social care settings
- Surveillance of haemolytic uraemic syndrome in children
- Measles cases in Europe: update to end-October 2011
New guidelines for the management of norovirus outbreaks in acute and community health and social care settings
A new report on the management of outbreaks of vomiting and/or diarrhoea in hospitals, and in other community health and social care settings, aims to achieve a balance between the prevention of spread of infection and the need to minimise disruption of services while outbreak control measures are in place [1].
Developed following a Department of Health workshop held in July 2010, the title of the guidance reflects the fact that, while there are other causes of vomiting and/or diarrhoea outbreaks (and its recommendations will therefore apply to all viral gastroenteritides), the principal and most common cause is norovirus, which is one of the most infective agents seen in health and social care establishments [2].
The guidance, published on the HPA website [3], was developed by a multi-agency working party (the members of which acted as representatives of their respective organisations) and involved a number of stakeholder consultation exercises [4]. There was also the full involvement of NHS management representation through the NHS Confederation. It is therefore anticipated that the resulting joint ownership of the guidance between infection prevention and control (IPC) practitioners on the one hand, and the managerial sector on the other, will reduce conflicts of interest and tensions within organisations.
This is important because, an introduction/methodology section of the guidance notes, differing patterns and dynamics of outbreaks will require different, tailored IPC responses which may be misconstrued as inconsistency of approach and it is, therefore, important that the underlying principles are understood by all sections and levels of an affected organisation.
The introduction continues:
This guidance is based on a principle of minimising the disruption to important and essential services and maximising the ability of organisations to deliver appropriate care to patients safely and effectively. There is a shift of focus towards a balance between the prevention of spread of infection and maintaining organisational activity. In effect, this means a move away from the traditional approach of early, complete ward closure and an adoption of a pragmatic, escalatory system of isolation using single rooms and cohort nursing without compromising patient care both for norovirus itself and other essential healthcare. This is a key difference to previous guidance of the Public Health Laboratory Service Working Party published in 2000.
The guidance draws on current practice that shows that cases should be managed in single rooms and bays in the first instance if this is possible. This will allow some flexibility in the response and also for cleaning to take place allowing smaller wards to be able to re-open more quickly. Other recommendations cover closure of affected bays to admissions/transfers, use of signage, restriction of access to affected areas, deep cleaning, etc.
There are separate recommendations for healthcare workers in outbreak situations, including the need to ensure staff are aware of work exclusion policy, the need for staff to be allocated to duties in either affected or non-affected areas but not both, etc.
References/notes
1. "New guidelines for the management of norovirus". HPA press release, 25 November 2011.
2. The guidance applies to nursing and residential homes. It is not specifically intended to cover schools, colleges, prisons, military establishments, hotels or shipping but it enshrines generalisable principles that will be of use in managing outbreaks in those institutions.
3. Guidelines for the management of norovirus outbreaks in acute and community health and social care settings , November 2011 [1.2 MB PDF]. Downloadable from the HPA website: Publications Infectious diseases Gastrointestinal illness reports and guidance Guidelines for the management of norovirus outbreaks in acute and community health and social care settings.
4. The working party comprised representatives of the following organisations: the HPA; the NHS Confederation; the British Infection Association; the Healthcare Infection Society; the Infection Prevention Society; the Sowerby Centre for Health Informatics Newcastle; and National Concern for Healthcare Infections. Observers from UK departments of health and the Community Care Sector also participated. Other external stakeholders are listed in an appendix to the guidance.
Surveillance of haemolytic uraemic syndrome in children
A study aiming to better define the incidence of haemolytic uraemic syndrome (HUS) in children in the UK and Ireland has been jointly launched by the British Paediatric Surveillance Unit (BPSU) and HPA. The study also involving paediatric nephrologists and public health bodies in the Devolved Administrations and the Republic of Ireland will provide valuable data on the incidence of HUS, clinical progression and management of cases, and outcomes of disease one year after presentation. By linking incidence, exposure and clinical data with laboratory reports, the study aims to determine which strains of VTEC are causing HUS. The results will be compared with those of a previous BPSU-HUS study (1997-2001) to allow changes in epidemiology and any necessary changes to clinical management to be determined.
HUS is a rare but serious condition that can develop following diarrhoeal illness caused by vero cytotoxin-producing Escherichia coli (VTEC). The peak incidence of HUS is in children under five years of age. Patients generally develop HUS a week or more after their symptoms have disappeared, by which time they present a minimal risk to other people, which means the previous regular connection with the HPA may have ceased. Cases of HUS are therefore not often identified through the existing VTEC enhanced surveillance system for England.
HUS was included in the notifiable disease list (Schedule 1) of the Health Protection (Notification) Regulations 2010. However, it is known that data collected through the Notifications of Infectious Disease system is incomplete and this study will allow a more complete understanding of the epidemiology of the disease.
Clinicians in England, Wales, Northern Ireland and the Republic of Ireland will be asked to report cases of HUS under the age of 16 through the BPSU. Scottish clinicians will continue to report through the existing HUS surveillance system run by Health Protection Scotland, and data from this system will be included in the study. The study will run for 13 months with a one year follow-up questionnaire.
Together with the national surveillance system for VTEC, data collected will help identify factors associated with an increased risk of developing HUS, in the hope that, in the future, it may be possible to prevent at-risk children from developing HUS after a VTEC infection. Further information is available at: VTEC@hpa.org.uk.
Measles cases in Europe: update to end-October 2011
The fifth European monthly measles monitoring (EMMO) surveillance report has been published by the European Centre for Disease Prevention and Prevention (ECDC) [1]. Although no new outbreaks were reported in the 29 EU and EEA/EFTA countries during October, over 1,000 new measles cases were detected through epidemic intelligence, bringing the total number of cases for 2011 to more than 30,200. Two cases of sub-acute sclerosing panencephalitis (SSPE), one of whom died, were reported in October. Between January and September eight measles-related deaths and 23 cases of acute measles encephalitis were reported.
WHO Regional Office for Europe published it's Epidemiological Brief in October covering the measles outbreaks and preventative measures taken across 53 member countries [2]. The report highlights the nearly three-fold increase in cases compared to the same period in 2007. The wider impact of the outbreaks in Europe was also examined and in particular the link between the resurgence in measles in South America and its connection with Europe.
Confirmed measles cases in England and Wales to the end of October 2011
In England and Wales, 956 laboratory confirmed measles cases have been reported to the end of October 2011 (see table 1 and figure). Following the peak in April 2011, the monthly total of confirmed cases has been falling with between 53 and 68 confirmed cases reported in the last three months. The majority of cases are in unvaccinated individuals (92% total).
Outbreaks in schools and small family clusters are continuing to occur, particularly in London (401 cases) and the South East (255 cases) regions where most cases have been diagnosed. A history of travel abroad or contact with someone who had travelled was the source for infection for 150 confirmed cases this year.
January-October 2011
Month |
London |
East Mids |
East of England |
North East |
North West |
South East |
South West |
West Mids |
Wales |
York & Humber |
Total |
Jan-11 |
7 |
1 |
|
|
2 |
10 |
9 |
1 |
|
1 |
31 |
Feb-11 |
6 |
|
1 |
|
1 |
17 |
1 |
2 |
|
4 |
32 |
Mar-11 |
39 |
5 |
2 |
|
10 |
35 |
8 |
6 |
|
31 |
136 |
Apr-11 |
61 |
|
3 |
2 |
12 |
48 |
13 |
14 |
1 |
13 |
167 |
May-11 |
80 |
2 |
11 |
2 |
7 |
44 |
13 |
2 |
8 |
5 |
174 |
| Jun-11 | 53 |
1 |
8 |
5 |
4 |
28 |
20 |
7 |
5 |
1 |
132 |
| Jul-11 | 60 |
1 |
6 |
|
|
28 |
3 |
1 |
3 |
1 |
103 |
| Aug-11 | 35 |
1 |
7 |
|
1 |
8 |
2 |
5 |
1 |
|
60 |
| Sep-11 | 32 |
2 |
2 |
3 |
1 |
13 |
|
|
|
|
53 |
| Oct-11 | 28 |
1 |
|
3 |
2 |
24 |
5 |
1 |
1 |
3 |
68 |
Total to October |
401 |
14 |
40 |
15 |
40 |
255 |
74 |
39 |
19 |
59 |
956 |
Table 2. Number of confirmed cases of measles by region and age, England and Wales:
January-October 2011
Month |
London |
East Mids |
East of England |
North East |
North West |
South East |
South West |
West Mids |
Wales |
York & Humber |
Total |
Under 1 year |
22 |
3 |
1 |
2 |
7 |
8 |
1 |
5 |
2 |
3 |
54 |
1-4 years |
79 |
2 |
6 |
2 |
6 |
27 |
4 |
4 |
2 |
8 |
140 |
5-9 years |
59 |
2 |
8 |
3 |
8 |
51 |
17 |
7 |
4 |
2 |
161 |
10-14 years |
65 |
3 |
7 |
3 |
7 |
73 |
22 |
9 |
4 |
5 |
198 |
15-19 years |
43 |
2 |
8 |
3 |
3 |
53 |
16 |
5 |
3 |
18 |
154 |
20-24 years |
21 |
|
3 |
|
6 |
11 |
4 |
5 |
2 |
15 |
67 |
25-29 years |
37 |
|
1 |
1 |
2 |
6 |
7 |
|
1 |
2 |
57 |
30-34 years |
32 |
|
1 |
1 |
1 |
6 |
1 |
2 |
|
|
44 |
≥35 years |
43 |
2 |
5 |
|
|
20 |
2 |
2 |
1 |
6 |
81 |
Total, all age groups |
401 |
14 |
40 |
15 |
40 |
255 |
74 |
39 |
19 |
59 |
956 |
Number of confirmed measles cases by month of onset, England and Wales:
January 2006 to October 2011
References
1. European Centre for Disease Prevention and Control (ECDC). European measles monthly monitoring, October 2011. Stockholm: ECDC; 2011. Available from: http://ecdc.europa.eu/en/publications/Publications/Forms/ECDC_DispForm.aspx?ID=778.
2. World Health Organisation, Regional Office for Europe (WHO Europe). WHO Epidemiological Brief: a monthly publication on vaccine-prevantable diseases and immunisation data and analysis, No.18 (October 2011). Available from: http://www.euro.who.int/__data/assets/pdf_file/0006/153195/Epi_Brief_Issue_18.pdf.