American College of Physicians: Internal Medicine — Doctors for Adults ®

Monday, May 6, 2013

Preventing norovirus transmission in your home

"Noroviruses are perhaps the perfect human pathogens. These viruses possess essentially all of the attributes of an ideal infectious agent: highly contagious, rapidly and prolifically shed, constantly evolving, evoking limited immunity, and only moderately virulent, allowing most of those infected to fully recover, thereby maintaining a large susceptible pool of hosts."
--Aron J. Hall, CDC

Several weeks ago, my son came down with norovirus. There has been a lot of norovirus this year in Iowa, the U.S. and the world. One of the reasons is that there's a new variant of genotype II.4, named Sydney 2012, that was reported through CDCs CaliciNet to be causing 58% of outbreaks in December 2012. So it's likely that none of us are immune to this variant, meaning that the three others in my family were now at high risk of becoming ill with norovirus. To make matters worse, we were about to celebrate my daughter's birthday and I didn't want her to become ill on such an important day. So my wife and I, educated by previous norovirus outbreaks in the family (2005 and 2010), hatched a plan to beat the virus this time. Let me foreshadow a bit, none of us got sick. Let me tell you how we did it.

The enemy
Noroviruses has a very low infectious dose (≥18 viral particles) and infected patients shed 5 billion infectious doses in each gram of feces. The virus is environmentally stable, can survive up to two weeks on surfaces and is resistant to many common disinfectants. Alcohol hand rub, is thought to be a suboptimal form of hand disinfection with soap and water being preferred. The virus is transmitted fecal-orally and is aerosolized, meaning it spreads widely in the environment. Recent evidence even suggests that commercial dishwashers are ineffective in cleaning norovirus off of dishes and silverware. Finally, since 51% of cases caused by Sydney 2012 were caused by human to human transmission, household transmission is a big mechanisms of spread.

Caveats, limitations and yes I know, but humor me
Now, as many of you know, I'm an infectious disease physician and epidemiologist and I like to identify limitations in almost anything I read. So, I'll save you some of the trouble and point out the weaknesses in this case report. First, it's a case report. Second, we never tested for norovirus in clinical or environmental specimens. Third, we don't know if we were susceptible to this strain, however unlikely that would be.

Case report
Our kindergarten-aged son first expressed norovirus symptoms when strapped into his booster seat in the back seat of our car. The other three of us were in the car at the time. We drove home and he was sick three to four more times in the bathroom. We quickly changed his clothes and quarantined him to a bathroom with a TV to watch for the next 24 hours. We then cleaned up the car and hatched a plan to beat back in-house transmission.

The plan
1) We began practicing strict hand hygiene with soap and water. We rarely used alcohol hand rub, if at all.
2) We realized that all dishes in the dishwasher from the morning he became ill were potentially contaminated and double washed them in the dishwasher. We also removed those dishes from circulation for about 7 days.
3) We each began using a unique set of dishes. We each had our own glass, bowl, dish and utensils. We each rinsed and washed those individually so that we couldn't transmit virus to each other. At the time, we didn't know if others were contagious or not.
4) We didn't wash the booster seat, clothes, towels etc. that were overtly or potentially contaminated for about two weeks; we just kept them in a bag in the corner of the basement.
5) Finally, we were lucky that we have two bathrooms in the house. One was our son's bathroom for one week and the other was for the three "uninfected" family members.

That's it. Most of these steps are easily reproducible in any household. I completely understand that the availability of a second toilet could have made a big difference and not everyone has one available. Although in 2010, we also had a second toilet available and it didn't make a difference since we all got sick. Finally, the big change to our infection control in 2013 versus 2010 or 2005 was that we all had our own utensils, glasses and dishes. I suspect that made the difference this time and is probably worth future study. It would be hard to do a randomized trial of such an intervention (which is why I wrote up this case report), but it could be done.

So good luck out there. Be safe. You never know when norovirus will strike, but don't think you can't beat back this virus. You just gotta use your head, soap and water and your own spoon. Oh, and I know I've now totally jinxed myself. I'll be OK. I'm keeping a bucket next the bed.

Reference: Hall AJ, J Infect Dis 2012

Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands). This post originally appeared at the blog Controversies in Hospital Infection Prevention.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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