NOROVIRUS

CONTROL IN
HOTELS
HOTELIER CONDENSED VERSION

Prepared by: Dr E. Delgado and

Prof. Rodney Cartwright , January 2010
1. Introduction
Noroviruses are a group of viruses that are the most common cause of gastroenteritis (stomach
bugs) in England and Wales. In the past, noroviruses have also been called ‘winter vomiting
viruses’, ‘small round structured viruses’ or ‘Norwalk-like viruses’.

Outbreaks of vomiting and diarrhoea due to the Norovirus are being described from all countries in
hotels, holiday camps, cruise ships, hospitals and schools. The infection spreads rapidly from
person to person mainly through the air, although environmental contamination is very important.

Although most affected persons will be ill for a day or two, the infection is very unpleasant and the
large number of persons who can suffer means that hoteliers must be aware of the early signs of
an outbreak and take appropriate action.

It is not possible to prevent infections entering a hotel but the situation can be managed by
implementing pre-planned procedures. Your hotel plan should be drawn up with the co-operation
of the local public health department. Hoteliers may also wish to consult an external health
advisor.

This guidance provides basic information and advice on how to control outbreaks, and reflects the
knowledge at present, but advances continue to be made. These notes are for guidance only in
helping hoteliers develop their own plans.

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2. Norovirus fact sheet

What are the signs and symptoms of infection?

Classically Norovirus infection has the following characteristics:

 The most common symptoms are nausea, vomiting and diarrhoea. Symptoms
often start with the sudden onset of nausea followed by projectile vomiting and watery
diarrhoea. However, not all of those infected will experience all of the symptoms.
 Duration of illness 12–60 hours
 Incubation period of 12–48 hours
 Staff and guests affected

There is evidence that new strains of the causative virus are emerging and while with some
strains vomiting is the predominant symptom, with others it is mainly diarrhoea with vomiting
quite mild. It can affect adults and children in different manner.

Other symptoms include nausea, abdominal cramps, headache, muscle aches, chills and
fever. Symptoms last between one and three days and recovery is usually rapid thereafter.
All age groups are affected. The severity of the vomiting may result in dehydration especially in
the elderly and very young.

How does the virus enter the hotel?

 A guest who may be unaware that they have the virus when they check in. If a guest is
ill with vomiting or diarrhoea on arrival they should be restricted to a safe area – see
below- until you have consulted the hotel doctor.
 A staff member who may be unaware that they have the virus when they come to work.
All ill staff members should report by telephone before coming to the hotel and should
be excluded until recovered.
 Another person who is visiting the hotel who may be unaware that they have the virus.
 Contaminated food – this is rare, but the type of food that is high risk is shellfish,
especially if harvested in an area where there is a Norovirus outbreak in the local
population.

How does the virus spread?

 The virus is easily transmitted from one person to another. It can be transmitted by
contact with an infected person. The infectious dose is very low, swallowing as few
as 10 - 100 virus particles may be enough to cause illness.
 When an infected person vomits or has diarrhoea, an unseen cloud (aerosol) of virus
enters the air and can be breathed in by others in the area.
 Some of the virus will also settle on surfaces and furnishings leading to environmental
contamination. The virus can subsequently be picked up by a guest or staff member
and infect them.
 If someone is ill in the dining room, kitchen or similar food area, any uncovered food
can become contaminated by the virus cloud. If this food is eaten the virus will spread.

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How is the diagnosis made?

 Mainly from the clinical symptoms. Norovirus infection should always be suspected
if someone has unexpected vomiting. Such vomiting may come on so suddenly that
they have no time to go to their room or a toilet area. House keeping staff must report
any requests for new linen as a result of a vomiting or diarrhoea incident in a room. If
further cases occur in other guests within a few days the diagnosis of Norovirus is
heightened.

 Unexplained diarrhoea may be due to Norovirus infection but may be confused with
food poisoning. Norovirus diarrhoea usually does not last as long as food poisoning
diarrhoea which can persist for many days. If a guest or staff member has acute
diarrhoea that clears in 24 –30 hours do not assume that there is no problem, it may be
start of a Norovirus outbreak. Be extra alert.

 Laboratory Tests. These are becoming more readily available but specimens of
faeces or vomit need to be collected in the first day or two of the illness. Laboratories
with the necessary expertise and equipment to do the test will be able to advise on how
long it takes for a result to become available.

Laboratory tests cautions

 Even if tests are negative persons may still be suffering from Norovirus infection.
 Preventative actions should be taken if the clinical signs suggest Norovirus.
 Waiting for laboratory results will delay effective control.

Who is at risk of getting norovirus ?

 There is no one specific group who are at risk of contracting norovirus – it affects
people of all ages. The very young and elderly should take extra care if infected, as
dehydration is more common in these age groups.
 Outbreaks of norovirus are reported frequently anywhere that large numbers of people
congregate for periods of several days. This provides an ideal environment for the
spread of the disease. Hotels may be particularly affected by outbreaks of norovirus.

What is an outbreak?
 In a hotel setting it is difficult to establish a clear definition of what an outbreak is,
definitions can vary. It will depend on several factors such as the size of the hotel, the
number of people staying there, whether the initial cases, in guests and/or staff, were
within one family or not, the number of cases, the period of time, etc. However, as a
general rule, if there are 5 or more cases within a period of 24 hours, displaying the
above clinical symptoms, then this should be regarded as an outbreak. In this situation
the senior management of the hotel should be informed of the outbreak. This should be
escalated and discussed with their tour operator’s health and safety departments and
advice should be sought from their internal or external health and hygiene advisors.

Outbreak patterns
The outbreaks in hotels that have been studied show similar patterns if there are no prompt
effective control measures.
 The number of cases rises sharply at the onset, diminishing over the next few days.

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  Further new cases usually occur shortly after the arrival of new guests. Within a day or
two of new guests arriving new cases of the illness are reported.
 The number of new cases slowly falls each week over a period of five to seven weeks.

3. Actions to control Norovirus infection

Key General Measures

Be prepared ! … failing to prepare is preparing to fail !

 ACTION PLAN: every hotel should have an action plan that is appropriate to that hotel
and easy to understand. It should include what to do, where, when, how, by whom. Also
allocation of responsibilities should be clearly stated.
 TRAINING: ensure that all staff have been trained on their response to suspected or
confirmed Norovirus or Influenza infection.
 EQUIPMENT: have the necessary cleaning equipment available at all times.
 EARLY RECOGNITION of the problem will allow to act promptly and will reduce the
opportunities of the virus to spread.

Recognition

 All staff must be aware of the signs of probable Norovirus infections.

 Keep records of reported cases, including basic information like name, booking
reference, child/adult, room number, date of arrival, date of onset of illness, symptoms
and whether seen by a doctor. This provides a basic tool for the early identification of
an outbreak, as well as the basis for a simple, but useful, retrospective epidemiological
analysis of the cases.
 Act promptly - delay only helps the virus to spread.
 Food handlers should never be involved in cleaning or decontamination following
episodes of vomiting.
 Any vomiting incident must be dealt with immediately: put the 3 Cs – see below – into
action. One case equals action - do not wait for the outbreak.
 Isolate actual and suspect cases – guests or staff.
 Be prepared to close part or the entire hotel sooner rather than later.
 Exclude ill staff. They should not return to work until 48 hours after symptoms
disappeared. They may need some encouragement if they receive no pay when off ill.

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3.1. The Vomit Action Plan – the 3 Cs

Keep it simple

First: Cover

 All vomit must be covered as soon as possible. Place towels, table cloth, news paper
etc over the vomit before calling for help. This will reduce further air contamination.

Second: Clear

 Move all guests and non essential staff away from the area. Ideally clear the room of all
persons.
 Close the door and open the windows for at least one hour in order to thoroughly
ventilate the room.

Third: Clean

 Summon the special cleaning team to clean up the vomit and clean the whole room or
area.
 An example of a cleaning procedure:

Materials required:
 Disposable vinyl or latex gloves
 Disposable apron
 Absorbent paper towels
 Disposable cloth
 Plastic waste bag
 Hypochlorite solution 1000ppm
 Warm water and detergent

Put on disposable gloves and apron.

Gather the spillage together, using absorbent paper towels, and place in plastic waste bag.
Wash area with warm water and detergent using a disposable cloth.
Disinfect area using hypochlorite solution; allow solution to remain in contact with surface
for 10 minutes if practicable.
Remove gloves and apron and place in plastic waste bag.
Wash hands thoroughly with soap and running water, ensuring that all surfaces are
covered. Hand wipes are NOT a suitable substitute.
There is evidence that when a person vomits, the virus particles are aerosolised over an
area of approximately 8 m. Therefore the whole of the room in which this occurs must be
thoroughly cleaned and all surfaces wiped with a hypochlorite solution.

3.2. In an outbreak

 Do not panic. Life may become difficult but accept the situation, follow a prearranged
plan and be prepared to take drastic action early. This is likely to cost less and protect
the hotel for future business.

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 Keep the staff informed and give them clear instructions. You need their help.
 Increased surveillance. All staff should be extra alert at recognising and reporting any
new cases. Guests may be ill in their rooms and tell no-one but the chamber maid may
be aware of illness.

3.2.1. Cleaning

 Norovirus is extremely infectious – this means that only a few virus particles are
necessary to cause illness. The virus is also extremely hardy, and can live in the
environment for 2-3 weeks, so thorough and appropriate cleaning is essential.
 All cleaning staff should have training in cleaning procedures that are documented.
 Equipment used in the control of an outbreak should be identified and kept solely for
this purpose. Staff should know where it is stored and how to access it at all times.
 It is advisable that specialised “hit-squads” should be formed and given extra training in
the cleaning of affected rooms and public areas, and in the cleaning up of vomit
spillages. Other cleaning staff should only clean the rooms of unaffected guests.
 Public areas must be cleaned frequently, and shared toilet facilities should be cleaned
hourly for the duration of the outbreak.
 Place hand washing notices in all toilets.

Cleaning the rooms of affected guests

 Whilst guests are ill, their rooms should be given extra attention, particularly the
bathrooms. In addition to the usual cleaning, all hard surfaces that are handled
frequently such as taps, cistern handles, door handles, telephones, bedside tables
etc should be disinfected with a solution of hypochlorite 1000 ppm using disposable
cloths. Start by disinfecting hard surfaces in the bedroom before proceeding to the
bathroom, ending with the toilet itself. Then dispose of cloth immediately into plastic
waste bag. Use a fresh cloth for each room. Using colour coded cloths will help in
preventing cross contamination.
 If mops are used the head must either be disposable or capable of being laundered.
Re-usable ones should be laundered daily.

When affected guests depart

 Clean their rooms first so that they are left vacant for as long as possible.
 Open all windows but ensure that the door remains closed.
 Remove all bed linen. Soluble red alginate bags should be available for soiled linen
to prevent further handling and sorting by laundry staff.
 All bedding should be laundered by a process in which the temperature in the load
is maintained at 65° C for not less than 10 minutes, or preferably at 71°C for not
less than three minutes.
 Thoroughly air mattresses.
 If weather permits, place soft furnishings in sunlight for several hours, as ultraviolet
light is known to inactivate viruses.
 Consider steam cleaning of carpets and soft furnishings. There is evidence that the
virus can survive temperatures of up to 60ºC, so steam cleaning will only kill the
virus if water at temperatures above this has contact with the carpet/soft furnishing.
However, vacuuming will re-circulate the virus so is to be discouraged, unless a wet
system is utilised.

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3.2.2. Food

 Consider serving only hot plated food and temporarily stopping buffet service.
 If buffet style is provided consideration should be given to providing staff to serve the
customers at the buffet.
 Consider offering customers sterile wipes to clean their hands as they enter the dining
room. This will not kill the virus but reminds the guests that they must also take
precautions. Hand washing with soap and water is the ideal.
 If anyone vomits in an area with uncovered food, including food display areas, there is a
risk that uncovered food and surrounding surfaces may have been contaminated by the
virus. The food must be discarded, all surfaces thoroughly cleaned with a hypochlorite
solution (1000 ppm chlorine) and the area aired for at least one hour by opening doors
and windows. There should be mesh over window openings to prevent the entry of
flies.

3.2.3. Sickness Log

Every hotel and/or representative should maintain a simple sickness log in which all reports
of sickness or accidents by guests are recorded. Basic data should include name, booking
reference, child/adult, room number, date of arrival, date of onset of illness, symptoms and
whether seen by a doctor. Every tour operator should ensure that such a log is maintained
and is available for inspection. See the templates section of the code for an example
sickness log.

3.2.4. Staff Health - Hotel and Tour Operator Staff

 Ensure that the staff health policy requires that staff who are feeling unwell with
vomiting, nausea and/or diarrhoea do not enter the hotel but report in sick. If there is
any doubt that they could be suffering from gastro-enteritis they should be excluded
from work. This applies to all staff including administrative and maintenance. Enquire
about similar illness in the families and household contacts of staff. Close relatives or
household contacts who may have become exposed to the virus should not work in a
hotel or food establishment until they have remained well for 48 hours after being in
contact with a sick person. Contacts working in a hospital or residential home should
notify their supervisor before attending for work.
 A staff sickness reporting log should be kept, recording similar information to the guest
sickness log.
 If staff is affected they should not return to work until 48 hours has passed since the last
symptom.
 If ill staff live in the hotel they should remain confined to their quarters and should not
share a room with other staff who are still working until 48 hours after the last symptom.

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3.2.5. Water Supplies

 Ensure that the water supply to the hotel meets the minimum standard as laid down in
the WHO Drinking Water Guidelines or the current EC Drinking Water Directive.
 If emergency supplies are needed for example, in times of water shortage it should
come from sources approved by the public health authorities. Certificates of
cleanliness and disinfection should be available. If there is any doubt as to the quality
of the water, guests and staff should be instructed not to drink it or clean their teeth in it.
In hotels, chlorination should be considered. Advice can be sought from a specialist
 Suspect water must not be used to make ice.

3.2.6. Waste Water

 Wastewater including effluent from hotel sewage treatment plants should not be used to
irrigate the grounds and gardens of the hotel.
 The rooms of those guests who become ill should be recorded. If there is a clustering
of rooms the possibility of contaminated water feeding those rooms should be
considered. The pipe work should be checked to ensure that accidental cross linkage
of waste and water pipes has not occurred.

3.2.7. Recreational Water

 Swimming pool water should be adequately treated and a full record of the treatment
maintained.
 The quality of the water at any beaches should be known and the proximity of any
sewage outfalls. If there is a possibility of untreated or partially treated sewage from the
municipality or hotels contaminating bathing water advice should be given that guests
should bathe in a pool or at a known safe beach.
 Guests and in particular children should be advised not to swim or play in any
freshwater streams or rivers unless it is known that no sewage enters the water
upstream.

3.2.8. Children’s Clubs

 If children attending the club are affected the club should be closed until at least 72
hours after any affected child has recovered.
 Particular attention should be taken in the cleaning of children’s play clubs.
Uncontrolled vomiting and diarrhoea is more likely in young children and the play area
and toys may become heavily contaminated. All the area and contents should be
cleaned with disinfectant daily, Toys in children’s clubs should be capable of
withstanding disinfection and this should be carried out on a regular basis.

3.2.9. About the utilization of sanitizers for hand disinfection

 Sanitizers must not be relied upon. Some may well be effective if used properly but
should only be used as an adjunct to proper hand washing.
 A quick squirt of a hand sanitizer can lead to a false sense of security.

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3.2.10. Hotel Closure

 If an outbreak is not controlled within a few days consideration should be given to

closing the hotel for at least 4 days, ensuring that any guests in the hotel return home
and not go to other hotels as this may spread the infection. At the same time strict
exclusion should be in place for any staff, visitors or workmen with symptoms. They
should be excluded for at least 48 hours after symptoms have ceased.
 During closure, a deep clean of the hotel, including floors, wall and ceilings should be
undertaken, preferably by an expert cleaning contractor. All fabric and soft furnishings
should be steam cleaned.

3.2.11. Communications - Outbreak Notification

External communications

In the event that a Norovirus outbreak is suspected, it is essential that the hotelier notifies
the following people:

 The local public health authority.

 The tour operators and suppliers contracted with the hotel. Please note that tour
operators reserve the right to dispatch an independent consultant to the premises in
order to conduct an outbreak investigation.
 Consideration should be given for a potential press statement, although this should be
discussed with the Tour Operators.

Please note that if an FTO tour operator has customers in a premises where Norovirus is
suspected they will notify: The Federation of Tour Operators, who in turn will notify its
members with a request for members who are in the property to work together and share
information.

Internal communications

Guests in residence

 Consideration should be given to issuing a letter or posting a notice informing guests in

residence of the situation and emphasising that the condition is common in the U.K.
particularly during winter months.
 Personal hygiene is the most effective way of reducing the spread. Guests and staff
should be adviced to increase their personal hygiene after using the toilet and when
touching food (with warm running water and soap for at least 15 - 20 seconds and dried
thoroughly afterwards with a disposable paper towel).
 Guests who feel unwell should be requested to stay in their rooms and contact the
reception by phone. This will reduce the risk of them vomiting in a public area.
Arrangements should be made to provide food and water in their rooms.
 Affected guests must not use the pools.
 Affected guests should be encouraged to use their own toilette and washing facilities
 Appendix 2 is an example of a letter - It is an example only and needs to be reworded
for every occasion AND the contents discussed with the tour operators before being
issued. Please note tour operators may wish to produce their own letters or posters of
notification

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  Appendix 3 is an example question and answer fact sheet - It is an example only and
may need to be reworded for every occasion AND the contents discussed with the tour
operators before being issued. Please note tour operators may wish to produce their
own letters or posters of notification.

Hotel Staff

 All staff must be aware of the situation and they should know their roles and
responsibilities during the outbreak.
 If the hotel belongs to a group or hotel chain, they should notify their head office and/or
central health and safety department.

3.2.12. What about guests who are still ill on departure?

 Ill guests and those still recovering should be kept away from incoming guests in the
hotel. This can be arranged either by having separate check out and check in areas or
by arranging for checking out to be at a different time to check in.
 Ill guests should not fly. The difficulty here is the practicality of enforcement as guests
main aim will be to get home. Guests who are still vomiting are, however, an infection
hazard to all other passengers and arrangements should be made for them to remain at
the hotel until they have been symptom free for 72 hours. Ill guests should not travel on
transfer coaches. If they require transport to another location this should be by car and
if they feel sick they should be advised to notify the driver so the car can stop. There
will be some risk to the driver unless he has recently also had the illness.

3.2.13. Guests not yet arrived

 Consideration should be given to advising would be guests of the situation where the
illness has not been controlled within two weeks. The incidence may initially drop, but if
there is a rise again after new guests have arrived this should trigger consideration of
notifying new potential guests.
 It is recognised that this has many difficulties but legal advice has been that it would be
difficult to argue that guests should not be informed of a potential risk to their health.
Hoteliers should discuss the matter with the Tour Operators.

Caveat

These notes have been prepared using the available knowledge. It should be recognised that
while they represent good practice there is no guarantee that their implementation will result in the
prevention of or control of an outbreak. There is much that is still to be learnt about the control of
Norovirus and Influenza infections.

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Appendix 1

Cleaning and disinfection procedures for Norovirus outbreaks

Hypochlorite Solutions

The recommended level of 1000 ppm is 0.1% hypochlorite or bleach solution.

 0.1% is 1 part of bleach in 1000 parts of water

 Equals 10ml bleach in 10 litres of water
 Equals approximately 1 egg cup of bleach to 1/2 bucket of water

Guidance for cleaning up vomit and faeces

Individuals who are assigned to clean up vomit or faeces should take the following precautions in
order to minimise the risk of infection to themselves:

1. Wear rubber gloves and plastic disposable apron.

2. Use paper towels to soak up excess liquid. Note: In order to avoid spread it is suggested that
the liquid be covered and the covering sprayed with the detergent. The waste should be
scoped into it’s self. Transfer the paper towels and any solid matter directly into a plastic waste
bag.
3. Clean the soiled area with detergent and hot water, using a disposable cloth.
4. Disinfect the contaminated area with freshly made 1000 ppm (0.1%) hypochlorite solution. Note
that hypochlorite is corrosive and may bleach furnishings and fabrics.
5. Dispose of apron and cloths into a waste bag for burning.
6. Wash hands thoroughly using soap and water for at least 1 minute and then dry them.

Treatment of specific materials.

 Contaminated linen and bed curtains should be placed carefully into separate laundry bags.
They should be washed in a hot wash. If an outside laundry is used they should be consulted,
as the laundry is potentially infectious.
 Contaminated carpets should be cleaned with detergent and hot water, and then disinfected
with hypochlorite (if bleach-resistant) or steam cleaned.
 Contaminated hard surfaces should be washed with detergent and hot water, using a
disposable cloth, then disinfected with 0.1% hypochlorite solution. Cloths should be disposed of
as waste. Non-disposable mop heads should be laundered in a hot wash.
 Horizontal surfaces, furniture and soft furnishings in the vicinity of the soiled area should be
cleaned with detergent and hot water, using a disposable cloth.
 Fixtures and fittings in toilet areas should be cleaned with detergent and hot water using a
disposable cloth, then disinfected with 0.1% hypochlorite solution.

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Cleaning up vomit in food preparation areas.

1. Using the above principles, carefully remove all vomit and clean the area.
2. Disinfect the food preparation area (including vertical surfaces) with a freshly prepared
hypochlorite- based cleaner that releases 1000 ppm of available chlorine.
3. Destroy any exposed food, food that may have been contaminated and food that has been
handled by an infected person.
4. Any further incident of vomiting should be reported to hotel managers.

The above recommendations for cleaning and disinfection of vomit and faeces are modified from
those made by the U.K. Advisory Committee on the Microbiological Safety of Food Working Group
on Food-borne Viral Infections.

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Appendix 2

Example of letter to customers during Norovirus outbreak

Dear Guests,

We hope that you are enjoying your holiday at the [insert hotel name] hotel. The health and safety
of our customers is of paramount importance and we have an on-going system of assessing and
monitoring standards within the premises.

You may be aware that some guests staying at the hotel have reported that they are suffering from
stomach upsets. We are writing to advise you that following a thorough investigation by an
independent consultant and by the company with whom this property has a hygiene contract, the
conclusion of the investigation has been attributed to a virus, similar to one that has been prevalent
in the UK in recent months.

Whilst we are confident that we are taking every precaution possible to safeguard the health and
well being of our guests, we feel that it is our responsibility to inform you of the situation. You may
also be aware that the property is closing between [insert dates] to carry out maintenance work,
which at the same time, will assist in reducing the possibility of the virus reoccurring.

We hope that this has not affected the enjoyment of your holiday, and if you have any concerns
regarding this letter please do not hesitate to contact us

Yours sincerely

Hotel Manager

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Appendix 3

Example of question and answer fact sheet

What is Norovirus?
Norovirus is a stomach upset caused by a virus that causes nausea, vomiting and diarrhoea. It
starts very suddenly and often the vomit shoots out without control. The symptoms last 1 – 3 days
although the affected person may only be sick 2 –3 times. However, not all of those infected will
experience all of the symptoms.

Can I eat or drink anything?

Yes if you feel like it. Do not attempt to eat normal amounts of food but stick to small portions of
light food. You should drink bottled water with some sugar and a pinch of salt. It is best to avoid
gassy drinks and alcoholic drinks.

What medicines can I take to help me?

It is not normally necessary to take a medicine as the illness only lasts a few hours.

What if I do not feel better in two days?

It is advisable to consult a doctor if you are not improving.

Can it spread to my family and friends?

Yes. When you are sick large amounts of the virus pass into the air as an invisible mist. The virus
particles can pass to others in the room or area. Frequent and proper hand washing using soap
and water is an essential to prevent the spread of the illness.

How long will it be before they become ill if they have caught the virus?
It usually takes 1 –2 days for the illness to develop although it can happen within 12 hours or take
up to 3 days.

Why has the infection hit this hotel?

There is no particular reason. The infection can occur anywhere – in a hotel, a hospital, a
residential home, a school and even throughout a town or community.

How did it get into the hotel?

Another guest or a member of staff who was developing the infection but was not yet ill most
probably brought the virus into the hotel.

Could it be anything I ate?

Occasionally outbreaks have been associated with certain foods and particularly raw shellfish such
as oysters but this is rare.

What should I do if I feel sick?

Return to your room as soon as possible or, if you do not think that you will make it, go outside.
This will reduce the risk of spreading the infection to others. Get someone to notify the
representative of your tour operator who will then advise you further.

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