It’s Friday afternoon and you’re a busy hotel manager. You’re working hard on an income projection report for the hotel’s owners and are really looking forward to a restful weekend. The phone rings and it’s reception, saying that a number of guests are ill in their rooms, with diarrhoea and vomiting. The receptionist tells you that some of them have already posted on social media that they have food poisoning and won’t be staying here again. The housekeeper has also phoned in sick with the same symptoms, and reception wants to know if they can phone the agency to get some temporary cleaners in and access the already-depleted contingency budget. You ponder: ‘What if we could stop or better manage this thing that always keep happening this time of year – it would be great to get ahead of the curve, wouldn’t it?’ 

Norovirus is the leading cause of infectious gastroenteritis, with statistics showing increased prevalence during the colder months. The UK Health Security Agency has advised that norovirus reporting in England is currently higher than usual, and reports have risen earlier in the year than expected. Reasons include post-covid changes in immunity, improved testing and surveillance and the emergence of a new strain (UKHSA, 29 November 2024). 

Outbreaks often occur in establishments such as hotels, nurseries, schools, hospitals and residential homes where people are in close proximity to one another. As catching the virus is more likely during the winter period (due to people spending more time in doors), businesses should and can be prepared, with mitigations in place.   

Once notified of an outbreak, the local authority is responsible for starting an investigation, usually led by an EHP. So, what are the key things that can be done and what advice is the local authority likely to give?  

Identifying a lead person for infection prevention and control (IP&C) in the business is a good start. This employee could plan, coordinate and check preventative and reactive measures, put contingency plans in place and gather useful contact details for support and advice, reporting back to management so they are informed of any gaps that might need attention or resources. Ensuring this person is adequately trained so they have an understanding of infection control guidelines and what good cleaning and disinfection arrangements look like is a good business investment.  

It’s Sunday evening and the hotel manager wonders who to contact following news that ten percent of the guests are now infected. Someone was sick in the restaurant on Saturday, but it was quickly wiped up (that was alright, wasn’t it?). And by Sunday staff are struggling to keep track and manage all the data entered on a spreadsheet, hastily put together, about who is ill, when they got ill and what room they are in. The manager thinks it would be helpful if a pattern could be seen. If only the spreadsheet had been set up in readiness to collect all the data required, such as the locations where guests were unwell (so these could then be checked, cleaned and disinfected) and food history before symptoms started (of particular benefit to prove it wasn’t the hotel’s food!)). Whether stool specimen advice had been given to guests and a note of anybody having provided a sample might also have been sensible. Oh, and a record to show the hotel had advised each ill guest to stay in their room, ideally for 48 hrs after feeling better (or go home), now, with hindsight, seems prudent.  

The manager was sure they saw a couple in the bar this morning who were being provided room service last night. Didn’t one of them vomit three times yesterday and take to bed? We’ve given them hand-washing advice, haven’t we? And, thinks the manager, I hope we can prove all this if a claim comes in saying there’s any negligence involved in preventing and controlling this problem. 

But what about cleaning and housekeeping? Effective, routine cleaning and disinfection should, in any event, be ongoing to help to prevent infections from intensifying during outbreaks. Public areas and touchpoints like door openers, handrails and lift buttons should be cleaned and disinfected frequently (norovirus is easily spread through environmental contamination). A documented cleaning plan and schedule should be in place describing what to clean, where, when, how and to what standard, and who does and checks this, with records to show this has taken place effectively.   

Cleaning staff need to be trained, supervised, provided with the right facilities (mop heads that are stored clean and head-up to dry after use) and equipment they know how to use. Let’s hope the manager has these records, along with COSHH assessments, manual handling risk assessments, PUWER checks, PPE, first aid and PAT testing records. That heavy floor cleaner does have a very long electrical lead, thinks the manager. Do we routinely check leads for damage? Maybe the supervisor or housekeeper could do a quick toolbox talk? 

Using the right chemical at the right concentration/contact time is important. Once cleaned, then any hard areas subject to hand contact should be disinfected. The recommended disinfectant for norovirus is hypochlorite solution is a 0.1% solution (1,000 parts per million (ppm) of available chlorine). Alternative disinfectants are available for easily damaged textiles such as soft furnishings and carpets. But what about that vomit on the restaurant floor? The National Infection Control Manual (Appendix 9 in the England* and Wales** manuals; Standard Precautions section in the Northern Ireland*** manual) contains a useful flowchart on the management of blood and body spills. The spillage should be soaked up as far as possible using disposable paper towels. To contain and solidify the remaining spill, superabsorbent gel granules can be sprinkled over it, then removed. If vomit only, the area should be disinfected with a 1,000 ppm (1%) available chlorine solution. If blood is present, the concentration is 10,000 (10%). Body fluid clean-up kits (grab bags, contents regularly checked against required inventory) should be readily available for trained staff use.  

After a sleepless Sunday night, the manager calls the local authority first thing Monday morning, and an EHP visits later that day (in this scenario the LA is adequately resourced to do so!). Having taken initial details over the phone, the EHP logs on to RIAMS Libraries (especially useful as they can access it from home) and has a quick refresh on dealing with a suspected outbreak prior to visiting the hotel. The officer finds several useful guidance documents and procedures including Norovirus Outbreak Procedure FP32, Infectious Disease and Foodborne Illness Outbreak FP17 and Specimen Collection for Infectious Disease Sampling FP28 (available here) and scans through each document to refamiliarise themselves.  

The EHP tells the hotel manager that until proven otherwise, the assumption is that the cause is food related and possibly bacterial. The EHP starts to gather relevant information, namely details of those affected, symptoms, onset dates, food histories and details of illness among staff, then gives the manager an outbreak questionnaire so that relevant details can be recorded next time any outbreak occurs.   

From the quick onset (incubation period 24–48 hrs) and recovery of guests (24–48 hrs later), the EHP thinks this is a norovirus outbreak caused by an infected person(s) coming into the hotel around last Wednesday. They need, though, to rule out other potential sources such as contaminated food or water (e.g. shellfish or unwashed salad) and also check out the hotel’s food safety management system. The manager hopes the chef has been keeping all the monitoring records up to date. 

The EHP contacts the regional consultant in communicable disease control (CCDC)/Health Protection Service in Northern Ireland and provides them with full details of the situation. (Had those who became ill been vulnerable or from a school, the officer may have needed to consider liaising with the relevant local authority/social services/school.)  

A few hours later, the EHP has learnt that the housekeeper (now back at work) helped to clean up a ‘travel sickness’ spillage in the coach that dropped off guests last Wednesday, but did not report that incident to anyone. According to the housekeeper, this is a fairly regular occurrence with that travel company, and their coaches don’t have proper cleaning and disinfection equipment. The EHP gives cleaning and disinfection guidelines to the hotel manager, including advice about setting up a hotel cleaning hit squad.  

With the aim of isolating the causative organism, the EHP leaves some faecal sample pots, guidance on their use and details of collection arrangements. They also suggest the hotel develops a written plan on outbreak control and prevention. This could include providing norovirus information to guests and travel companies, to help prevent the illness being brought into the hotel in the first place. Hand-washing provision also needs to improve, the EHP notes. The hot water in the communal hotel toilets is so hot that people are not washing their hands properly. There are no signs reminding guests or staff about handwashing, nor how to do it properly. Not only that, there are no hand sanitiser dispensers (containing product with at least 60% alcohol) in the hotel reception or restaurant dining room entrance. This said, hand sanitisers are immaterial in this situation, as the EHP tells the manager, because they do not work against norovirus: effective handwashing is the best way to stop its spread (Norovirus, NHS 2021).   

The EHP gives further advice on excluding staff with diarrhoea and vomiting from work (they should only return 48 hrs after cessation of symptoms) and to review the hotel’s process for dealing with soiled laundry from guest rooms, to prevent cross-contamination. (The hotel’s current practices could easily spread norovirus from room to room) Once the initial incident is over, the EHP cautions that the LA will consider whether any follow-up action is required.  

The manager realises there is a lot of work to do, but once in place, the chaos encountered on this occasion could be avoided, with less disruption, better room occupancy rates, publicity for the right reasons and more income. What’s not to like?  

References 

*National infection prevention and control manual for England (NHS England, updated 23 May 2024 – version 2.10)  

**National Infection Control Manual (NHS Scotland, updated 17 May 2012) Adopted by NHS Wales 

***Northern Ireland Regional Infection Prevention and Control Manual (Department of Health Social Services and Public Safety Northern Ireland)