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Nina M. D’Amiano, MD. Candidate, Class of 2024 Johns Hopkins University School of Medicine. MPH Candidate, Class of 2024, Johns Hopkins Bloomberg School of Public Health.

Unlike hospitals, ambulatory settings have traditionally lacked adequate infrastructure and resources to support infection prevention and monitoring.

Infection Control and Prevention in the Outpatient Physical Office Setting

Update: Norovirus is spreading this winter, with nearly 100 outbreaks reported in early December 2024. To protect themselves, hand hygiene is vital; however, is alcohol hand sanitizer effective? 

, or the stomach flu, consists of viruses that irritate and inflame the stomach and intestine linings. Highly contagious, norovirus can cause days of nausea, vomiting, diarrhea, and fever, resulting in severe dehydration, reduced nutrient absorption, and even death.

Norovirus causes an estimated 685 million cases of acute gastroenteritis worldwide each year, according to the 

. This includes 200 million cases of children, resulting in 50,000 deaths. The virus is responsible for at least 

of all gastroenteritis outbreaks and is estimated to total $60 billion in health care costs and lost productivity worldwide. And while respiratory virus season is slowing down, norovirus numbers remain in the wrong direction. Statistics from 15 states participating in the

 reported 1,208 outbreaks from August 1, 2023, to April 9, 2024, compared with 986 during the same period last year.

Unlike enveloped respiratory viruses such as influenza, respiratory syncytial virus, and SARS-CoV-2, which are transmitted by airborne particles, Norovirus usually spreads from direct contact with infected fecal matter, vomit, or person or surface. Also, unlike most respiratory viruses, norovirus can live on surfaces, still infecting people, for up to 

Many people, including those in health care, believe alcohol-based hand rub (ABHR) is the answer. Yet scientific research proved long ago it is not. Having worked for 25-plus years developing ABHR formulas, I can attest that ABHR has its place in health care settings, especially in fighting many respiratory viruses such as SARS-CoV-2. However, ABHR is useless against norovirus, making health care professionals more likely to contract the virus. This raises the question: If ABHR is ineffective against norovirus, why do so many health care facilities continue to use it for that purpose?

The Q&A below closely examines why ABHR doesn’t work against norovirus and why remaining dependent on ABHR facilitates the spread of the virus and lowers hand hygiene compliance rates.

 We have heard from many sources—including the CDC—that ABHR is ineffective against norovirus and can exacerbate its spread. Why?

 making it hardy and more resistant to pH and temperature changes and some disinfectants—including alcohol. ABHR cannot kill norovirus because the alcohol, regardless of percentage, cannot penetrate the capsid, the protein shell of a virus particle surrounding its nucleic acid. In contrast, SARS-CoV-2 is an enveloped virus with a fragile covering easily penetrated by alcohol sanitizers. The confusion comes in because the average person often does not know the difference between nonenveloped and enveloped viruses. The emphasis on ABHR during the COVID-19 pandemic further advanced the misinformation that ABHR works against all viruses.

Q. Is the finding that ABHR does not work against Norovirus new?

 showed that ABHR is ineffective against norovirus and could potentially increase the risk of an outbreak of highly contagious diseases—including norovirus—in health care settings. Two years later, the 

 stated that ABHR is “useless” against norovirus.

Lee-Ann Jaykus, PhD, a respected researcher and professor at North Carolina State University, definitively told 

 that hand sanitizers will not inactivate norovirus. Aron Hall, DVM, MSPH, Dipl ACVPM, the CDC’s Norovirus expert, told

 that ABHR is “ineffective against the virus” and that “soap and water can wash it away, but it takes really hot water to kill it.” This means the virus is not killed by warm water. Last year, senior 

 contributor Bruce Y. Lee quoted Hall: “Alcohol gels won’t kill the virus. Even if you were to use so much hand sanitizer on your hands that you felt like you were wearing hand sanitizer mittens, the live virus could still remain on your hands.” Further, while proper handwashing removes norovirus,

show most health care workers wash their hands properly less than 50% of the time.

Q. Since ABHR is ineffective against norovirus, what infection prevention protocols must health care facilities follow when a patient is discovered to have norovirus, and are there any complications with the protocol that must be considered?

 Any individual showing norovirus symptoms needs to be immediately isolated, and health care workers must switch from ABHR to hand washing with soap and water. Unfortunately, however, there are significant drawbacks to this protocol. For one, it is too little too late since by the time a patient is diagnosed with Norovirus, it has already spread to the entire ward and even the whole facility by staff still using ABHR. Further, handwashing does not kill the virus and only removes it if handwashing is done correctly. To kill the virus requires a water temperature of 140 

F (60 °C), which is far too hot for human hands. In addition, the absence of a nearby water source and time constraints can make handwashing between interactions difficult in a busy health care environment and lead to lower hand hygiene adherence.

Q. Does ABHR cause other health concerns directly related to the spread of norovirus?

 Yes. ABHR can dissolve the lipid level, 

 that protects the skin and causing dermal damage to hands and even eczema; the same is true of too much handwashing. This skin damage makes people more vulnerable to norovirus.

Q. How can ABHR misuse negatively impact health care hand hygiene adherence?

A. Dermal damage makes skin sensitive, so those with dermal issues wash their hands less frequently, linked to decreased

. In May 2023, the World Health Organization (WHO) conducted its 

 on hand hygiene in health care settings and found, “Average hand hygiene [adherence] without specific improvement interventions remains around 40%. In critical care areas, such as intensive care units, average [adherence] levels are around 60%.” These low scores have spawned a new industry that measures and reports on hand hygiene adherence.

Q. If ABHR is ineffective against norovirus and causes dermal damage to the skin, why do health care facilities and workers continue to use it?

 In many cases, even health care personnel do not understand the difference between enveloped and nonenveloped viruses. Add to this that the CDC, WHO, other respected health agencies, and powerful ABHR manufacturers have spent years and millions of dollars promoting ABHR. Understandably, this promotion skyrocketed during the COVID-19 pandemic, leaving many people convinced ABHR is the answer for preventing all types of viruses, although this is not the case. The only way to rectify this is to help spread the word that ABHR fights respiratory viruses but does 

 work against norovirus; ABHR encourages the spread of norovirus through a false sense of security and dermal damage that discourages proper hand hygiene.

Q. Are there any solutions other than thorough handwashing that can be used against norovirus?

. Yes. Hypochlorous acid (HOCl). The human immune system produces HOCI to kill invasive organisms and fight infection. White blood cells create HOCl in humans to defend against infection, bacteria, and general illness. It works by breaking down the cell walls of pathogens and killing them. Outside the body, HOCl is made using electrolysis to break down a simple saltwater solution.

 in the United Kingdom and Europe. US studies show that HOCl

 inactivates both enveloped and nonenveloped viruses

. HOCl contains no alcohol, benzalkonium chloride, hydrogen peroxide, or other chemicals. It is so safe that it is used in products such as wound care and eyecare formulas and is approved by the 

 as a nonrinse sanitizer for meat, poultry, fish, vegetables, and fruits.

Q. Are all HOCl products the same in terms of effectiveness against norovirus?

 No, not all HOCl-based products are equal. They differ in their percentage of HOCl and free available chlorine, shelf lives that can vary from days to years, and pH ranges from acidic to alkaline, making some inadvisable for use on the skin. In 

, Cleveland Clinic dermatologist Shilpi Khetarpal, MD, advised verifying that a product with HOCl is billed for skin care before use.

The best HOCl antimicrobial spray for hand hygiene use on the skin contains stabilized HOCl (S-HOCl). This stabilized formulation has all the attributes of HOCl plus additional benefits that make it exceptionally well-suited for hand hygiene.

S-HOCl is hypoallergenic with a neutral pH, making it safe for use on skin, a feature few HOCl solutions can match. The best S-HOCl formulas have a 2-year shelf life compared to HOCl’s average 30-day shelf life. It is also advisable to look for an S-HOCl hand hygiene spray that:

Has an antimicrobial designation that has a 510(k) registration

Is accepted by the National Eczema Association

Carries designations from other reputable organizations, verifying it is safe for use on skin.

I am a huge proponent of using ABHR to eliminate bacteria and enveloped viral pathogens, and our company still manufactures it for this reason. However, ABHR will not kill nonenveloped viruses like norovirus, no matter how much you use it. This puts health care staff, patients, and visitors at risk for norovirus every day.

It is time to adjust and adapt to improve hand hygiene protocol to best protect everyone at your health care facility. It’s time to exchange ABHR for an antimicrobial S-HOCI hand hygiene spray with efficacy against norovirus and all enveloped and nonenveloped viruses that will increase hand hygiene adherence.

Alcohol-based hand sanitizers do not protect against norovirus, a highly contagious virus. Effective alternatives like hypochlorous acid-based sanitizers are crucial for better infection control.


Alcohol-Based Hand Sanitizers Ineffective Against Norovirus: Effective Alternatives and Infection Control Strategies

, norovirus is spreading widely during this winter season, with nearly 100 outbreaks at the beginning of December 2024. What is norovirus, and how can individuals protect themselves? 

First identified by Albert Kapikian and colleagues in Norwalk, Ohio, in 1972, Norovirus continues to cause infections and disease outbreaks in the US over 50 years later.

 It is the most common cause of epidemic gastroenteritis, causing 19 to 21 million cases per year, and is responsible for 2.27 million outpatient visits, 465,000 emergency room trips, 109,000 hospitalizations, and 900 yearly deaths.

 The virus is particularly dangerous in children under 5 years, adults over 85, and immunocompromised people. These groups have a higher risk for severe disease and are responsible for most outpatient or emergency room visits.

Outbreak potential, transmission, and symptoms

Norovirus outbreaks are likely to become more common without definitive public health action such as a widely available vaccine. “People are traveling more, which facilitates the spread of the virus to new areas. Norovirus’ genetic diversity and rapid evolution can lead to the emergence of new strains that may cause more outbreaks. Climate change might also be playing a role in outbreak patterns and where outbreaks happen,” says Raj Dasgupta, MD, FACP, FCCP, FAASM, a board-certified physician in internal medicine, critical care, pulmonology, and sleep medicine and chief medical advisor at Sleep Advisor.

Norovirus has many nicknames, including stomach flu, gastric flu, winter vomiting virus, and the cruise ship virus. But it’s not related to the common flu caused by influenza viruses. There are several strains of the Norovirus, but they all belong to the 

 family, which consists of nonenveloped, positive-sense, single-stranded RNA viruses. They are highly contagious, and 10 viral particles can cause an infection. The primary way the virus spreads is through food-related transmission. Food contaminated by food service workers during preparation is a common source of infection. Outbreaks from eating contaminated fruits and vegetables, as are those from fish and oysters, are common. Person-to-person spread is also possible when droplets from infected people’s vomit or stools infect others. Contaminated surfaces are also part of its spread.

The virus mutates fast, and the CDC has said new strains are responsible for 50% more infections.

 “Norovirus is quite a shape-shifter,” said Dasgupta. This constant evolution means new strains pop up from time to time, which could affect how outbreaks happen and how effective preventive measures are,” he added.

Two people testing positive for the Norovirus is regarded as an outbreak. In the US, there are 2000 outbreaks yearly, most of which occur between November and April.2 Outbreaks have happened in several settings, including health facilities, cruise ships, military barracks, schools, care homes, and resorts. The incubation period for Norovirus is 12 to 48 hours, with 33 hours being the median. 

The most common symptoms are nausea, vomiting, and diarrhea. But people also report body pains, headaches, abdominal pain and cramping, and chills. Fever is a less common symptom that has also been reported. Symptoms last for 1 to 3 days and may resolve on their own. Immunocompromised people, those who recently received transplants, older adults, and neonates have a higher risk of fatal illness and need extra attention.

Prevention and control, trusted methods, and newer options

The mainstay of prevention is proper handwashing. Studies show that washing hands with soap and running water for 20 seconds is the most effective hand hygiene for eliminating the virus.

 Alcohol-based sanitizers are less effective. Though they can reduce the viral count on the hands, they are best used alongside proper handwashing.

Decontamination of surfaces also plays a vital role in infection control. During diarrhea and vomiting episodes, the virus is inadvertently sprayed into the air and on surfaces. Sinks, toilets, beds, chairs, counters, doors, faucet handles, and floors are all potential sources of infection. All potentially contaminated surfaces must be decontaminated, and any items that cannot be decontaminated must be discarded.

 The pathogen can survive on surfaces for 2 weeks. It can also survive freezing temperatures and warm water but dies when exposed to temperatures of 145 degrees Fahrenheit (62.7 degrees Celsius).

Bleach kills the virus. Five to 25 tablespoons of chlorine bleach in a gallon of water creates an effective disinfection solution that can be used to disinfect surfaces and bedding.

 Bipolar ionization is a newer technique that has also been used to reduce infectivity and kill the virus. 

"In addition, because Norovirus can reside on touchable surfaces like a doorknob, phone, computer keyboards, handrail, or other surface that a contagious person has recently touched, adding Bipolar ionization to your home or office HVAC system can help kill surface contamination in public spaces as it continuously sanitizes surfaces thereby lessening the risk of infection," said Philip M. Tierno, Jr, PhD, professor of microbiology and pathology, NYU Grossman School of Medicine and NYU Langone Medical Center:

To control infections, people sick with Norovirus also need to be excused from work, Tierno added. Most people stop shedding the virus within 3 days, but immunocompromised people can keep shedding it in stool for months.

 Allowing sick people to work endangers the public. One sick person can infect hundreds because of how contagious the virus is. But it's often challenging to enforce this because many food handlers do not get paid sick leave. Lawmakers need to do more to provide legislation mandating paid sick leave for workers in the interest of public health.

For years, the Norovirus couldn’t be cultured in laboratories, but recent advancements have allowed scientists to grow them on gut-like tissue enriched with bacteria. It is hard to culture in the lab, hindering research on killing, controlling, and detecting it. Disturbing, considering the illness costs the US 7.6 million in direct costs and 165.3 million in productivity losses each year.

There’s no treatment for Norovirus yet. In most people, it is a self-limiting illness that resolves after about 3 days. The focus of care is maintaining adequate hydration and treating symptoms. Probiotics may help control diarrhea, but this is still being investigated. Extreme fluid loss is possible and can lead to complications such as dehydration, hypokalemia, hyponatremia, metabolic acidosis, hemolytic uremic syndrome, and kidney failure.

This year, scientists reported clinical improvements in 4 immunocompromised people infected with chronic norovirus treated with favipiravir, including in combination with nitazoxanide. The drugs reduced infectivity, but more extensive studies are needed to ascertain safety and utility in larger populations.

No widely available vaccine for Norovirus is available, but several contenders are undergoing clinical trials. One of the most promising candidates was created by researchers from Washington University School of Medicine, who merged recombinant forms of norovirus with existing rotavirus vaccine and elicited an immune response to both viruses from mice.

 It remains to be seen if this result can be duplicated safely and effectively in humans.

Perhaps because most people recover without incident and the annual death toll remains below 1000, Norovirus does not receive as much attention as it should. But concerted efforts to fast-track vaccine development and identify agents that reduce infectivity could be lifesaving for vulnerable groups and help reduce the enormous annual cost implications of norovirus outbreaks.

Lucero Y, Matson DO, Ashkenazi S, George S, O'Ryan M. Norovirus: Facts and Reflections from Past, Present, and Future. Viruses. 2021;13(12):2399. Published 2021 Nov 30. doi:10.3390/v13122399

https://www.cdc.gov/norovirus/burden.html

Capece G, Gignac E. Norovirus. [Updated 2023 Aug 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: 

https://www.ncbi.nlm.nih.gov/books/NBK513265/

Preventing norovirus. Centers for Disease Control and Prevention. Published May 10, 2023. 

https://www.cdc.gov/norovirus/about/prevention.html

Norovirus. National Collaborating Centre for Infectious Diseases. Published January 25, 2023. 

Bartsch SM, O’Shea KJ, Lee BY. Corrigendum to: The clinical and economic burden of norovirus gastroenteritis in the United States. 

 (Online University of Chicago Press)/the Journal of Infectious Diseases. 2021;224(4):741. doi:10.1093/infdis/jiab197

Kreins A, Roux E, Pang J, et al. Favipiravir induces HuNoV viral mutagenesis and infectivity loss with clinical improvement in immunocompromised patients. 

. 2024;259:109901. doi:10.1016/j.clim.2024.109901

Kawagishi T, Sánchez-Tacuba L, Feng N, et al. Mucosal and systemic neutralizing antibodies to norovirus induced in infant mice orally inoculated with recombinant rotaviruses. 

 U S A. 2023;120(9):e2214421120. doi:10.1073/pnas.2214421120

Norovirus, discovered in 1972, causes millions of gastroenteritis cases yearly. Learn prevention methods, symptoms, and updates on vaccine development.

Norovirus: An Old Virus Seeking New Public Health Actions

's) Editorial Board members—a diverse group of professionals dedicated to advancing infection prevention and control practices. This series highlights each member's unique expertise and contributions to the field.

From groundbreaking research to innovative strategies, these experts are at the forefront of enhancing health care safety. Join us as we learn their insights, experiences, and visions for the future, providing valuable knowledge and inspiration to elevate infection control protocols.

In this installment, we hear from Tabrikah Mohammed, MSc, BSN, CIC, CPHQ, FAPIC, senior infection control officer, MSc, BSN, TQM, CIC, CPHQ, FAPIC. 

Tabrikah Mohammed, MSc, BSN, CIC, CPHQ, FAPIC, is an accomplished nursing professional with a diverse educational background and vast experience in infection control. She obtained a bachelor of nursing degree from Sharjah University in 2011 and a master of health care administration from the Royal College of Surgeon Ireland in 2013.

Tabrikah has furthered her expertise by obtaining certification as a CIC in 2018 and a CPHQ in 2021. She is also the founder of the IPQ Academy, where she imparts her knowledge and experience to other health care professionals. As the cofounder, head of the scientific committee, and infection control expert at the 

Middle East North Africa Federation for Hospital Sterilization Sciences

 (MENA FHSS), she has significantly contributed to the healthcare sector.

Emirates Infection Prevention and Sterilization Society

 (EIPSS), a nonprofit organization dedicated to advancing knowledge in infection prevention and sterilization practices in the United Arab Emirates. EIPSS operates under the 

Currently, Tabrikah serves as a senior infection control officer in 

, where she applies her skills and knowledge to ensure the safety of patients and healthcare workers. She is also a member of the 2023 editorial advisory board for 

, a testament to her reputation as an expert in infection control.

Tabrikah's contributions to infection control have been recognized through several awards, including the 

IP Idol from Certification Board of Infection Control and Epidemiology, Inc

 by Saudi Society for Infection Prevention and Control in 2023. She is also an international speaker at various conferences and conducts workshops.

Tabrikah sees these topics as trending right now:

These programs aim to optimize the use of antibiotics to combat antibiotic resistance. They involve the proper selection, dosage, and duration of antibiotic treatment to minimize resistance and adverse effects.

: Real-time data and advanced analytics track infection trends and outbreaks within healthcare facilities, allowing quicker and more effective responses.

Artificial intelligence and machine learning

: These technologies are applied to predict outbreaks and optimize infection control strategies.

Personal Protective Equipment (PPE) Innovation

: PPE is continually being innovated, with improvements in comfort, durability, and protection levels. Reusable PPE is also being developed to address supply chain issues and sustainability concerns.

Infection Control in Nonhospital Settings

: Infection prevention in long-term care facilities has become a major focus, particularly due to residents' vulnerability to infections like COVID-19 and influenza.

: There’s increased attention to infection prevention in schools, workplaces, and other community settings.

: Online platforms for infection prevention training have expanded, making education more accessible and scalable.

: There’s a growing emphasis on interprofessional education and collaboration in infection prevention, recognizing that effective infection control requires teamwork across various healthcare disciplines.

: Educating patients and their families on infection prevention practices, such as hand hygiene and recognizing signs of infection, is becoming more prevalent.

: There is a trend towards involving patients in their care, including infection prevention measures, to improve outcomes.

: There is an increasing focus on sustainable practices in infection prevention, such as reducing single-use plastics and developing environmentally friendly disinfectants.

Infection Prevention in Nonhospital Settings:

There is a growing focus on infection prevention in long-term care facilities, outpatient clinics, and community settings. Tailored infection control measures are being developed for these environments.

Telehealth services have expanded significantly, reducing the need for in-person visits and thereby lowering the risk of infection transmission. Remote monitoring of patients helps in managing infections and chronic conditions more effectively.

could focus on a range of timely and impactful topics. Here are her suggestions:

1. Emerging Infectious Diseases and Global Threats

 Coverage of the latest research and developments regarding new viruses or bacteria, particularly those with pandemic potential.

 Updates on global efforts to prevent and control infectious diseases, including responses to outbreaks and lessons learned from recent events.

 New technologies, treatments, and policies to mitigate the rise of drug-resistant infections.

Meet the experts shaping infection prevention: Infection Control Today's Editorial Board members share insights, experiences, and cutting-edge strategies to enhance health care safety and quality. Meet Tabrikah Mohammed, MSc, BSN, CIC, CPHQ, FAPIC.

Nina M. D'Amiano, MD

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