Gastro Enteritis Outbreak in A Residential Complex for the Elderly

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Gastro Enteritis Outbreak in A Residential
Complex for the Elderly
Legend OP Hosp Visit
Staff Meeting
In house Training
First Case
? First Case Peak
State/Local dept. Involved Prelim
Norvo CDC
CDC confirms
23rd 24th 29th 30 31 2 3 6 7 8 9
10 1 1 12 17 18 19 25
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B. Party B. Party Env. Dept Lab
samples Phone survey
sent
yes/no

Jan Feb
Jun
Contact
Frankfort Lab report
(Forms filled)
Bact ve Fwd. CDC
In house Training
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BACKGROUND
Residential Complex for Elderly is 3
tiered Independent Living 61
Occupants Assisted Living 82
Occupants Nursing Home 27 Occupants
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• Study Objective
• Identify Source and Risk Factors and for the
  outbreak.
• With Emphasis on food-borne disease factors.

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ASSISTED LIVING FACILITY
RESIDENTS (N 82) AFFECTED NOT AFFECTED (N
23) (N
59) STAFF (N 35) AFFECTED NOT AFFECTED (N
13) (N 22) STUDY DESIGN 11 Unmatched
Case-Control Study. Study Tools
Questionnaire Based Study. Face to face group
interview. Telephone survey
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• Study Setting
• Assisted Living Facility AND some Inputs from
• Nursing Home
• Independent Living
• Main Outcome Measures
• Attack rates at the 3 living facilities for
  residents
• Attack rates for the staff at the assisted living
  facility
• Specific food items related attack rates for the
  staff

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Age of Participants
RESIDENTS (N 82)
AFFECTED NOT AFFECTED Mean age 85
Mean age 85 (N 23)
(N 59)
STAFF (N 35)
AFFECTED NOT AFFECTED Mean age 37
Mean age 43 (N 13) (N 22)
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Results Figure 1 Common Symptoms
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Results Fig 2 Date of Onset of Illness
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Results Table No. 1 Some Variables Studied
for Association in the Assisted Living Facility
(Data is only for the Staff)    1. Social Event
Gathering No Association.   2. Travel No
Association.   3. Child care exposure No
Association   4. Drinking water source No
Association   5. Spatial clustering No
Association
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Results Table No 2 (a) Attack Rates
  Telephone survey to ascertain GI illness
in 3-week time frame Resident data forms and
staff interviews Interview with management of
Nursing Home
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Results Table No 2 (b) Attack Rates Staff
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Results Table No 3 Risk of GE Associated with
Eating of Particular Food amongst staff of a
Residential Facility
None of these foods were shown to be associated
with the illness.
 
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Laboratory Confirmation
Lab Specimen sent on 11th Feb Number type of
specimen One emesis, one stool Preliminary
reports State and CDC Frankfort Excluded
bacteria, forwarded to CDC, CDC reported probable
noro virus Final report CDC June 7th Both
samples were tested for norovirus (RT-PCR) When
using the Region B primer set, 1 of the 2 samples
was positive for norovirus.  When using the
Region C primer set, 2 out of 2 samples were
positive for norovirus.  In conclusion, this
outbreak of gastroenteritis was associated with
multiple strains of norovirus belonging to
genogroup II.
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Conclusion

• The source of outbreak was not likely to be food
  borne.
• The likely spread was person to person.
• Clinical, Epidemiological and Preliminary Lab
  findings are suggestive of Noro virus outbreak.
• About half of all GE outbreak in US are Noro
  Virus

Note Similar outbreaks were being reported
throughout US (Virginia, Nevada, Alaska,
California) and also in Europe.Europe
(Netherlands, Germany, England) reports emergence
of a new noro virus variant, a geno group II 4
virus . Lancet 2004363682-8.
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Lessons Learnt

• Functional Aspects
• The Hospitals and the HD need to work together.
• Establish contact with KY DPH Epidemiology early.
• Daily update with Director of the MCHD.
• Investigational aspects
• 4 Talk to as many people in the facility as
  possible.
• 5 Check tool for appropriateness large font
  for elderly.
• Notify health providers They assist in case
  finding.
• Take and specimen containers on initial visit
  make specimen collection a top priority

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Lessons Learnt

• Some useful tools for investigation could be
•                         i.      Large calendar of
  time frame involved with significant events of
  the time to help staff and residents be oriented
  to dates.
• ii Group meetings help in standardizing
  the information people receive and ascertains
  memories that are agreed upon by the staff. New
  sources of documented evidence can be unearthed,
  such as communication book.

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Shortcomings

• Shortcomings of this investigation
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• 1.   1)  1/3 of residents have some memory loss
• Working through management to obtain individual
  data has significant limitations.
• Delay in obtaining information from staff.