Norovirus is a highly contagious virus that causes flu-like symptoms of nausea, vomiting, diarrhea and abdominal cramping.

(Image from CDC website)

The dreaded “stomach flu” that hits particularly hard in winter is not a flu at all. It is norovirus, a highly contagious virus that causes symptoms of diarrhea, vomiting and stomach cramping. According to the Centers for Disease Control and Prevention (CDC), the illness often begins suddenly and lasts for one to two days with no long-term adverse health effects. True “flu” is a respiratory disease caused by the influenza viruses; sometimes the “true flu” can also cause gastrointestinal symptoms similar to norovirus. Getting an annual flu vaccine can help prevent flu; unfortunately, there is no vaccine for the norovirus and antibiotics, useful only for bacterial infections, do not help.

Norovirus is extremely common and has gained notoriety as a vacation cruise spoiler and an unwelcome visitor in child and adult care facilities, schools, restaurants, hospitals and dormitories. Norovirus particles are extremely small and are discharged by the billions in the stool or vomit of infected people, according to CDC. Yet, fewer than 100 virus particles are highly likely to make a person sick. The virus spreads through direct contact with an infected person or when an individual touches a contaminated surface and then touches their mouth or even their nose.

A 2011 study found norovirus is the leading cause of foodborne illness in the US, responsible for 5.5 million cases each year. In many cases, sick food handlers are responsible for these outbreaks. Eating foods contaminated with norovirus is a leading cause of hospitalizations.

Recipe for an Outbreak

Close quarters and a breakdown in sanitation is the simple recipe for a norovirus outbreak. Attention to surface disinfection is critical to controlling the spread of norovirus. Proper hand washing is another “must” as the virus can be transmitted easily via contaminated hands. It is important to know that a norovirus carrier can infect others for at least three days after recovery.

These steps, from CDC, can help reduce your risk of contracting norovirus:

• Wash your hands carefully with soap and water, especially after using the toilet and changing diapers and always before eating or preparing food.
• Carefully wash fruits and vegetables, and cook oysters and other shellfish thoroughly before eating them.
• If infected with norovirus, do not prepare food for others while experiencing symptoms and for three days after recovery (see Norovirus: Food Handlers).
• After throwing up or having diarrhea, immediately clean and disinfect contaminated surfaces by using a solution made with chlorine bleach and water:

Disinfecting against Norovirus with Chlorine Bleach

• Immediately remove and wash clothing or linens that may be contaminated with vomit or stool. Handle soiled items carefully—without agitating them—to avoid spreading the virus. If available, wear rubber or disposable gloves while handling soiled clothing or linens and wash hands after handling. Soiled items should be washed with detergent at the maximum available cycle length and then machine dried.

Joan Rose, PhD, is the Homer Nowlin Chair in Water Research at Michigan State University and a member of the Water Quality and Health Council.

¹http://emergency.cdc.gov/disasters/disease/pdf/diarrhea-evac.pdf
²http://health.utah.gov/epi/diseases/norovirus/Guidelines_for_Environmental_Cleaning_125846_7.pdf

Eight people who walked by just such a water wall in a Wisconsin hospital lobby in 2010 are believed to have contracted the disease by inhaling the mist from the streaming water. Legionella can affect people whose immunity may be depressed due to an underlying illness, or due to a medication regimen; smokers may also be vulnerable. One of the patients affected in Wisconsin was a delivery person who had been a smoker and had made two deliveries to the hospital. Others had visited the pharmacy adjacent to the water wall to obtain medications.

The outbreak is an unintended consequence of well-intentioned efforts to create a soothing and welcoming healthcare environment. For now, we know those decorative water walls are a bad idea unless sanitary conditions are meticulously maintained.

Legionella under the Rocks

A new study published in the journal Infection Control and Hospital Epidemiology notes that although the decorative water wall underwent routine cleaning and maintenance, the bacterium Legionella pneumophila found a niche at the base of the water wall. The bacterial breeding ground was identified as a bed of sponge-like foam installed under decorative rocks to prevent water splashing.

In a January 11, 2012 interview with National Public Radio, the study’s lead author, Dr. Thomas Haupt, a respiratory disease epidemiologist for the Wisconsin Division of Public Health, was asked whether chlorine in the water would have prevented the outbreak. Haupt replied that chlorine in the atrium of a hospital “would have caused a lot of smell.” Haupt also described what seems to have been a “perfect storm” for Legionella contamination: Lights installed under the foam material in the trough and the trough’s close proximity to a fireplace helped provide a warm environment highly conducive to Legionella growth.

Haupt’s study notes the Wisconsin outbreak is the second example of Legionnaires disease associated with a decorative fountain in a healthcare setting. (The first example occurred in 2007.) The Wisconsin Department of Public Health has developed interim guidelines advising healthcare facilities with similar water walls or fountains to “establish strict maintenance procedures and conduct periodic bacteriologic monitoring to assess levels of Legionella.”

Fortunately, all eight Wisconsin patients recovered from Legionnaire’s disease and the hospital water trough has been converted into a planter. Going forward, let’s either use the tools we have to keep Legionella in check in decorative water walls, or keep them dry.

Jerod M. Loeb, Ph.D. is Executive Vice President, Healthcare Quality Evaluation at The Joint Commission in Oakbrook Terrace, Illinois.

Chlorinated wash water used during cantaloupe processing can help reduce the risk of foodborne illness to consumers.

Last summer a family-owned farm in Colorado became the focal point of the largest foodborne illness outbreak in the US in 25 years. Tragically, cantaloupe contaminated with Listeria bacteria sickened 146 people in 28 states, killed 30 and caused one pregnant woman to miscarry, according to the Centers for Disease Control and Prevention (CDC). The US Food and Drug Administration (FDA) concluded the outbreak likely could have been prevented if Jensen Farms had maintained its facilities in accordance with existing voluntary FDA guidance. FDA has no enforceable regulations on cantaloupe processing, and farm facility auditors conducting inspections do not consider FDA voluntary guidance when scoring facilities. Scores can be lowered only if practices are inconsistent with FDA regulations. That could, and should, change.

Recently the House Committee on Energy and Commerce released a report outlining multiple operational problems contributing to the cantaloupe contamination. The investigation report notes FDA officials were “highly critical of the processing methods used at Jensen Farms,” and emphasized two probable causes of the contamination: a change in processing equipment and a decision not to chlorinate cantaloupe wash water. In 2011, after 20 years of cantaloupe production with no reported food safety problems, these decisions helped spell disaster at Jensen Farms.

Deadly Decisions

Eric and Ryan Jensen inherited Jensen Farms upon the recent death of their father. Ironically, the House Committee report states that during an August, 2010 safety audit, one of the Jensen brothers expressed interest in improving their processes. The auditor suggested the Jensens consider replacing the hydrocooler, which sprays water on cantaloupes to cool the harvested fruit. The auditor considered the hydrocooler a “hotspot” due to its recirculating water. Believing they were strengthening their food safety efforts, the Jensens purchased and retrofitted equipment previously used to process potatoes. The House Committee cited FDA’s characterization of this equipment as “inappropriate” and “difficult to clean.” Listeria was later detected on the felt roller brushes of this processing equipment.

Up until 2011, Jensen Farms followed FDA voluntary guidance with regard to using antimicrobial solutions, such as chlorine, in cantaloupe wash water. Disinfectants are added routinely to produce wash water to help destroy pathogens like Listeria. This measure is particularly important for cantaloupe with its convoluted outer surface that can harbor moisture and bacteria. According to the House Committee report, the Jensen brothers discontinued this precaution in 2011, a fact that was noted on the front page of that year’s audit report. No reason was given for this process change, and Jensen Farms received a glowing audit score because scores are not based on adherence to FDA voluntary guidelines.

Going Forward

According to the House Committee report, the cantaloupe distributor for Jensen Farms, Frontera Produce, is working with NSF International, a standard-setting organization, and other firms to improve the current audit system. Additionally, the new Food Safety Modernization Act requires FDA to establish an accreditation system and model auditing standards. These measures should be taken without delay to prevent a repeat of the preventable tragedy that started last summer at Jensen Farms. We’ll be watching…

Chris Wiant, M.P.H., Ph.D., is president and CEO of the Caring for Colorado Foundation. He is also chair of the Water Quality & Health Council.

“Clostridium difficile,” is a spore-forming bacterium that can live in the lower gastrointestinal tract of some humans and is shed in feces. Persons hosting C. diff may have no symptoms and be unaware that they are contagious. Other persons will become infected under specific circumstances. A C. diff infection may produce watery diarrhea, fever, loss of appetite, nausea or abdominal pain and tenderness. According to the Centers for Disease Control and Prevention (CDC), patients who are at increased risk for infection include those who:

• are taking antibiotics
• have had gastrointestinal procedures
• have had a prolonged stay in a healthcare institution
• have a serious underlying illness
• are of an advanced age.

Any surface or medical device that becomes contaminated with feces may serve as a reservoir for C. diff spores including toilets, bathtubs, or electronic rectal thermometers. In the healthcare setting, the spores are thought to be transferred to patients mainly via the hands of healthcare personnel who have touched a contaminated surface or item. Dr. Robert Orenstein, of the Mayo Clinic Arizona, calls C. diff infection “a significant threat to our public health”. His goal is to reduce the risk of C. diff infection by reducing environmental contamination and he has a strategy that just might work.

A Tale of Two Hospital Units

In a 2011 publication Dr. Orenstein describes a study in which two high-risk hospital units were targeted for daily cleaning of high touch surfaces with germicidal bleach wipes (in addition to terminal cleaning after a patient is dismissed). The researcher chose bleach wipes because a 10 percent solution of hypochlorite bleach destroys the spore form of C. diff. The study showed that over a six-month period the units experienced a 92 percent decline in hospital-acquired C. diff infection! This result was achieved without any other interventions, such as increased attention to hand hygiene. Further, Dr. Orenstein reports, the results were sustained for over one year with only two infections in 12 months. Meanwhile, infection rates in other units in the study hospital remain high.

To implement these effective risk reduction measures, environmental service staff were trained in proper use of bleach wipes. Housekeepers worried about the irritating effects of bleach were given plain surgical masks and ventilation was ensured. As the study progressed, patient and employee tolerance of the wipes was monitored and found to be satisfactory. Orenstein notes no reports of equipment damage; keyboard covers, however, “often had a haze after the product dried on them.” A wet cloth applied to the covers removed the haze, which is a salt residue.

Dr. Orenstein’s study provides importance evidence to help destroy C. diff—a significant hospital public enemy found on surfaces in healthcare settings. Healthcare officials should consider adopting a bleach disinfection strategy for daily and terminal cleaning, a step that could help decrease the risk of serious infection.

Barbara M. Soule, R.N. MPA, CIC, is an Infection Preventionist and a member of the Water Quality & Health Council.

Neti pot¹ use is being blamed for the deaths of two Louisiana residents who developed a rare fatal brain infection after using the device to clear their sinuses (The Advocate article). The infections are believed to have been caused by the water-dwelling parasite, Naegleria fowleri. According to the Centers for Disease Control and Prevention (CDC), Naegleria may be present in warm lakes and rivers and geothermal waters, such as hot springs and natural spas. It can also live in inadequately chlorinated swimming pool water. If the parasite is inadvertently inhaled and migrates from the human nose to the brain, it can cause “amoebic meningoencephalitis” and almost certain death. People cannot be infected with this parasite by drinking water.

Neti pot users circulate warm saline water through the nostrils; if water is contaminated with Naegleria, which appears to have been the case for two unfortunate people in Louisiana, the result can spell tragedy. In the case last June of one victim, a young man in his 20s, the infection was traced to the man’s home water system even though the parasite was not found in city water samples. More recently a 51-year old Baton Rouge woman succumbed to the brain infection caused by Naegleria. These cases are troubling, and we anticipate more information will be forthcoming as a result of further investigation.

Naegleria: Rare but Deadly

The Louisiana Department of Health cites statistics that demonstrate how rare Naegleria infections are: Between 2001 and 2010, 32 infections were reported in the US, most in southern states and mostly during summer, particularly during extended heat waves. Of the 32, 30 were caused by contaminated recreational water and two resulted from contact with a geothermal water supply. Updated statistics will include the recent deaths associated with neti pots.

What You Should Know about Naegleria

The greatest risk to humans of Naegleria is its inadvertent inhalation in contaminated water, usually through two routes:

Contact with recreational waters:

• When swimming in freshwater lakes and rivers, particularly in the South, nose clips can be worn to prevent inhaling infected water. Caution should also be exercised around geothermal waters. The CDC recommends avoiding water-related activities in warm freshwater during periods of high water temperature and low water levels. It is best not to dig in or stir up sediment while taking part in water-related activities in shallow, warm, freshwater areas.
• Swimming pools must be adequately disinfected to destroy Naegleria and other waterborne pathogens. The CDC and the Water Quality & Health Council recommend swimmers use pool test kits to check pH and free chlorine levels of chlorinated pools before swimming. If readings are out of the appropriate range (pH between 7.2 and 7.8; free chlorine level between 1 and 3 parts per million), a pool manager should be notified. If pool chemistry is not properly adjusted, the local public health department should be contacted.

Net pot use:

• When using a neti pot, follow directions for preparing saline water solutions. A December 6 press release issued by the Louisiana Department of Health and a CDC online resource urge neti pot users to use distilled, sterile or previously boiled water (least expensive option) to make up the irrigation solution.
• Clean and disinfect neti pots after use. After washing with soap and water, rinse with a solution of ½ tablespoon of chlorine bleach added to ½ gallon of water and allow to air dry.

News of rare Naegleria infections is not cause for alarm, just reason to be well-informed. We pledge to follow this issue and keep you updated.

Barbara M. Soule, R.N. MPA, CIC, is an Infection Preventionist and a member of the Water Quality & Health Council.

For more information on disinfecting surfaces, please go to www.disinfect-for-health.org.

For more information on disinfecting pools, please go to www.healthypools.org

It’s easy to appreciate the need to disinfect germs on surfaces, but have you ever wondered how germs exist on surfaces in the first place? Enter the biofilm. In recent years, scientists have increased their understanding of these dense colonies of bacteria that produce an extracellular material that binds a community of different microorganisms together and anchors them to both living and inanimate surfaces.

Biofilms form in virtually every imaginable environment on Earth; they can be harmful or beneficial to humans. In fact, the human body has biofilms in the mouth and intestinal track that can protect our health or harm it. Dental plaque is a common example of a biofilm that forms on tooth surfaces. The products of metabolism of the bacteria in plaque are responsible for tooth decay and gum disease. Biofilms can harbor human infectious agents in the environment, but they also can promote remediation of contaminated groundwater and soils. They assist in metals mining and they play an important natural role recycling matter on Earth. Hence, understanding “the good and the bad” characteristics of biofilms under diverse conditions is of great interest.

Power in Numbers

A 1996 review article in the journal Science reported on an important shift in understanding in microbiology: that bacteria, instead of floating freely, commonly aggregate as clumps surrounded by slime and stuck to surfaces. If not disrupted, these biofilms thrive under the right conditions.

Before the latter third of the 20th century, microbiologists focused on free-floating bacteria grown in laboratory cultures; they now understand that 99 percent of all microbial activity in an open ecosystem is in biofilms. In these microbial communities bacteria are bound together in a sticky web of polysaccharide fibers secreted by bacteria that connect and protect cells. Water and nutrients circulate and waste products are removed through open channels that operate similarly to a living being’s circulatory system. The biofilm operates more like a multicellular organism than a collection of organisms, increasing the odds of survival among “community” members. Bacterial colonies even communicate among themselves by a primitive system of chemical signals.

Any bacterium can form a biofilm once it finds a place to stick. According to the Science review article, “Slamming up against a hard surface sets off a genetic cascade that turns on specific genes to make polysaccharides and other substances needed to establish the biofilm colony. Even bacteria that have long floated in test tubes will stick if given the chance.”

Where You Don’t Want Biofilms

Biofilm formation is a critical issue for almost all surfaces in health care and food preparation settings. Biofilms can grow on medical implants, creating the opportunity for infections to flourish and even facilitate human deaths, for these tough microbial communities can resist antibiotics and evade the immune system. Biofilms on food-contact surfaces in restaurant, institutional and home kitchens afford foodborne pathogens such as as E. coli and Salmonella the opportunity to survive. Thus, cleaning and disinfecting key surfaces to prevent or remove biofilms helps to prevent the spread of institutional infections and foodborne illness.

Affecting Water Quality

Biofilms eventually develop on the interiors of most water distribution systems. Known as “biofouling,” the microbial growth represents a contamination that may present a threat to public health. As noted above, biofilms can harbor human pathogens that are difficult to kill. Chlorinating the water supply is the usual method employed to control biofilm growth. Superchlorination, in which chlorine levels are raised temporarily, may be combined with mechanical flushing and scouring, and used when biofilm causes water quality problems.

Although water treatment operators fight a constant battle against biofilms, these bacterial communities can also be used to improve water quality. Sand filters, for example, use biofilms beneficially. As raw water trickles through sand grains, bacteria that feed on organic material in the water attach to the grains, setting up biofilm colonies. The constant stream of nutrients “feeds” the biofilms, clearing the water of the undesired organic matter. Biofilm-treated water requires less disinfectant and forms fewer disinfection byproducts.

Scientists will continue to probe the good and the bad of biofilms: how these micro communities live, interact and die, in order to promote beneficial uses and control the harmful impacts. Stay tuned for the next exciting, exacerbating and enlightening developments on biofilms.

___________________
¹Biofilms may include protozoa, which are single-celled microorganisms that are major consumers of bacteria.

Joan Rose, PhD, is the Homer Nowlin Chair in Water Research at Michigan State University and a member of the Water Quality and Health Council.

For more information on disinfecting surfaces, please go to www.disinfect-for-health.org.

Last year at this time the Water Quality & Health Council conducted a survey that found Americans are more concerned about being around an annoying relative during the holidays than they are about getting sick from improperly prepared holiday food. I can’t help you with cranky Uncle Joe, but I do have some simple tips on keeping the holiday meal safe for him and everyone else around the table.

Food Safety: 5 Tips for a Healthy Thanksgiving

1. Clean – Wash all food contact surfaces with hot, soapy water followed by disinfecting with 1/2 tablespoon chlorine bleach in 1/2 gallon of water. Do this before and after working with raw foods, especially meat and poultry.
2. Wash Hands – Thoroughly wash hands with warm, soapy water before and after all food preparation and after handling turkey.
3. Compartmentalize – Keep fresh fruits and vegetables separate from raw meat, poultry and seafood.
4. Cook – to kill any bacteria that might be present, thoroughly cook meat, poultry and eggs to the appropriate temperature.
5. Chill – Refrigerate leftover perishables at 40 degrees within two hours after cooking or serving.

Bonus Tip: Are You Transporting a Dish? The food editor of Epicurious.com offers tips on traveling with food this Thanksgiving. Among the “safest bets for road travel” are cranberry sauce (the high acid content of cranberries is unfriendly to bacteria), rolls and pies (excluding custard and pumpkin pies). For road trips longer than one hour, pack all food items in a cooler with ice. Dishes such as casseroles that are meant to be served hot should be prepared the day before, refrigerated and then transported in ice.

Whether you are hosting Thanksgiving or contributing a specialty dish this year, the members of the Water Quality & Health Council want to wish you a Happy and Healthy Thanksgiving. Oh, and regarding Uncle Joe, maybe I do have a tip: Why not spend a few minutes with him and see if there’s something positive hiding under his gruff exterior? Trying to find out what Uncle Joe enjoys is always a good way to start! You may be pleasantly surprised.

For more information on food safety, please visit www.disinfect-for-health.org.

Linda Golodner is President Emeritus of the National Consumers League and Vice Chair of the Water Quality & Health Council.

The New York Times reported (November 10) the New York City Health Department was monitoring conditions in Manhattan’s Zuccotti Park, the center of the Occupy Wall Street movement, a site from which protestors were recently evicted. The Times reported Dr. Philip M. Tierno, Jr. of the New York University Langone Medical Center believed conditions in the park could leave park-dwellers susceptible to respiratory viruses, norovirus and tuberculosis. The article concluded with a quote from one of the protesters, who boasted, “We’re the biggest tourist attraction in New York, and we shake everyone’s hands.” This statement raises a red flag among public health officials and epidemiologists.

What Protesters Should Know and Do about Disease Prevention

Wash Hands: Proper hand-washing is one of the best ways to prevent the spread of infection. This very simple activity, says CDC, has the potential to save more lives than any single vaccine or medical intervention. The Times article notes that hand sanitizer had appeared in Zuccotti Park. Hand sanitizer is acceptable if soap and water are not available, but according to CDC, hand sanitizers are not effective when hands are visibly dirty.

Get a Seasonal Flu Vaccination: CDC states that flu is a serious contagious disease that can lead to hospitalization and even death. A yearly flu vaccine is recommended as the first and most important step in protecting against flu virus. Whereas some protesters in Zuccotti Park welcomed free flu shots when a local health center offered them, others refused vaccinations, according to The Times, citing a government conspiracy. The 2011-2012 flu vaccine will protect against three influenza viruses, including influenza A (H1N1) virus.

Avoid Close Contact with Sick People (and take precautions to avoid contact when you are sick): It is very important to cover the nose and mouth with a tissue when coughing or sneezing, and then throw the tissue in the trash. Avoid touching the eyes, nose and mouth.

Close living quarters contributes to the spread of respiratory infections. One such infection, “Zuccotti Lung,” has appeared among New York protesters. In a news video, a doctor compares crowded park quarters to those of a cruise ship, raising the risk of the spread of intestinal and respiratory viruses. It is important to limit contact with those who are sick.

Proper Sanitation: Even though conditions are better than exist in encampments set up for refugees from both human-caused and natural disasters around the world, basic sanitation (e.g., safe water supplies, sanitary disposal of human waste, readily available facilities for washing, food sanitation and disinfection of food preparation surfaces) are critical for proper hygiene in city park camps. Doctors warn conditions in parks could leave Occupiers susceptible, not only to respiratory viruses, but also to norovirus, the winter “stomach bug” that can cause vomiting and diarrhea. In an outbreak situation, these symptoms could quickly overwhelm limited bathroom facilities in encampments.

In conclusion, while Occupiers exercise their right to protest, they must also make public health a priority.

Fred Reiff, P.E., is a retired official of the Pan American Health Organization, and lives in the Reno, Nevada area.

The Food and Drug Administration (FDA) recently announced a new nationwide, year-long effort to collect and analyze samples of pet products for Salmonella bacteria. FDA wants to know how prevalent Salmonella is in dry pet food, treats and supplements; the agency aims to remove contaminated products from interstate commerce.

There are several documented cases of human disease outbreaks resulting from contact with Salmonella-contaminated pet products. Between January 2006 and December 2007, for example, seventy human cases of salmonellosis were linked to Salmonella- contaminated dry dog food manufactured in the United States. Children (who love to interact with pets and may inadvertently contact feeding bowls), the elderly and individuals with compromised immune systems are among the most vulnerable.

Here are some tips to prevent contamination from pet products:

Purchase and Storage

• Purchase products in good condition (with no damage to packaging).
• Store dry products in a cool, dry place (under 80 °F).

Pet Boundaries

• Keep pets away from household food storage and preparation areas.
• Keep pets away from garbage and household trash.
• Supervise young children around pets and keep them away from pet feeding areas.

Preparation

• Wash your hands for 20 seconds with hot water and soap before and after handling pet products.
• Use a clean, dedicated scoop or spoon to transfer pet food to feeding bowl; do not use your pet’s feeding bowl as a scooping utensil.
• Wash pet food bowls thoroughly with hot, soapy water to clean.
• Disinfect feeding bowls periodically (see downloadable poster):
• Wash with hot soapy water to clean; thoroughly rinse off soap
• Sanitize with chlorine bleach solution (1/4 cup bleach + 1 gallon water); leave wet for 10 minutes
• Rinse and dry.

We will be interested to learn the results of FDA’s examination of pet products for bacterial contamination. Meanwhile, pet owners, heed precautions to keep your family healthy.

Linda Golodner is President Emeritus of the National Consumers League and Vice Chair of the Water Quality & Health Council