[PPT] - Welcome Address Clodagh Fitzgerald Chair, NHP 20 th February 2013 PowerPoint Presentation

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Welcome Address

Clodagh Fitzgerald Chair, NHP 20th February 2013

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Norovirus and the Leisure Industry

Dr Paul McKeown

Health Protection Surveillance Centre

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Outline

Background
The Virus
Prevention &

Control

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Prejudices & Preconceptions

Not worthy of attention
Minor illness
How many people has it killed this year?
Difficult to diagnose
Clean it up quickly and things will be fine
Sawdust and Jeyes Fluid = All Things

to All Men

Vomit isn't infectious not like diarrhoea
“Actually I’m trying to run a hospital/hotel

here, in case you hadn't noticed…”

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Background and Discovery

1929 Dr. John Zahorsky – “winter vomiting disease”
Bacterial gastroenteritis agents readily identified – bacteria

are larger – can be readily filtered

Before viruses could be identified or visualised – huge burden
f “viral gastroenteritis”
Noroviruses cannot be cultured (grown)

made identification even harder

Norwalk OH – October 1968

– Elementary school – 50% (116/232) pupils and staff – 32% secondary attack rate

“Norwalk” virus

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Virology - Caliciviridae

GGI GGII

Norovirus Sapovirus

 RNA virus – genetically flexible  38nm diameter

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Microbial Dimensions

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0.1mm

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0.025mm

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A Salmonella Bacterium

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200 nm*

*1 millimetre = 1 000 000 nanometers Each Salmonella bacterium is 1000nm or 1/1000mm long

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Each Norovirus is about 35nm in diameter

10,000 Noroviruses would stretch across the waist of the dot on the letter “i” of standard news print

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The tip of the Dublin Spire is 6 inches in across – Were the Dublin Spire a hypodermic needle, a Norovirus particle would, relatively speaking, be the same size as a POINT of a pin

More Meaningful Context…

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Background

Leading causes of gastroenteritis
Causes particular problems where people congregate

(hospitals, nursing and residential homes, childcare facilities, schools, hotels, cruise ships and places of employment)

Rapid spread both faeces (bowel motions) and vomitus
Greater congregation in winter → ↑proximity → ↑

dissemination → ↑ risk of outbreaks

Such outbreaks massive disruption to →:

– disruption to care – disruption to business continuity, – substantial economic loss, and, – mortality in vulnerable patient populations (occasionally).

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Molecular Identification

1995-6: first identification of global epidemic – GII.4 strain
The latest is the Sydney strain
Shift and drift
Readily genetically mutable, → short term/partial immunity
Able to reinfect in a very short time period (<3/12)
Certain individuals with a particular

genetic profile have innate resistance (probably accounts for apparently discriminatory nature of human infection during outbreaks)

NVRL

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Epidemiology

50% of all global GE outbreaks
≈ 23 million cases pa in US
Antibodies by age 3-4; >50% prevalence by 50 years
20% adult GP attendances for acute GE have evidence of NoV
5-10% of children with acute GE have NoV
>106 particles/g or ml of vomitus or faeces
Tiny inoculum (1-10 particles)

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How common is Norovirus?

Seasonal variations – low in summer, higher in winter
Hard to accurately gauge
One percent of the population affected during low activity

years

This rises to 3-5% during upsurge seasons
Typical NoV season lasts ∼ 14-20 weeks so:

– Low activity season (1%) ∼ 2,000 cases/wk (or 40,000 per season) – Upsurge season (3-5%) ∼ 6,600 and 11,000 cases/wk (132,000-220,000)

Recent work in the Netherlands indicates (using their

estimates) that Ireland could have 170,000 cases per year (120,000-240,000)

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Norovirus Seasonality - Netherlands

20 40 60 80 100 120 2 2 1 2 2 2 3 2 4 2 5 2 6 2 7

Aantal gemelde outbreaks

II4 non II4

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Source: Koopmans M, van Pelt W

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Norovirus Seasonality – Ireland*

*Notifications (Blue) Outbreaks (Red)

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Clinical Features

Incubation period*: 24-48 hours (range 18-72 hours)
Onset: Gradual or abrupt – often “public vomiting” – aerosol formation
Gastrointestinal symptoms:

– Nausea ∼ 80% – Vomiting ∼ 70% – Abdominal cramps ∼30% – Non-bloody diarrhoea (4-8 stools per day) ∼ 70% – May be Vomiting and/or diarrhoea

Systemic symptoms:

– Muscle aches ∼ 25% – Headache ∼ 25% – Malaise (generally feeling seedy) – Fever in ∼ 40% (38.0-390C )

Duration: 12-72 hours

*The period between taking the virus into the body and developing symptoms

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Diagnosis

Outbreak criteria (Kaplan) – very characteristic picture

– Bacterial infection excluded – Vomiting >50% of cases – Mean incubation period: 24-48 hours – Mean duration of illness: 12-60 hours

Laboratory

– Electron microscopy (SRSV) – PCR - polymerase chain reaction – amplifies DNA (and RNA) – ELISA – uses antibodies to detect a pathogen

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Surveillance

Departments of Public Health → HPSC
Notifications and outbreaks reported
Not all cases reported
Sufficient to gauge trends and determine
verall level of activity
Alerts are sent out when levels high

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National Reporting

Week 5 (Jan 28 – Feb 3)

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Number of Norovirus/suspected norovirus outbreaks and resultant numbers ill for Weeks 40 - 51 2012

Outbreak location Number

utbreaks

Number ill Number hospitalised Number deceased

Comm. Hosp/ Long-stay unit

28 656 20 1 Residential institution 21 318 6 Hospital 20 533 284 Hotel 4 106 Childcare Setting 1 25 Restaurant / Cafe 1 4 1 School 1 17 Other 1 19 2 Total 77 1678 313 1

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So, why is Norovirus so easily spread?

Hardy
Temperature stable ( survives

>600C – 25% survive >750C)

Small infectious dose
Genetically mutable
Limited immunity
High 20 infection rate (>40%)
Prolonged shedding (for several

days)

Large human reservoir with high

numbers of susceptibles

Asymptomatic infection common
Survives weeks in the

environment

Multiple transmission routes

(persons-to-person, food, water, aerosol)

Resistant to most disinfectants

(requires household bleach at a concentration of 1:1000)

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Where are noroviruses found during Hospital

utbreaks? Norwich 2011
Soap dispensers
Patients lockers
Computer keyboards
Computer mice
Telephones
Door handles
Light switches
Hand/grab rails

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In other words – those areas that are most frequently touched by hands

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Guidance

HPSC has Norovirus resources
n its website
Available at

http://www.hpsc.ie/hpsc/A-Z/Gastroenteric/Norovirus/Publications/

Key document - Guidance on

the Management of Outbreaks

f Noroviral Infection in Tourist

and Leisure Industry Settings

Available at

http://www.hpsc.ie/hpsc/A-Z/Gastroenteric/Norovirus/Publications/File,2

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General Control Measures

Clean up vomit - widely → aerosolisation
Decontaminate
Cleaning toilet areas
Washing hands
Exclude for 48H
Food handlers should NEVER clean up soiling

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Control in Hotel Setting

Guidance on the Management of Outbreaks of Noroviral

Infection in Tourist and Leisure Industry Settings at www.hpsc.ie

NoV cannot be prevented - but it can be controlled
Duty-of-care issues
Hotels are vulnerable to norovirus outbreaks

– Vulnerable individuals (e.g. elderly, young children) – Communal food sources – Communal areas – Mobility of staff – Economic consequences

Key is Preparedness

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Preparedness in Hotel Setting

Development of Policy and Protocols

Cleaning and

decontamination

Handwashing
Hotel Response Team

(even for small hotels)

Vulnerable areas

(kitchens, food preparation/storage areas, communal areas, guests’ rooms)

Surfaces touched by hand
Isolation of sick guests
Exclusion of staff
Accommodating guests

who arrive ill to the hotel

Communication/reporting

to local Medical Officer of Health

Sickness log
Encouraging reporting of

sickness by guests

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Preparedness in Hotel Setting

Training

Proper training of staff will do more to limit the impact of

norovirus in a hotel than ANY OTHER MEASURE

Management should provide training for staff on outbreak

identification and control

A specially selected, dedicated ‘Hotel Response team’ should

be identified and trained

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Preparedness in Hotel Setting

Communication

A Hotel policy on communication in the event of an outbreak

should be devised covering

– Guests in residence – Intending guests – Local GPs – Local MOH – Local EHOs – Other businesses (e.g. coach operators/laundry companies)

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Preparedness in Hotel Setting

Outbreak Identification

If two or more guests or members of staff develop sudden onset

vomiting within a 3 day period it is likely to be a norovirus outbreak

All vomit should be considered infectious
If any guest vomits, the staff member who witnesses or is called to deal

with this should immediately:

1. Cover the area of vomit 2. Clear other guests away 3. Cordon off the immediate area 4. Call the Hotel Response Team who will 5. Clean and decontaminate the area.

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The 5 “Cs”

1. Cover the area of vomit 2. Clear other guests away 3. Cordon off the immediate area 4. Call the Hotel Response Team who will 5. Clean and decontaminate the area.

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Next Steps following Outbreak Identification

Initiate frequent, regular handwashing
Identify and isolate ill guests
Identify and exclude Ill staff
Notices and alerts
Establish sickness logs
Vomiting in Kitchen –discarding of exposed food
Suspend serving cold/RTE foods – move to a hot food menu

where possible

REPORT TO PUBLIC HEALTH AND EHOs

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Finally

Noroviruses are a fact of

life

Outbreaks WILL occur (in

even the best regulated establishments)

It is no reflection on a

hotel’s hygiene (at least it needn't be)

Preparation and

prevention are key

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20th February 2013

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From Training Provider to Trusted Business Partner

Derek Carter, Learning & Development Manager

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Current context for training & development Selling to large organisations: a recipe for success

Overview

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Backdrop for Food Safety Training:

Greater customer & client awareness Increased inspection / audit activity Very commercial focus Need for lean operations

Current Context for Training & Development

From: To:

Separate event
Integrated into daily routine
“Just in case”
“Just in time”
Evidence of training
Evidence of competence
Classroom
OJT / Blended / Self Directed
Low-tech
Hi-tech
Older learner profile
Generation X & Y
Train for the job
Invest in talent as a differentiator

T&D Context has Shifted in the Last 5 Years:

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Recipe for Success

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“Challenging Status Quo”?

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“Challenging Status Quo”?

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Let’s Connect!

www.aramark.i e www.facebook.com/aramark.irela nd

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20th February 2013

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BREAK (10 minutes)

20th February 2013

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Guide to Commission Regulation (EC) No 2073/2005 on microbiological criteria for foodstuffs

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Aims

Background This is a difficult concept/will attempt to keep it simple Reminder re Regs 2073/2005 Guidance Note 26 for FBOs Compliance with Regs 2073/2005 by type of establishment e.g. retail & catering establishments

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Background

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 Process Hygiene Criteria

 The acceptable functioning of a production process,

either during or at the end of a manufacturing process and improvements in production hygiene in case of Unsatisfactory results.

 Food Safety Criteria

 Acceptability of a product or batch of foodstuff for

products placed on the market during their shelf-life and the product must be Withdrawn or Recalled in cases of Unsatisfactory results

Microbiological Criteria

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Detail provided in a microbiological criterion

 Food concerned  Microorganism of concern  A sampling plan (n & c)  Microbiological limits (m & M) or

limit (m=M)

 An analytical reference method

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 Corner Shop/Small Retail Shop  Unlikely to require samples  Low risk establishments  GHP – may be sufficient to ensure

compliance with Regs

 e.g. cleaning (ham slicer), known

suppliers/avoid Cowboys, ensure fridge is working and preferably a probe for monitoring those fridge temperature, wash-hand basin

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 Large Retail Outlet/Supermarket  Include many of our common retail chains  HACCP/FSMS  Supplier specifications – Ham/Coleslaw proof

that L mono does not pose a risk to health

 may consider own in-house testing of Ham and

so it would be food safety criteria, category 1.2 (see table in next slide)

 Guidance from FSAI on matters to consider wrt

sampling e.g. INAB accreditated laboratories

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Large Retail Outlet/Supermarket cont’d

 Business expansion, starts Ready Meals  Ensure there are valid procedures based on HACCP

principles to control the hazards and ensure safe product e.g. cook to >+75°C & check with probe/cooking (ensure valid critical limits for this CCP)

 Re-heating instructions – RTE food (Part B, No.2 of

GN 26)(EHOs are confused too)

 Must test for L monocytogenes= verification  Food Safety Criteria, 1.2 or 1.3  The issue of identifying the RTE status of a foodstuff

is a cause for confusion and is a hurdle that competent authorities and FBOs must overcome

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(Chapter 3.2 of Annex I) specifies sampling frequencies for minced meat, meat preparations and mechanically separated meat. These sampling frequencies must be respected by FBOs as a minimum. However, there is a derogation for small slaughterhouses and establishments producing minced meat and meat preparations in small quantities. These businesses are exempt from the sampling frequencies specified in the Regulation when justified on the basis of a risk analysis and consequently authorized by the competent authority. Be aware that there is a legal requirement (Art 6 of Regs) to label cooking instructions on Minced meat, meat preparations and meat products, from all animal species other than poultry, intended to be eaten cooked. Need for thorough cooking prior to consumption Applies to foods sold loose or pre-packaged Foods sold loose (point of sale notice)

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 Fast Food, Take/Away  GHP, HACCP, Staff Training, FSAI Safe

Catering Pack, I.S. 340: 2007, Language issues with a % of FBOs, often more concerned with compliance with general food safety law

 Restaurant  See above

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 Hotels/Hospitals

 Compliant with Regulation 852/2004 and

ther food safety regulations, HACCP, I.S.

340: 2007

 Staff trained, NHP, Management Food

Hygiene Course

 Good foundations – food tested by suitable

laboratory – Guidance Note 3, HPA

 Foods very short shelf-life, cooked – eaten

that day, cooked – blast chilled – re- heated/consumed within 5 days

 Food Safety Criteria, 1.3 for L

monocytogenes, batch samples only

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Conclusion

 Complicated  Help is at hand, GN 26, Q&A on

2073(still at draft stage)

 Guidance Note for Competent

Authorities (draft only)

 Valid/Verification of HACCP will

mainly ensure compliance

 Testing/Sampling

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20th February 2013

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New Exam Format New Exam Format

Mary Gorby-EHOA Mary Gorby-EHOA

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New Marking Scheme New Marking Scheme

 Total Marks = 500 Marks

Total Marks = 500 Marks

 200 marks for Project (40%)

200 marks for Project (40%)

 300 marks for written Exam (60%)

300 marks for written Exam (60%)

MCQ 175 marks

MCQ 175 marks

LQ 125 marks

LQ 125 marks

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The Course Project The Course Project

Select a prepared dish from your workplace Select a prepared dish from your workplace menu and then complete the following menu and then complete the following tasks: tasks:



List the ingredients and describe the processes employed in List the ingredients and describe the processes employed in the preparation of the chosen dish. 30 Marks the preparation of the chosen dish. 30 Marks



Construct a flow diagram of the steps involved in the Construct a flow diagram of the steps involved in the preparation of the dish. 30 Marks preparation of the dish. 30 Marks

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The Course Project (cont.) The Course Project (cont.)



Determine the Critical Control Points 30 Marks Determine the Critical Control Points 30 Marks

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Suggest suitable monitoring and corrective action Suggest suitable monitoring and corrective action procedures for each Critical Control Point 50 Marks procedures for each Critical Control Point 50 Marks

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Instructions for the student: Instructions for the student:

 The project must be submitted to the

The project must be submitted to the course tutor no later than 1 month after course tutor no later than 1 month after the date of the examination. e.g. Exam the date of the examination. e.g. Exam held on the 1st July 2013 then the held on the 1st July 2013 then the submission date is 1st August 2013 submission date is 1st August 2013

 The project contributes 40% of the final

The project contributes 40% of the final marks. marks.

 Student is informed about the project at

Student is informed about the project at the commencement of the course. the commencement of the course.

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Instructions for the Tutor: Instructions for the Tutor:



The corrected projects must be marked and the originals The corrected projects must be marked and the originals (along with the marks) sent by registered post to the NHP (along with the marks) sent by registered post to the NHP

ffice no later than 7 weeks after the exam date.
ffice no later than 7 weeks after the exam date.



In order to achieve high marks in this project, the student In order to achieve high marks in this project, the student must display an extensive understanding of the principals must display an extensive understanding of the principals

f HACCP and an ability to transpose this knowledge to
f HACCP and an ability to transpose this knowledge to

their work environment in a practicable manner. their work environment in a practicable manner.



Excessive Excessive reliance and duplication of large extracts from reliance and duplication of large extracts from the course textbook and NSAI standards should not result the course textbook and NSAI standards should not result in the student achieving high marks. in the student achieving high marks.

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20th February 2013

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