OUTBREAKS OF
GASTRO ENTERITIS
IN RESIDENTIAL HOMES
GUIDANCE FOR MANAGERS
INTRODUCTION
Viral gastroenteritis is a recognised problem in institutional settings and can
also occur in hotels.
The guidance is structured to enable managers to
appreciate how the virus can infect their staff and residents and how they can
take positive steps to control the spread of the illness. In addition, the
document shows how the regulatory authorities work with the home to
identify the source of an illness and to control the outbreak.
While documented guidance is useful as a training aid it is not the ideal form
of reference when an outbreak occurs and the final section of this leaflet is
therefore devoted to the preparation of a contingency plan (see appendix 1).
Further advice and information can be obtained from the officers of the
Environmental Health Division on 01922 653010.
WHAT IS VIRAL GASTROENTERITIS?
Viral gastroenteritis is an illness caused by one of a group of viruses known
as “Small Round Structured Viruses” (SRSV’s). The virus can be ingested
with food or water, transferred by faecal soiling of surfaces or acquired from
infected droplets within the atmosphere.
The illness occurs regularly in any institution and can affect hotels,
residential homes, and tourist establishments.
THE VIRUS
The viruses cause a variety of combinations of symptoms but diarrhoea and
vomiting predominate. Other systems are fever, abdominal pain, headache,
giddiness and flatulence! Effect varies according to the virulence of the virus,
and the individuals state of health. Exposure to the infection results in only a
short term immunity to the particular SRSV involved. Only a very low
number of virus particles are necessary to cause illness.
HOW THE VIRUS ARRIVES AND IS SPREAD
SRSV’s are usually introduced to a home by infected individuals among the
staff or residents but can be present on foodstuffs to cause a food borne
illness.
Infected individuals shed virus particles when breathing, coughing and
sneezing but gross contamination arises when minute droplets (aerosols) are
liberated from vomit or faeces. Toilets and bathrooms can thus be heavily
contaminated by virus laden aerosols from vomit or diarrhoea.
Similarly a single episode of vomiting in a public area or meeting room can
heavily contaminate the atmosphere. The survival time of the virus in the
atmosphere is not known, but it is believed that dilution of the number of
virus particles in the atmosphere may reduce the likelihood of infection.
Infected individuals can spread the virus to other premises. Some cases may
not show any symptoms yet can infect others, who in turn may become ill.
Food which has been contaminated by the viruses shed by an infected
individual can then cause illness in consumers.
The predominant means of spread is however believed to be “person to
person”. The illness can be contracted from the atmosphere by an infective
individual or by hand to mouth transfer of the virus from contaminated
surfaces e.g. door handles.
THE ILLNESS AND ITS EFFECTS
Sporadic cases are not usually reported or identified. The virus is usually
isolated when an outbreak is investigated.
The illness is sudden and can be severe. The combination of symptoms is
unpleasant and exhausting for the patient. Elderly or chronically ill patients
can suffer a stressful period of illness.
The symptoms usually abate within 24-48 hours and there are no lasting
effects. As the symptoms coincide with those of several food borne diseases
the victims will invariably assume that they are suffering from food
poisoning. Indeed the illness usually affects a large number of people at the
same time and thus resembles an outbreak of food poisoning!
The principal effect is not upon the victims but upon the business where the
outbreak occurred. Media interest is heightened, customer complaints are
numerous and bad publicity is engendered.
A planned and structured response is required to reduce the effects upon both
the victims and the business.
RECOGNISING AN OUTBREAK
Sporadic cases of gastro intestinal illness are not unusual and can arise from
changes of diet or various pathological causes. Potential food borne disease
outbreaks and SRSV outbreaks are often recognised because an unusual
number of people are ill at the same time and in association with the same
place. If your staff note an unusual number of residents showing gastro
intestinal symptoms they should determine how many individuals are
affected, when the illness commenced, what symptoms were involved and the
name of anyone removed to hospital.
Although the law requires any medical practitioner attending a patient to
notify the Council of any case or suspected case of food poisoning it is
prudent for a manager also to notify any cases to the Council Environmental
Health Officer.
Notification by a manger is appropriate if a number of guests are suffering
from gastrointestinal illness, or previous residents contact the home to allege
gastrointestinal illness, or if a food handler or a number of staff report
symptoms of gastrointestinal illness.
To notify a suspected or potential outbreak telephone the following numbers:
Normal office hours: 01922 653010
Out of hours: 01922 650000
CONTROLLING THE OUTBREAK
THE ROLE OF THE ENVIRONMENTAL HEALTH OFFICER AND
THE OUTBREAK CONTROL TEAM
Any report of an outbreak of gastroenteritis in a residential home will receive
a prompt response. The initial response will be a brief telephone interview
which is intended to identify the salient facts. If the notification appears to be
justified the Environmental Health Officer will visit the residential home.
The investigation procedure is as follows:
a) The Environmental Health Officer will visit to obtain information
regarding victims and menus, to deliver specimen kits, to interview a
representative number of victims, to obtain details of staff absences, to
ascertain that precautions are being taken and to advise on additional
precautions and any deficiencies noted.
b) The Environmental Health Officer will notify the Public Health
Laboratory (PHL) and the Consultant in Communicable Disease Control
(CCDC).
c) A tentative diagnosis will be made by the Consultant in Communicable
Disease Control and the Director of the Public Health Laboratory.
d) Specimens will be collected and will be delivered to the laboratory.
e) The situation will be monitored daily and further precautions will be
instituted should they appear to be necessary.
f) When the laboratory results are received and the causal organism has
been identified, specific advice will be prepared and any further control
measures which may be appropriate will be introduced.
THE ROLE OF RESIDENTIAL HOME MANAGEMENT
The management team should follow a contingency plan (see appendix 1).
Salient information should be communicated to staff, residents and the media
on a planned basis and the responsibilities for such briefings should be
identified in the contingency plan.
Management are responsible for ensuring that the control measures specified
in the contingency plan are brought into force and are maintained until the
episode is over.
When an outbreak of gastrointestinal disease occurs it is inevitable that
uninformed commentators will unfairly assume that the cause is a food
poisoning agent and that the homes catering staff are responsible. Until
laboratory findings are available the investigation team will form a tentative
diagnosis based upon the enquiries made in the home. Necessarily these
enquiries will centre upon the food handling and preparation. Indeed, the
investigators will tend to treat any outbreak of gastroenteritis as a suspected
food poisoning until the contrary is proved.
It is recommended that the catering staff (particularly the chefs) are regularly
reminded that they are not seen as the cause of the illness and that the
investigation may in fact be the best means of establishing that they are
operating in an exemplary manner.
THE ROLE OF COMPANY MANAGEMENT
Controlling an outbreak requires additional staff, resources and commitment.
It is essential that the contingency plan of action has been approved at the
highest level in the organisation and will not subsequently be overruled at the
whim of, for example, a Director.
Clear lines of communication and
responsibilities should be detailed in the contingency plan. The company
management should be in a position to ensure that the contingency plan is
being followed and experienced mangers should be available to correct any
failures.
METHODS OF CONTROL
The principle methods of control are the safe sourcing and preparation of
food and water, exclusion or quarantine of cases and rapid cleaning of
contaminated areas. Staff should receive appropriate training to ensure that
they appreciate what they must do and more importantly, why they are doing
it.
DIARRHOEA OR VOMITING AMONGST STAFF

Send affected persons home;

Tell them not to come back for at least 48 hours after they have recovered
(recovery is being able to eat without nausea, no vomiting for 24 hours
and a formed stool);

Pass details to Environmental Health Officer as soon as possible;

Disinfect any area where the person has vomited and/or any toilet
facilities they have used.
DIARRHOEA OR VOMITING AMONGST RESIDENTS

Tell them what is going on;

If any residents are removed to hospital, ensure that the Environmental
Health Officer is aware of their removal so that the hospital control of
infection staff can be warned and can take appropriate precautions;

Try to persuade ill residents to stay in their room.
CLEANING
It is vital that physical evidence of illness is promptly and thoroughly
removed by trained personnel who have access without delay to the correct
materials. (See appendix 3).
RELATIONSHIPS WITH THE MEDIA
The Environmental Health Division, if asked by the media, will confirm that
an outbreak or cases of illness are associated with a home. When the media
are aware of an episode of illness we will divulge approximate numbers,
common symptoms, tentative diagnosis and appropriate precautions. We will
naturally seek through the media to address any apparent public concern but
we will not discuss your business affairs or the way you conduct your
business.
The Consultant in Communicable Disease Control will also talk to the media
and he will seek to provide a medical perspective while still maintaining
confidentiality.
APPENDIX 1
CONTINGENCY PLAN
The contingency plan should be prepared and distributed amongst managers
and supervisors. The plan should make clear the means by which the control
measures will be implemented.
Materials and equipment referred to in the plan should be kept in separate,
secure storage. Contractors referred to in the plan should be aware of your
potential needs and should have confirmed that they can provide the service
referred to in the plan within your anticipated time scales.
A contingency plan normally consists of an introduction, distribution list, and
a statement of the purpose (aims) of the document. The document should
then establish to responsibilities of in-house managers and other agencies, the
mobilisation/call out arrangements and the way in which information will be
provided for customers. Communications with the media should be allocated
to particular individuals and the control measures should be set out in detail.
The document should also include specimen documents for maintaining an
event log and identify where the stores and supplies of cleaning equipment
etc can be located.
APPENDIX 2
DETAIL OF CONTINGENCY PLAN
The contingency plan should include the following information;
CONTACT NUMBERS
Environmental Health Division
CCDC
Public Health Nurse
Service Manager (if L.A. home)
INITIAL INFORMATION TO BE GIVEN TO ENVIRONMENTAL
HEALTH DIVISION;
Number of cases of gastroenteritis (staff and residents)
Symptoms
Date and time of onset (Chronological)
Food history/menus
MEASURES TO PUT INTO PLACE;
Staff meeting; discussion of work and delegation of duties
Disinfection regime; handwashing, disinfection of common contact points,
ppe for all staff.
Formation of “hit squad” to clear up any faeces/vomit; gloves and aprons
must be disposed of before any other activities are carried out.
Washing of all soiled clothes or bedding; boil bags should be used.
Isolation of residents who are ill.
Prohibition of intake of new residents.
Cancellation of all trips/visits.
Letter to all friends/relatives advising of situation
Segregation of kitchen staff – must not leave kitchen while at work.
Exclusion of staff who are ill for at least 48 hours after symptoms have
cleared up.
APPENDIX 3
CLEANING ‘HIT SQUAD’
The contingency plan should provide for a number of members of staff to be
available on a shift basis to clean up evidence of the illness.
It is
inappropriate for these people to be employed on any duties other than
cleaning potentially infected areas during an outbreak. The cost of a 24-hour
cleaning hit squad is minimal in comparison to the trade which will be lost as
a result of outbreak publicity.
Separate equipment and materials should be used by the “hit squad” and the
recommended cleaning methods are:
a) Hard surfaces:
Wipe clean with paper towels
Place soiled wipers in plastic sack
Wipe inward to restrict soiling
Wash with detergent solution mixed in bucket and disposable wiper
Wash with disinfectant solution
Ventilate room to maximum possible extent and leave to air dry.
b) Fabric and soft surfaces:
If possible remove in bags for laundering
If fixed in position then treat as hard surface.
NB. Need to saturate with detergent and disinfectant and dry by physical
means prior to ventilating area. The use of heat as a source of cleaning
energy is recommended and a temperature of 60oC is recommended. The
use of wash and extract vacuum equipment is recommended.
NOTES AND AMMENDMENTS