Gastroenteritis Outbreak Management In Aged Care

Did you know aged care residents are particularly susceptible to disease outbreaks?

Infection outbreaks in aged care facilities tend to have significant impacts on both the residents’ infection rates, and mortality rates (Utsumi 2010).

Reasons for this include comorbid medical conditions; high-density living arrangements; and frequent contact with visitors and staff (Latta 2018).

Contact with staff, visitors, hospital admissions and transfers from other facilities all increase the likelihood of a disease being brought into and spread around a facility (Latta 2018).

This article will address gastrointestinal infections as they are one of the most common ‘outbreak’ scenarios in aged care facilities (Utsumi 2010).

Outbreak management in aged care facilities falls under Standard 5 of the Aged Care Standards: Organisation’s Service Environment.

What is an Outbreak?

To classify as an outbreak, a disease must occur suddenly and in excess of what would typically be expected in a specific community, geographical area or season. Outbreaks have the potential to last days, weeks or even years (World Health Organisation 2019; Banerjee 2015).

It is worth knowing how to define an outbreak as distinct from an epidemic or pandemic. An epidemic is an occurrence of a cluster of illnesses of a similar or the same nature and derived from a common source, in excess of what would normally be expected in a community or region. Ebola is an example of an epidemic (Banerjee 2015).

A pandemic is a worldwide epidemic, which would have started as an outbreak, and then evolved to become an epidemic. The 2009 flu pandemic is a useful example, in which 18,449 deaths occurred over 214 countries (Banerjee 2015).

Gastroenteritis

Gastroenteritis is the condition in which infection and/or inflammation inflicts the digestive system; it generally is a short-term illness. Common symptoms often include abdominal cramps, diarrhoea and vomiting. Causes of gastroenteritis can include viruses, bacteria, bacterial toxins, parasites, chemicals and some medicines (Better Health Channel 2019).

Infectious gastroenteritis is able to be spread with ease, from person to person or via contaminated food or water. Hand washing is particularly important in reducing the risk of contracting gastroenteritis (Health Direct 2018).

Recognising Outbreaks

In the situation of a suspected outbreak, a case definition is required. This is a set of criteria used for determining what should be classified as a case (Australian Government Department of Health 2010).

An outbreak management team forms a case definition once an outbreak has been declared. The case definition includes the following four components:

• Well-defined clinical symptoms (ideally with laboratory confirmation);
• Information relating to time of contraction (timing of onset of symptoms);
• Persons affected; and
• The location where the outbreak is occurring.

(Australian Government Department of Health 2010)

Early recognition of an outbreak by care workers, nurses and other staff, and the implementation of outbreak control measures, is instrumental to the reduction of the spread of the disease. Outbreaks should be promptly reported to the Public Health Unit (Latta 2018; Australian Government Department of Health 2010).

Recognition at an early stage creates opportunity for the following measures to be carried out promptly:

• Environment cleaning and disinfection;
• Application of personal protective equipment;
• Infection control signage;
• Isolation of infected residents; and
• Management of ill residents and staff.

(Department of Ageing and Aged Care 2014)

Investigating an Outbreak of Gastroenteritis

The steps for starting an investigation on a suspected outbreak of gastroenteritis involves assessing the following:

• Type of outbreak setting;
• Number of affected;
• Severity;
• Suspicion of a foodborne source.

(Australian Government Department of Health 2010)

If two or more people are showing signs of gastroenteritis, such as diarrhoea and vomiting, in a 24-hour period within a facility, and these people have shared a common exposure or food source this can constitute as an outbreak and commencing an investigation immediately is recommended (Australian Government Department of Health 2010).

Management of Gastroenteritis Outbreaks

The following standard infection control measures are advised to reduce the number of affected persons during an outbreak in any location.

Infection control at a basic/minimal level:

• Following effective hand hygiene and cough etiquette;
• Correct use of personal protective equipment (PPE);
• Correct and safe use and disposal of sharps;
• Frequent and thorough environmental cleaning; and
• Incorporation of safe practices for handling blood, body fluids, secretions and excretions.

(Australian Government Department of Health 2010)

Transmission-based precautions (contact)

In addition to the standard measures listed above, adhere to the following advice to prevent the spread of infectious pathogens that cause gastroenteritis in aged care facilities (Department of Health and Human Services Victoria 2018).

Personal protective equipment should be worn in anticipation that contact might occur with a resident’s blood or bodily fluids, mucous membranes, skin that is not completely intact or other potentially infectious material or equipment (Department of Health and Human Services Victoria 2018).

Hand hygiene should be observed as it is one of the most effective infection control measures for preventing the spread of infectious pathogens. There must be adequate access for staff, residents and visitors to hand hygiene stations. These should be well-stocked and maintained. All resident care staff, residents and visitors should be educated on proper hand hygiene techniques (Department of Health and Human Services Victoria 2018).

Environmental cleaning and disinfection

Norovirus is the most common cause for gastroenteritis in aged care facilities. It is a robust organism that is capable of lasting on surfaces for up to 28 days. It is highly infectious, hence cleaning and disinfection is crucial to preventing it spreading. During the outbreak, it is advised that environmental cleaning occur at least twice a day with strong disinfectant (Department of Health and Human Services Victoria 2018).

Staff

Infected staff (any person working in the facility in any capacity) must be prevented from coming to work until at least 48 hours have passed since symptoms have ceased. During an outbreak, it is not advised for staff to move between wings/units of the facility. Ensure all staff are well-informed as to the risk of transmission (Department of Health and Human Services Victoria 2018).

Residents

If possible, all residents showing signs of gastrointestinal illness should be cared for in a single room with their own ensuite facilities. Like staff, the resident should be restricted to their room until at least 48 hours after symptoms have ceased (Department of Health and Human Services Victoria 2018).

Signage

Contact hazard/caution signs are to be placed outside symptomatic residents’ rooms to alert staff and visitors to the necessity of transmission precautions. Visitors should also be alerted to the outbreak within the facility itself via signage (Department of Health and Human Services Victoria 2018).

Preventing Outbreaks of Gastroenteritis

There are steps you can take to lower the chances of contracting gastroenteritis and/or spreading it to other residents/staff. The following can also be applied as general rules to limit the spread of infection.

• Frequent and proper hand washing, particularly after using bathroom facilities and prior to any food handling or preparation.
• Limit the sharing of kitchen utensils, plates and towels in the facility.
• Follow correct food handling procedures.
• Avoid the consumption of raw or undercooked foods.

(Sethi 2018; Government of South Australia 2015)

Declaring an Outbreak to Be Over

The criteria for being able to declare an outbreak is over differs depending on the virus in question; it is up to the outbreak management team to make the final decision (Australian Government Department of Health 2010).

A potential measure for the end of outbreaks in residential facilities is that symptoms in the last noticeable case has elapsed for more than seven days. As a general guide, norovirus outbreaks can be declared over if no new cases have occurred in 72 hours from the onset of symptoms of the last case (Australian Government Department of Health 2010).

It is important that staff, residents and visitors should be notified immediately when it has been officially declared that the outbreak is over.

Additional Resources

• Aged Care Quality Standards: https://agedcare.health.gov.au/quality/aged-care-quality-standards
• Outbreak Management Checklist:  https://www1.health.gov.au/internet/publications/publishing.nsf/Content/cda-cdna-norovirus.htm-l~cda-cdna-norovirus.htm-l-app5~cda-cdna-norovirus.htm-l-app5.4

References

• Australian Government Department of Health 2015, Gastro-Info - Outbreak Coordinator's Handbook, Australian Government Department of Health, viewed 26 August 2019, https://agedcare.health.gov.au/ageing-and-aged-care-publications-and-articles-training-and-learning-resources-gastro-info-gastroenteritis-kit-for-aged-care/gastro-info-outbreak-coordinators-handbook.
• Banerjee, A 2015, ‘Explainer: What’s the Difference Between an Outbreak and an Epidemic?’, in The Conversation, 7 January, viewed 27 August 2019, https://theconversation.com/explainer-whats-the-difference-between-an-outbreak-and-an-epidemic-34906.
• Better Health Channel 2018, Gastroenteritis, Better Health Channel, viewed 27 August 2019, https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/gastroenteritis.
• Latta, R, Massey, PD, Merritt, T, Eastwood, K, Islam, F & Durrheim, DN 2018, ‘Outbreak Management in Residential Aged Care Facilities – Prevention and Response Strategies in Regional Australia’, The Australian Journal of Advanced Nursing, vol. 35, no. 3, pp. 6–13.
• Pietrangelo, A & Nall, R 2018, 'Viral Gastroenteritis (Stomach Flu)', Healthline, viewed 27 August 2019, https://www.healthline.com/health/viral-gastroenteritis#longterm-outlook
• SA Health 2012, Keeping Clean Areas, SA Health, viewed 27 August 2019, https://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/healthy+living/protecting+your+health/your+home/keeping+clean+areas.
• Utsumi, M, Makimoto, K, Quroshi, N, Ashida, N 2010, ‘Types of Infectious Outbreaks and Their Impact in Elderly Care Facilities: A Review of the Literature’, Age and Ageing, vol. 39, issue 3, pp. 299–305.
• World Health Organisation 2019, Disease Outbreaks, WHO, viewed 26 August 2019, http://www.searo.who.int/topics/disease_outbreaks/en/