I. Executive Summary

Norovirus gastroenteritis infections and outbreaks have been increasingly described and reported in both non-healthcare and healthcare settings during the past several years. In response, several states have developed guidelines to assist both healthcare institutions and communities on preventing the transmission of norovirus infections and helped develop the themes and key questions to answer through an evidence-based review. This guideline addresses prevention and control of norovirus gastroenteritis outbreaks in healthcare settings. The guideline also includes specific recommendations for implementation, performance measurement, and surveillance. Recommendations for further research are provided to address knowledge gaps identified during the literature review in the prevention and control of norovirus gastroenteritis outbreaks. Guidance for norovirus outbreak management and disease prevention in non-healthcare settings can be found at Updated Norovirus Outbreak Management and Disease Prevention Guidelines [PDF – 854 KB].

This document is intended for use by infection prevention staff, physicians, healthcare epidemiologists, healthcare administrators, nurses, other healthcare providers, and persons responsible for developing, implementing, and evaluating infection prevention and control programs for healthcare settings across the continuum of care. The guideline can also be used as a resource for societies or organizations that wish to develop more detailed implementation guidance for prevention and control of norovirus gastroenteritis outbreaks for specialized settings or populations.

To evaluate the evidence on preventing and controlling norovirus gastroenteritis outbreaks in healthcare settings, published material addressing three key questions were examined:

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1. What host, viral, or environmental characteristics increase or decrease the risk of norovirus infection in healthcare settings?
2. What are the best methods to identify an outbreak of norovirus gastroenteritis in a healthcare setting?
3. What interventions best prevent or contain outbreaks of norovirus gastroenteritis in the healthcare setting?

Key questions are described within the Evidence Review section.

Explicit links between the evidence and recommendations are available in the Evidence Review in the body of the guideline and Evidence Tables and GRADE Tables in the Appendices. It is important to note that the Category I recommendations are all considered strong and should be implemented; it is only the quality of the evidence underlying the recommendation that distinguishes between levels A and B. Category IC recommendations are required by state or federal regulation and may have any level of supporting evidence. The categorization scheme used in this guideline is presented in Table 1 under Summary of Recommendations and described further in the Methods section and Umscheid et al. [This link is no longer active: “Updating the Guideline Methodology of the Healthcare Infection Control Practices Advisory Committee (HICPAC)”. Similar information may be found at Umscheid CA, Agarwal RK, Brennan PJ, Healthcare Infection Control Practices Advisory Committee. Updating the guideline development methodology of the Healthcare Infection Control Practices Advisory Committee (HICPAC). American journal of infection control. 2010;38(4):264-273.] for the process used to grade quality of evidence and implications of category designation. The Implementation and Audit section includes a prioritization of recommendations (i.e., high-priority recommendations that are essential for every healthcare facility) in order to provide facilities more guidance on implementation of these guidelines. A list of recommended performance measures that can potentially be used for reporting purposes is also included.

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Evidence-based recommendations were cross-checked with those from other guidelines identified in an initial systematic search. Recommendations from other guidelines on topics not directly addressed by this systematic review of the evidence were included in the Summary of Recommendations if they were deemed critical to the target users of this guideline. Unlike recommendations informed by the search of primary studies, these recommendations are stated independently of a key question.

The Summary of Recommendations includes recommendations organized into the following categories:

1. Patient Cohorting and Isolation Precautions,
2. Hand Hygiene,
3. Patient Transfer and Ward Closure,
4. Indirect Patient Care Staff – Food Handlers in Healthcare,
5. Diagnostics,
6. Personal Protective Equipment,
7. Environmental Cleaning,
8. Staff Leave and Policy,
9. Visitors,
10. Education,
11. Active Case-finding, and
12. Communication and Notification.

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Areas for further research identified during the evidence review are outlined in the Recommendations for Further Research. This section includes gaps that were identified during the literature review where specific recommendations could not be supported because of the absence of available information that matched the inclusion criteria for GRADE. These recommendations provide guidance for new research or methodological approaches that should be prioritized for future studies.

Readers who wish to examine the primary evidence underlying the recommendations are referred to the Evidence Review in the body of the guideline, and the Evidence and GRADE Tables in the Appendices. The Evidence Review includes narrative summaries of the data presented in the Evidence and GRADE Tables. The Evidence Tables include all study-level data used in the guideline, and the GRADE Tables assess the overall quality of evidence for each question. The Appendices also contain a defined search strategy that will be used for periodic reviews to ensure that the guideline is updated as new information becomes available.

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