For information or advice, please contact New Forest Environmental Health, 02380 285680
Gastro-enteritis Outbreaks in Hotels etc. – Essential Information for Managers
Introduction
The guidance is structured to enable managers to appreciate how the virus can infect their staff and guests, and how they can take positive steps to control the spread of illness. In addition, the document shows how regulatory authorities work with the trade to identify the source of an illness and to control an 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.
1. What is viral gastroenteritis:
Viral gastroenteritis is an illness caused by one of a group of viruses known as Noroviruses. The virus can be ingested with fluid or water, transferred by faecal soiling of surfaces or acquired from infected individuals by droplet or aerosol transmission within the atmosphere.
The illness occurs regularly in any resort or town and can affect hotels, guesthouses and other residential establishments.
1.1 The Virus
Infection by Norovirus may result in illness of mainly diarrhoea and vomiting, other symptoms include fever, abdominal pain, headache, giddiness and flatulence! Effects vary according to the virulence of the virus and an individual’s state of health. Only a very low number of particles are necessary to cause illness. Exposure to infection usually results in only a short-term immunity to the particular SRSV involved.
1.2 How The Virus Arrives And Is Spread
Norovirus is usually introduced to a hotel environment by infected individuals but can also 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. Virus-laden aerosols from vomit or diarrhoea can thus heavily contaminate toilets and bathrooms.
Similarly, a single episode of vomiting in a public area or meeting room can heavily contaminate the atmosphere. The survival time of Norovirus in the atmosphere is not known, but it is believed that dilution of number of virus particles may reduce the likelihood of infection.
Infected individuals can spread the virus to other premises. Some cases may not show any symptoms but can infect others, who in turn may become very ill.
Food that has been contaminated with viruses shed by an infected individual can then cause illness in consumers.
The predominant means of viral transmission is however believed to be “person-to-person”. The illness can be contracted from an atmosphere contaminated by an infective individual, or by hand-to-mouth transfer of the virus from contaminated surfaces.
1.3 Illness And Its Effects
Sporadic cases are not usually reported or identified. The virus is usually isolated when an outbreak is investigated.
Symptoms of the illness are sudden and can be severe. The combination of symptoms is often unpleasant and exhausting for the patient. Elderly or chronically ill people can suffer a stressful period of illness.
The symptoms usually abate with 24 to 48 hours and there are no lasting effects. As the symptoms are almost identical to those of several food-borne diseases victims will invariably assume that they are suffering form food poisoning. Indeed, the illness usually affects a large number of people at the same time and this resembles an outbreak of food poisoning.
The principle effect is not upon the victims but upon the business where an outbreak has 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.
2. Recognising An Outbreak
Sporadic cases of gastro intestinal illness are not usual and can arise form changes of diet or various pathological causes. Potential food borne incidents and Norovirus outbreaks are often recognised because an usual number of people are ill at the same time and in association with the same place.
If your staff note an unusual number of guests showing gastro-intestinal symptoms they should know that management must be informed. A responsible manager 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 the hotelier also to notify any case to the Council.
2.1 Notification
Notification by a hotelier is appropriate if a number of guests are suffering from gastro-intestinal illness, if previous guests have contacted the hotel alleging similar symptoms, or if a food handler or other members of staff report sick.
To notify a suspected or potential outbreak please telephone the Food Team on 02380 285680.
The Duty Manager who has reported an outbreak should be able to contact a Senior Council Officer.
When there is good reason to believe that an outbreak of gastro-intestinal illness has occurred in the hotel, the staff should be briefed as they can then assist in gathering and disseminating accurate information. Staff need to know why procedures have changed and, without being briefed, they could feel threatened by the on-going investigations.
2.2 Your Other Customers
Guests at the time of the cases being identified, and those who has subsequently arrives, including delegates at seminars, receptions and meetings may all be infected. Indeed anyone who uses the hotel while the control procedures are in force may also contract the illness.
It is important that guests who are due to arrive during the control period are aware of the potential hazard and be in a position to determine the risk.
Information should be given to prospective guests in sufficient time to enable a change of plan. Best practice appears to be to contact prospective guests by telephone with operators working to a prepared briefing not that is then reinforced by a letter confirming the information given in the telephone call.
Experience has shown that hospital admission will occur if guests with coronary conditions or debilitating diseases are infected. It is therefore important that prospective guests who are suffering from a serious medical condition, which could be exacerbated by viral gastro enteritis, should stay away.
An effective customer relations package is the best way to address potential complaints of litigation or allegations of misleading guests for reason of profit
The package should be part of your contingency plan.
3. Controlling The Outbreak
3.1 The Role Of The Environmental Health Officers And The Outbreak Control Team
Any report of an outbreak of gastroenteritis in a hotel 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 an Environmental Health Officer will visit the hotel.
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 cases, to obtain details of staff absences, to ascertain that precautions are being taken and to advise on additional measures 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 be delivered to the laboratory for analysis.
e) The situation will be monitored daily and further precautions instituted should they appear to be necessary.
f) When the laboratory results are received and the casual organism has been identified, specific advice will be prepared and any further control measures introduced where appropriate.
3.2 The Role Of Hotel Management
The hotel management team should follow a contingency plan. Salient information should be communicated to staff, guests 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 maintained until the episode is over.
Departmental managers will have a crucial role in ensuring that the investigators promptly receive any information they may require.
When an outbreak of gastro intestinal disease occurs it is inevitable that uninformed commentators will unfairly assume that the cause is a food poisoning agent and that the hotel’s catering staff are responsible. Until laboratory findings are available the investigation team will form a tentative diagnosis based upon enquiries made in the hotel. Necessarily these enquiries will centre upon food handling and preparation. Indeed, the investigators will tend to treat any outbreak of gastroenteritis as suspected food poisoning until the contrary is proved!
It is recommended that catering staff, particularly the chefs, are regularly reminded that they are not seen as the cause of illness and that the investigation may in fact be the best means if establishing that they are operating in an exemplary manner.
3.3 The Role Of Company Management
Controlling an outbreak requires additional staff, resources and commitment. It is essential that a contingency plan of action has been approved at the highest level in the organization 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.
3.4 Methods Of Control
The principal 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!
The following notes identify known problems and a sensible way to address them:
1. Diarrhoea or vomiting among staff:
(a) Send affected person home.
(b) Tell them not to return for at least 72 hours after they have recovered. (Recovery is being able to eat without nausea, no vomiting for 24 hours and a formed stool)
(c) Pass details to Environmental Health Officer as soon as possible.
(d) Disinfect any area where the person has vomited and/or any toilet facilities they have used.
2. Diarrhoea or vomiting among guests:
(a) Inform them what is going on and that an Environmental Health Officer will be calling to see them.
(b) If any guests 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.
(c) Try to persuade ill guests to stay in their room, select a chambermaid(s) to work exclusively on the rooms of ill guests and provide regular cleaning to that area throughout the day. Use the same individual to deliver room service. The objective must be, so far as is practicable, to isolate the affected guest by providing “exclusive” service.
3. 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.
The contingency plan should provide for a number of members of staff to be available on a shift basis to clean up evidence of 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 that will be lost as a result of outbreak publicity!
Separate equipment and material should be used by the “hit squad” and the recommended cleaning methods are:
a) Hard Surfaces: Wipe clean with paper wipers
Place soiled wipers in plastic sack
Wipe inward to restrict soiling
Wash with a detergent solution mixed in a bucket and disposable wiper
Wash with disinfectant solution
Ventilate room to maximum possible extent and leave to air dry
b) Fabric and If possible remove in bags for laundering if
soft surfaces: fixed in position then treat as hard surface
N.B. 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.
4. Failure To Comply
Officers will make every attempt to assist you in complying with this legal requirement. However, the Government has been given instructions that where compliance is not being achieved formal action must be considered by Local Authorities.
Initially this will involve the Officer using a written warning accompanied by an agreed deadline for completion. Failure to undertake the specified works may lead to the service of an Improvement Notice to secure compliance again accompanied by a deadline for completion. Failure to comply with the notice is a criminal offence. Flagrant beaches of the law may also result in a business facing legal proceedings, although these instances are rare.
5. Written Records And Your Defence
Although in law you do not have to provide written documents (e.g. a hazard analysis) or monitoring records, it is difficult to show that you are meeting the requirement of the Food Safety (General Food Hygiene) Regulations 1995, Regulation 4 (3)(a) to (e) without written documents or records.
If your food business is charged with an offence under the Food Safety Act 1990 (e.g. foreign body contamination of food), the Act provides a legal defence if you can show you exercised all “due diligence” to prevent the offence occurring.
To use this defence you would have to prove that you took all reasonable precautions to ensure the food you produce is safe to eat. You could do this by showing you have controls in place which would prevent the problem occurring and that you can show that these controls were operating at the time of the offence. In practice this could be demonstrated by your having undertaken a hazard analysis and providing records of the monitoring you carry out.
6. Finally
Please remember that this document and the hazard analysis information contained in it have been produced to give you advice on complying with the law. The information does not form a complete list but indicates the areas that your hazard analysis must seek to identify to enable effective control measures to be implemented.
Your business may have its own particular hazards and problems. The law requires that you identify these and implement effective controls.