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07 July 2014

In order to critically review the management of norovirus outbreaks,Hygiena International ATP test systems (involving a hand-held SystemSUREluminometer and UltraSnap swabs) have been used to evaluate the effectiveness of cleaning procedures, following two norovirus outbreaks on a cruise ship.

Norovirus is the most prevalent cause of infectious gastroenteritis in the UK, and the ATP Bioluminescence technique has been used for many years to identify potential sources of contamination in the food chain, in production and preparation areas as well as many other industrial and commercial applications such as restaurants and hotels etc. It has also been utilised more recently to monitor surface cleanliness, and used in conjunction with varying infection control measures to monitor many other areas of potential infection. These include confined environments as found in care homes and hospitals, where secondary or subsequent outbreaks often re-occur even after initial cleaning and sanitation procedures have been undertaken. Other potential areas of application include schools, or wherever food is prepared or consumed by the general public.

Any cleaning procedure is designed to remove residues of food and body fluids such that the subsequent application of disinfectants can function correctly and inactivate residual microbial contamination. Foods and body fluids contain large amounts of ATP i.e. adenosine triphosphate (the universal energy carrier) such that residues of ATP remaining on surfaces after cleaning provide a direct, objective measure of the efficacy of the cleaning process and residual contamination risk.

The Hygiena UltraSnap swabs contain a reagent known as luciferase/luciferin in the bulb of the swab. Once the swab is snapped and the bulb squeezed, an oxidation reaction takes place with any ATP present, emitting light. The light produced is directly proportional to the amount of ATP in thearea tested. This is a rapid method showing a strong correlation between ATP and microbial cells, with results measured in relative light units (RLU) can be obtained within 15 seconds.

The key to preventing the spread of norovirus is thorough and effective cleaning combined with disinfection during and after an outbreak, and the effectiveness of decontamination should be evaluated by Health Officers. The Hygiena System SURE test procedure is swift, provides a PASS/CAUTION/FAIL result and can be undertaken by personnel after only minimal training.

Previous research on outbreaks of norovirus (including on cruise ships),have inadequately described the control measures implemented. Other more specific detection methods for norovirus are also expensive and it can take some time before results become available. With the SystemSURE equipment, samples were taken in infected areas and toilets and all points of regular personal contacts(eg handrails, door knobs/levers etc) including some adjacent non-infected areas and points of contact following deep cleaning. The areas swabbed were random and taken from various sampling points immediately after cleaning, and focusing on typical high hand touch areas which can transmit infection. This study was moderate in size with 601 swabs/sampling sites measured in the case of two outbreaks. A benchmark of 100 RLU was used as the maximum acceptable safe reading,since previous studies showed that this is achievable in hospital near patient areas as well as at commercial catering establishments. Accordingly a traffic lights system was adopted of Pass (green) indicating <50 RLU, Caution(orange) representing 51 – 100 RLU being present and Fail (red) where >100 RLU existed.

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