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On a daily basis, family, friends and staff enter long-term care facilities to offer friendship and provide care. But nosocomial infections, specifically from norovirus and Methicillin-resistant Staphylococcus aureus (MRSA), can transform these safe havens into potential nightmares.
Of the more than 40 million individuals hospitalized annually in the U.S., about 2 million develop healthcare-associated infections, resulting in 99,000 deaths.1 The total annual financial burden of these infections is about $6.5 billion.1
Due to the discovery of two new norovirus strains - GII42006a and GII4-2006b - there has been a sharp increase in norovirus incidence, and the innocent recipients are primarily residents of long-term care facilities.2 MRSA infection is also a serious problem for long-term care.3 The transmission is easy and invisible, threatening patients and healthcare workers alike.
Definitions And Symptoms
Norovirus and MRSA are transmitted by fomites such as tables, counters, bed linens, bed rails, door knobs, TV remotes, lab-testing equipment and wall surfaces that may be contaminated with the infectious organisms.2,3
All noroviruses are single-stranded RNA, nonenveloped viruses that cause acute gastroenteritis in humans.4 The incubation period for norovirus is typically 24-48 hours, although symptoms may present within 12 hours of exposure.
Symptoms of norovirus include vomiting, diarrhea, abdominal cramps and low-grade fever. Dehydration is the most serious complication.4 Symptoms typically persist for 24-60 hours. Most individuals recover completely from norovirus, but children, elderly and immunocompromised individuals are at highest risk for serious complications.
Norovirus is highly contagious. Exposure to as few as 10 viral particles, each measuring only 27-35 mm in diameter, can lead to infection. An infected individual may shed viral particles from initiation of infection to 2 weeks after symptom cessation, although it is unclear if viral shedding past 72 hours post-infection is infective.4
Transmission routes include fecal-oral, water-borne, person-to-person, aerosolization and subsequent ingestion of vomitus droplets, fomite and environmental routes.4
MRSA is also known as oxacillin-resistant Staphylococcus aureus (ORSA), CA-MRSA (community-acquired MRSA) and HA-MRSA (hospital-acquired MRSA). This biological pathogen causes severe, persistent infections in humans.3 Presenting as a skin infection, it may develop into a serious invasive illness. Some MRSA strains produce toxins that attack white blood cells and soft tissues including those of the respiratory tract.
Treatment involves aggressive antibiotics and hospitalization with duration varying by patient. Healthy individuals recover, but the elderly, children and immune-compromised individuals are at risk of serious complications and possible death from a MRSA infection.3
Transmission routes are usually person-to-person and via fomites.3 Healthy individuals may harbor contagious MRSA colonies for years prior to infection.3
Control And Prevention
Hand hygiene is the most important factor in controlling norovirus and MRSA. Vigilant hand washing, along with use of alcohol-based hand sanitizing gels, is recommended.
Gels (70-90 percent ethanol or 40-60 percent isopropanol alcohol) are shown to be most effective against norovirus if the contact time is 1 minute.5
In long-term care, fomite sanitation and surveillance are also paramount. To destroy norovirus on surfaces and laundry, use either a chlorine bleach solution (concentration of 1,000-5,000 ppm or 1:50-1:10 dilution of household bleach) or use disinfectants that contain sodium hypocholorite, as recommended by the Environmental Protection Agency.6 Studies also suggest using hypochlorous acid fogs applied by a portable commercial generator.7,8
To destroy MRSA, use disinfectants registered on the EPA's list,9 many of which contain ammonium chloride. Ozone gas and high-efficiency particulate air (HEPA) filtration systems are also encouraged.10
Carefully clean door knobs, light switches, remote devices, soiled containers, utensils, dishware, linens, medicine trays, carts, charts and laundry equipment. Patients with confirmed cases of MRSA should be served disposable linens, cups, trays, flatware and dishware.3 Personnel who work directly with residents should follow all contact guidelines, including use of gowns, gloves and masks when indicated.3
In addition to cleaning, regularly monitor surfaces through swabbing and laboratory testing. Bacterial or viral "counts" should be taken from swabs on the work surfaces. This action is needed to determine presence, so control of norovirus and MRSA occurs to maintain a pathogen-free environment.
If a staff member becomes ill with a virus, he or she should not return to work for 72 hours following illness.2 Surveillance of staff for MRSA colonies using nasal swabbing and skin scrapes are indicated.3
Management's Role
Managers are responsible for establishing, implementing and monitoring hand hygiene, surface and equipment sanitation, and employee surveillance policies and schedules.
Explore and carefully choose EPA-recommended cleaning products and methods. In addition, managers provide important leadership by conducting comprehensive staff education on product use. Continuous staff education and reinforcement of protocols are needed, especially with staff turnover and the tendency for staff to return to old behaviors.
Employees play an important role in prevention of nosocomial norovirus and MRSA infections. By taking these cautionary measures, you can decrease the risk of contamination. Creating and maintaining a safe environment will lessen infection and allow you to focus on the real medical diagnoses.
Gail Frank is a professor and nutritional epidemiologist at California State University Long Beach, CA.
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