Norovirus

We've had a bulletin going around telling us about the Norovirus, or “Winter Vomiting Bug”.

The bulletin gives the details of the virus, that it lasts up to three dyas, that unless you are very young or very old it will pass with no long term effects and that the most important thing is to keep hydrated.

It also mentions that you shouldn't prepare food, or be around vulnerable people for forty-eight hours after the symptoms have gone.

(I wonder if this will be taken into consideration should staff members become sick?)

We are being asked to give this information to patients and to leave them at home in order to stop the virus spreading through hospitals.

All good advice and it's god to see us as a trust looking at the bigger picture, but unfortunately in the real world it doesn't quite work that well.

Lets say that I go to a patient and then a few days later they drop dead (of whatever reason, it doesn't really matter), I'll be the person who the Coroner's office looks at closely. I reckon I'd get a suspension at the least.

But that doesn't matter – It all comes down to risk management, it is riskier for more people for me to take such patients to hospital. So I'll leave them at home.

When I can.

The other major problem is that when someone calls an ambulance they often want to go to hospital. All the advice I can give about staying at home is for naught if they 'demand' to go to hospital. I can't refuse them this.

The only time I can refuse someone an ambulance is if they are violent or abusive towards me.

So, the other night I found myself in a patient's front room. They had been suffering from a presumed Norovirus infection. They were otherwise fit and healthy, but for one day had been having episodes of diarrhoea and vomiting. I explained that they didn't need to go to hospital.

But they insisted. They wanted to see a doctor because they were fed up with this one day worth of illness.

I tried to persuade them to stay, but they were having none of it. So I had to take them.

And this is why the policy will fail – because all you need is one infected person to insist that you take them to hospital and it all falls apart.

Oh well, maybe for the next epidemic my bosses will let us refuse to take people.

Of course then we'll have worried relatives threatening to beat us up if we don't take them.

That or they'll get a cab…

32 thoughts on “Norovirus”

  1. Norovirus infections:Triggered off by drinking water in the run-up to limited secondary spread from human to human

    The cold is the main cause to conserve virulent viruses e.g. in water.

    Norovirus can spread through:

    – contact with infected persons at 37C

    – contact with surfaces or objects in [heated] houses at 20C

    – eating contaminated food with over the year constant temperatures

    – drinking contaminated water with over the year changing temperatures from 20C to 3C.

    About the half of norovirus infections occur in the expanse without recognized clusters. Norovirus infections occur general strong seasonal in the cold dependent on environmental temperatures [water, soil, drinking water pipes]. There must be an abiotic vehicel like drinking water that changes its temperature in the cold. Norovirus infections exact start and finish at water pipe temperatures of 15C. So I'm convinced that norovirus infections mainly are triggered off by drinking water in the run-up to limited secondary spread from human to human.

    There is no other appropriate vehicel changing its temperature over the year to explain the strong seasonal norovirus epidemics in the cold.

    Its my conviction that in temperate climates the strong seasonal waterborne infections like norovirus, rotavirus, salmonellae and campylobacter are mainly triggered off by drinking water dependent on the drinking water temperature (in Germany minimum temperature february/march: important to viruses like norovirus and rotavirus – maximum temperature august: important to bacteria like salmonellae and campylobacter). Norovirus (and rotavirus, salmonellae and campylobacter) infections are triggered off by feces in food or in drinking water. The year over food temperature dont change in contrast to drinking water temperature. Logical norovirus infections have to be triggered off by contaminated drinking water in the run-up to limited secondary spread from human to human.

    The performance to eliminate viruses from the drinking water processing plants regularly does not meet the requirements of the WHO and the USA/USEPA. Conventional disinfection procedures are poor, because microorganisms in the water are not in suspension, but embedded in particles. Conventional disinfection procedures (chlorine, ozon) are less effective in the cold. Even ground water used for drinking water is not free from viruses.

    Extracts from the specialized literature:

    http://www.springerlink.com/content/x6138263qn388085/

    Bundesgesundheitsblatt – Gesundheitsforschung – Gesundheitsschutz

    Volume 50, Number 3 / Mrz 2007

    K. Botzenhart

    Konrad.Botzenhart@uni-tuebingen.de

    Institut fr Medizinische Mikrobiologie und Hygiene, Tbingen, BRD Institut fr Medizinische Mikrobiologie und Hygiene, Wilhelmstrae 31, 72074 Tbingen, BRD

    Viruses in drinking water

    Abstract

    Viruses in drinking water can cause infectious diseases. In the past, hepatitis A and E were the most frequently observed drinking- water-borne viral infections, but in recent years several small- and large-scale norovirus epidemics have been described, even in Europe. All virus species spread via drinking water are of fecal origin. They are regularly identified in waste water even after conventional multi-stage water treatment. The approved disinfection methods can cope with these viruses if they are not integrated in larger particles. For this reason particle separation is particularly important in water treatment. Virological tests are not reliable enough to ensure that drinking water is sufficiently virus-free. The examination of 100 mL of water for E. coli and coliform bacteria is not adequate proof either. If potentially contaminated raw water is used, consumer safety must be ensured by calculating the performance of water treatment plants on a case-by-case basis. Such a calculation takes into account the virus load of the raw water, the efficiency of the physical and chemical particle elimination steps and the effect of disinfection. Those factors which determine the effectiveness of disinfection, namely concentration and exposure time or UV radiation strength, must be adjusted according to the risk of viral infection, and calculated settings must be adhered to, even if favorable E. coli levels may make them seem excessive.

    Keywords: Drinking water, Viruses, Disinfection, Particle elimination,

    http://www.cdc.gov/ncidod/EID/vol11no11/05-0487.htm

    Emerg Infect Dis [serial on the Internet]. 2005 Nov.

    Maunula L, Miettinen IT, von Bonsdorff C-H.

    Norovirus outbreaks from drinking water.

    Abstract

    As part of an intensified monitoring program for foodborne disease outbreaks in Finland, waterborne outbreaks were investigated for viruses. The diagnostic procedure included analysis of patients' stool samples by electron microscopy and reverse transcriptionpolymerase chain reaction (RT-PCR) for noroviruses and astroviruses. When these test results were positive for a virus, the water sample was analyzed. Virus concentration was based on positively charged filters from 1-L samples. Of the total 41 waterborne outbreaks reported during the observation period (19982003), samples from 28 outbreaks were available for analysis. As judged by RT-PCR results from patient samples, noroviruses caused 18 outbreaks. In 10 outbreaks, the water sample also yielded a norovirus. In all but 1 instance, the amplicon sequence was identical to that recovered from the patients. The ubiquity of waterborne norovirus outbreaks calls for measures to monitor water for viruses.

    Dipl.-Ing. Wilfried Soddemann

    Free Science Journalist

    soddemann-aachen@t-online.de

    http://www.dugi-ev.de/information.html

    Epidemiological analysis:

    http://www.dugi-ev.de/TW_INFEKTIONEN_H5N1_20071019.pdf

  2. I would never call an ambulance for d&v, with the exception of my middle daughter. She had a fundoplication (stomach wrap) operation as a toddler, so vomiting can be extremely dangerous for her, and I dread the winter vomiting bugs as she often ends up in hospital having her stomach drained to prevent her trying to vomit. Norovirus, with its uncontrollable projectile vomiting is one of the worst, as she risks rupturing her stomach or her oesophagus, or both! Given her problems, I have (once) had an ambulance called for her (by our GP), as she was is such agony and the risk of rupture was too great given that we were a 70 minute drive from the nearest hospital.That said, the rest of us follow the usual route of plenty of fluids and rest!

  3. Completely unrelated to anything I wanted to say that I think you are brilliant, and that if I ever do need an ambulance I would be over the moon if someone who is clearly so passionate about their job and patients as you picked me up.

  4. I would be so glad to be told that I need not go to Hospital.Ambulance would cost 50 Pounds plus, the Emergency wait would be hours of frustration,{ some have known to die waiting for a MD}, and would cost a months AOP money, then top it off I would have 2% chance of catching a dangerous disease.The rush to the Hospitals the last thing I would want.

  5. Seriously though, what kind of idiot calls an ambulance because they have got the shits? In what world is that an 'emergency'? Prats. There should eb some sort of system of fines for people who waste the time of ambulance crews by calling them out for something utterly ridiculous. Honestly. Take a pack of dioralyte, have a glass of water and stop bloody whining, it'll be gone in a few days. I'd be great as an ambulance crew member, so sympathetic…..

  6. Here here!Unfortunately some people fail the “common sense” test though and call ambulances for all sorts of things that you or I would go to the pharmacist or doctor for (cough, cold, “man flu”, sprained ankle etc.).

    I personally think along the same lines as you – if someone calls an ambulance and it is not an emergency, they should still be treated, but also charged (or fined) for that privilege. I wonder if that would make some people stop and think before dialling 999?

  7. We have gone down this line so many times in the past. A major problem is that not only do people well-off enough to pay a fine call us out un-necessarily, but so do people on the dole or minimum wage. Frequently the latter call us as a free big white taxi because they “haven't got the money for a cab”. To my ind that shows that they are mis-using/abusing our service, with the sole intent of gettting a lift. If that person is on the dole/Jobseekers allowance etc etc, how much do we fine them, if at all. Furthermore, how does it make us look, taking money from someone who genuinely can ill-afford it?The ambulance service is hamstrung by the possibility of “someone might die and we may get sued”. The police and fire brigade can refuse to go out to calls which appear non-emergency, but we cannot, as the situation may not be as originally indicated. We need a system of public information (like the public information films on TV in the 1950s and 1960s), so that the public are educated in our “Raison D'etre” .

  8. It's a shame that NHS Direct is both relatively costly to call, and very variable in terms of quality of advice given. It seems to me that they're the ideal starting point for a free-to-call, “is it an emergency?” service, assuming that all NHS Direct staffers can be trained to not panic and send an ambulance at the drop of a hat (and note that in my experience of NHS Direct – two calls so far – I've not had an ambulance called for me).

  9. Yes… but the people it would make “stop and think” are the vulnerable people with low incomes (including but not limited to elderly people on tiny pensions, disabled people on benefit, people in risky but minimum-wage jobs) who would then not call an ambulance for anything short of a major car crash or actual death, for fear of being charged money they can't afford for having misjudged the extent of “emergency” for their chest pain, blood loss, tumble down the stairs, etc.Introducing a means-tested system or help with paying the fees for people with low incomes won't do the trick either. It just means the same number of time wasters will be split into one group of “I won't have to pay it, so who cares?” and another group of “I can afford it, so I'll pay it, and I will have Righeous Anger at every member of NHS staff I encounter because I'm paying to be here dammit.”

    πŸ™

  10. sigh, there's definitely an arguement for “emergency isolation wings” for stuff like this… maybe a couple of marquees on a bit of grassy/muddy land somewhere kitted out with tressle beds, porta-loos and other such mod cons. I mean, no considerate person would wish to bring such a dangerous infection into a hospital full of vulnerable people now would they…..

  11. Exactly right. You can't penalize people for *calling* an ambulance because the whole point is that they DON'T know what's going on. Could be a heart attack; could be pizza.But you could penalize them for insisting on hospital against the advice of trained responders. Especially when the diagnosis is confirmed by the hospital.

    I know this wouldn't help the problem of EMTs being run off their feet, but it might help some of the “big white taxi” and “beds in the hospital hallways” problems.

    ?

  12. How about this: no-one gets charged for calling an ambulance. If the crew judge you to be genuine (guidelines would be needed, obviously, but generally speaking any of the following are genuine, in my humble opinion: anyone requiring immediate treatment from the crew, anyone with a disabling injury, anyone with mobility problems preventing them from accessing treatment by other means. Not an exhaustive list, just the first ones I thought of).Anyone “non-genuine” can still travel to hospital by ambulance, but will be charged a reasonably significant fee for the journey. Up front.

    That way, no-one (low income, elderly, etc) has to worry about being charged for calling a truck, but we would not end up being used as a free taxi to hospital.

    I think a similar system operates in some parts fo Canada, unless I dreamt about that…

  13. Funny, as soon as I heard the advice being given out I thought of you and your colleagues. Exactly as you say, if you don't take them and something goes wrong it'll be your fault. If they insist they get their way. Presumably if you get it you'll be disciplined if you take the recommended amount of time off! You could call it a no win situation.

  14. “Seriously though, what kind of idiot calls an ambulance because they have got the shits? In what world is that an 'emergency'? Prats.”You've obviously never been alone, ill and feeling too sick to make a clinical judgement – you know, the sort all patients would need to make if you got your system of financial penalities in place to punish anyone unable to come up with consultant-level assessments of their needs.

    I have been, and while none of the times resulted in an ambulance being called, comments like yours make me see red!

    Not everyone has a 4×4 in the drive, and several family members around to drive them – and if you can get a cab to take you when you have uncontrollable vomiting & diarrhea, or indeed ANY medical problems, then let me know the cabbie's number!

  15. My hospital has 4 wards closed due to norovirus (closed to new admissions that is). Unfortunately infection control need tests proving the D+V is a result of norovirus. By the time the tests have come back most of the patients in one bay are infected. I cant believe how fast this thing spreads. Almost all the staff on my ward currently are bank.

  16. “Seriously though, what kind of idiot calls an ambulance because they have got the shits? In what world is that an 'emergency'? Prats.”For some people it is an emergency. I have an ileostomy and everyone else with an ileo that I have heard of who has had Norovirus has ended up in hospital, many of them via a 999 call having lost 2-3 litres of fluid in less than 15 mins… Calling 999/going to hospital is preferable to renal failure!!

  17. While I sort of agree that patients, particularly patients feeling the effects of being very sick, can't always make top-notch clinical decisions… it's the squits ffs.You don't need transportation (ambulance, taxi, 4×4, wheelbarrow) for D&V. Unless there are extenuating circumstances, you don't need a doctor either, or a hospital, or any treatment. You need a toilet, a bucket, a blanket, a cup, and a tap that supplies potable water.

    I cannot get my head round the idea that a person could reach adulthood without realising that the occasional day or two of stomach upset is just one of those things that happen sometimes and having a fair idea of how to deal with it. It's not a clinical judgement, it's common sense, and if a person really is so feverishly semi-conscious that they can't figure that out, they probably need the hospital more on the basis of the altered consciousness, than the squitting. And are likely in no fit state to attempt an argument with the ambo staff.

  18. That's not calling an ambulance for straightforward “got the squits and I don't like it” though. Your daughter's circumstances turn norovirus from “simple d&v” into something really quite dangerous that does require medical attention.

  19. Here is a message I received on a forum when I admitted that our Trust were pressuring staff to return 24hrs after D&V symptoms had abated – & the below comment is from someone who has never met me πŸ™ -“I pity anyone who has a baby in your care or has an attitude like yours and thinks 1st and foremost of their own career before the life of an innocent baby. And all over the possibility of a disciplinary you would be willing to risk the lives of your patients. I think that's despicable.”& I thought – 'my God, you are not even on the same planet as me, a disciplinary is not a POSSIBILITY – it is a REALITY!!

  20. That's exactly what I use them for, and they've been brilliant. Usually some advice on what to do next, or when to begin worrying, and, a couple of times, an ambulance – once for very severe dehydration due to diarrhoea and vomiting that led to a hospital stay of a few days, so the ambulance was needed.Recently, I got probably-norovirus and wasn't keeping water down for >24 hours, and they were great for telling me what signs to look for so I didn't get fally-over poorly again. No ambulance that time, just good advice. Sadly, all stuff I did already know, but medical knowledge goes out of the window when it's you that's poorly.

  21. It's not that simple. If you keep having the squits for long enough, or can't keep any water down (especially if the weather is hot), you can get dehydrated even as a nominally healthy adult and need an ambulance.Mostly, it's as you say, but if you are on your own and can't stand up and/or your pee is getting dark, then I think it's entirely forgiveable to call for help, even for 'just the squits'.

  22. But again… if you're that badly dehydrated and can't even keep very small occasional sips of water down, that's an additional factor that makes it no longer a simple 24 hours of d&v.If you're all alone and can't stand up and you're peeing blood, that's more additional factors that make it no longer a simple 24 hours of d&v.

    Making it entirely reasonable and forgivable to call for help, even making it understandable that a person might dial 999 instead of hunting out the numbers for their GP or NHS Direct. No problem with that at all.

    The gobsmacking bit, for me, is that bit where the medically trained people arrive at the patient's house, check them over, listen to what they have to say, establish that there aren't any special or severe circumstances and that the patient is better off at home, and give their professional advice accordingly – and the so, so ill patient starts stamping their feet and demanding to be taken to hospital for no good clinical reason.

  23. But have you tried that? a paramedic was tied up for an hour and a half, trying to get to speak to a Dr on my mums behalf. In the end I took over trying to get through, so the paramedic could go on to other calls; 40 min later I did get to speak to a receptionist, only to be told we had rung to late for a home visit that day. Had we been able to get through at the outset, two hours and ten mins earlier, we could have had a same day visitAgghh….. the frustration.

  24. One nitpick: I said dark urine, not bloody urine!I'm on the same page as goes arguing with the ambulance people. Ideally D&V should stay safely at home in most cases.

  25. Actually I don't have a 4×4 either and since I've had Crohn's Disease for 20 years (since I was 9) I have felt exceedingly ill while on my own many a time so kindly don't pass judgement on me with no knowledge of my circumstances. The media has been full of stories about the norovirus, explaining the symptoms and recommending that people stay home and drink fluids rather than spreading it about so you shouldn't be getting an ambulance OR a taxi to take you to hospital with the norovirus because that just means that it spreads further. The ambulance that was called was unneccessary and a waste of resources.

  26. the ward i was on my placement on recently ended up closed because of norovirus. got quite messy at points and a lot of the staff ended up with it too, we managed to work out it was brought on to the ward by a visitor.

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