Why "winter" vomiting disease? Seasonality, hydrology, and Norovirus epidemiology in Toronto, Canada

Potential pathogenic microorganisms in rural wastewater treatment process: Succession characteristics, concentration variation, source exploration, and risk assessment

Pathogenic microorganisms can cause infection, sepsis, and other diseases in humans. Although municipal wastewater plants are important sources and sinks for potential pathogenic microorganisms, data on rural wastewater treatment processes are limited. The proximity of rural wastewater facilities to human settlements and the trend toward wastewater resourcing could pose risks to humans. Here, a typical village in southern China was selected to analyze potential pathogenic microorganisms in wastewater, sewage sludge, and aerosols during the collection, treatment, and discharge of domestic wastewater. The succession characteristics and concentration variations of potential pathogenic microorganisms throughout the wastewater treatment process were identified using high-throughput sequencing and culture methods. Bacteria-associated health risks in facility aerosols were estimated based on average daily dose rates from inhalation and dermal exposure. Lower amounts of pathogenic bacteria and pathogenic fungi were detected in the effluent of the 1-ton treatment scale and the 10-ton treatment scale facilities, compared to those in the influent. Pathogen effluent concentrations were significantly lower than influent concentrations after treatment in rural wastewater facilities. 16 and 29 potential pathogenic bacteria and fungi were detected in aerosols from wastewater treatment facilities, respectively. Furthermore, the potential pathogen concentrations were higher than those in the background air. Aerobic units are the main source of pathogen emissions from aerosols. There were 42 potential pathogenic bacteria and 34 potential pathogenic fungi in the sewage sludge. Biochemical units were the main source of potential pathogens in sewage sludge, and more potential airborne pathogens originated from wastewater. In rural wastewater resourcing processes with greater pollutant exposure, the effluent of rural wastewater treatment facilities (WWTFs), downstream rivers, and facility aerosols, could be important potential sources of microbial risk. Inhalation is the main pathway of human exposure to airborne bacteria. Therefore, more attention should be focused on microbiological risk in rural wastewater treatment processes.

Gastroenteritis Forecasting Assessing the Use of Web and Electronic Health Record Data With a Linear and a Nonlinear Approach: Comparison Study

BACKGROUND

Disease surveillance systems capable of producing accurate real-time and short-term forecasts can help public health officials design timely public health interventions to mitigate the effects of disease outbreaks in affected populations. In France, existing clinic-based disease surveillance systems produce gastroenteritis activity information that lags real time by 1 to 3 weeks. This temporal data gap prevents public health officials from having a timely epidemiological characterization of this disease at any point in time and thus leads to the design of interventions that do not take into consideration the most recent changes in dynamics.

OBJECTIVE

The goal of this study was to evaluate the feasibility of using internet search query trends and electronic health records to predict acute gastroenteritis (AG) incidence rates in near real time, at the national and regional scales, and for long-term forecasts (up to 10 weeks).

METHODS

We present 2 different approaches (linear and nonlinear) that produce real-time estimates, short-term forecasts, and long-term forecasts of AG activity at 2 different spatial scales in France (national and regional). Both approaches leverage disparate data sources that include disease-related internet search activity, electronic health record data, and historical disease activity.

RESULTS

Our results suggest that all data sources contribute to improving gastroenteritis surveillance for long-term forecasts with the prominent predictive power of historical data owing to the strong seasonal dynamics of this disease.

CONCLUSIONS

The methods we developed could help reduce the impact of the AG peak by making it possible to anticipate increased activity by up to 10 weeks.

Developing an Integrated "Regression-QMRA method" to Predict Public Health Risks of Low Impact Developments (LIDs) for Improved Planning

Worldwide Low Impact Developments (LIDs) are used for sustainable stormwater management; however, both the stormwater and LIDs carry microbial pathogens. The widespread development of LIDs is likely to increase human exposure to pathogens and risk of infection, leading to unexpected disease outbreaks in urban communities. The risk of infection from exposure to LIDs has been assessed via Quantitative Microbial Risk Assessment (QMRA) during the operation of these infrastructures; no effort is made to evaluate these risks during the planning phase of LID treatment train in urban communities. We developed a new integrated "Regression-QMRA method" by examining the relationship between pathogens' concentration and environmental variables. Applying of this methodology to a planned LID train shows that the predicted disease burden of diarrhea from Campylobacter is highest (i.e. 16.902 DALYs/1000 persons/yr) during landscape irrigation and playing on the LID train, followed by Giardia, Cryptosporidium, and Norovirus. These results illustrate that the risk of microbial infection can be predicted during the planning phase of LID treatment train. These predictions are of great value to municipalities and decision-makers to make informed decisions and ensure risk-based planning of stormwater systems before their development.

Norovirus detection in wastewater and its correlation with human gastroenteritis: a systematic review and meta-analysis

Norovirus (NoV) is a major cause of sporadic cases and outbreaks of acute gastroenteritis (AGE), thereby imposing threat to health globally. It is unclear how quantitation of wastewater NoV reflects the incidence of human AGE infections; therefore, we conducted this systematic review and meta-analysis of published NoV wastewater surveillance studies. A literature search was performed, and all studies on NoV wastewater surveillance were identified. Quantitative results were evaluated. The results showed that the overall detection rate of NoV in wastewater was 82.10% (95% confidence interval [CI]: 74.22-89.92%); NoV concentration was statistically significant in terms of season (P < 0.001), with higher concentration in spring and winter. There were positive correlations between NoV GII concentration in wastewater and GII AGE cases (rs = 0.51, 95% CI: 0.18-0.74, I2 = 0%), total AGE cases (rs = 0.40, 95% CI: 0.15-0.61, I2 = 23%) and NoV outbreaks (rs = 0.47, 95% CI: 0.30-0.62, I2 = 0%). Results of cross-correlation analysis of partial data indicated that variations in GII concentration were consistent with or ahead of those in the number of AGE cases. The diversity of NoV genotypes in wastewater was elucidated, and the dominant strains in wastewater showed a consistent temporal distribution with those responsible for human AGE. Our study demonstrated the potential association of NoV detected in wastewater with AGE infections, and further studies are needed to confirm this conclusion.

Norovirus Genogroup II Epidemics and the Potential Effect of Climate Change on Norovirus Transmission in Taiwan

The activity of norovirus varies from season to season, and the effect of climate change on the incidence of norovirus outbreaks is a widely recognized yet poorly understood phenomenon. Investigation of the possible association between climatic factors and the incidence of norovirus is key to a better understanding of the epidemiology of norovirus and early prediction of norovirus outbreaks. In this study, clinical stool samples from acute gastroenteritis outbreaks were collected from January 2015 to June 2019 in Taiwan. Data analysis from our study indicated that more than half of the cases were reported in the winter and spring seasons, including those caused by norovirus of genotypes GII (genogroup II).2, GII.3, GII.6, and GII.17, and 45.1% of the patients who tested positive for norovirus were infected by the GII.4 norovirus in autumn. However, GII.6 norovirus accounted for a higher proportion of the cases reported in summer than any other strain. Temperature is a crucial factor influencing patterns of epidemic outbreaks caused by distinct genotypes of norovirus. The results of this study may help experts predict and issue early public warnings of norovirus transmission and understand the effect of climate change on norovirus outbreaks caused by different genotypes and occurring in different locations.

Relative Risk Prediction of Norovirus Incidence under Climate Change in Korea

As incidences of food poisoning, especially norovirus-induced diarrhea, are associated with climate change, there is a need for an approach that can be used to predict the risks of such illnesses with high accuracy. In this paper, we predict the winter norovirus incidence rate in Korea compared to that of other diarrhea-causing viruses using a model based on B-spline added to logistic regression to estimate the long-term pattern of illness. We also develop a risk index based on the estimated probability of occurrence. Our probabilistic analysis shows that the risk of norovirus-related food poisoning in winter will remain stable or increase in Korea based on various Representative Concentration Pathway (RCP) scenarios. Our approach can be used to obtain an overview of the changes occurring in regional and seasonal norovirus patterns that can help assist in making appropriate policy decisions.

Short-Term Impacts of Meteorology, Air Pollution, and Internet Search Data on Viral Diarrhea Infection among Children in Jilin Province, China

The influence of natural environmental factors and social factors on children’s viral diarrhea remains inconclusive. This study aimed to evaluate the short-term effects of temperature, precipitation, air quality, and social attention on children’s viral diarrhea in temperate regions of China by using the distribution lag nonlinear model (DLNM). We found that low temperature affected the increase in children’s viral diarrhea infection for about 1 week, while high temperature and heavy precipitation affected the increase in children’s viral diarrhea infection risk for at least 3 weeks. As the increase of the air pollution index may change the daily life of the public, the infection of children’s viral diarrhea can be restrained within 10 days, but the risk of infection will increase after 2 weeks. The extreme network search may reflect the local outbreak of viral diarrhea, which will significantly improve the infection risk. The above factors can help the departments of epidemic prevention and control create early warnings of high-risk outbreaks in time and assist the public to deal with the outbreak of children’s viral diarrhea.

The Short-term Effects of Temperature on Infectious Diarrhea among Children under 5 Years Old in Jiangsu, China: A Time-series Study (2015-2019)

The association between meteorological factors and infectious diarrhea has been widely studied in many countries. However, investigation among children under 5 years old in Jiangsu, China remains quite limited. Data including infectious diarrhea cases among children under five years old and daily meteorological indexes in Jiangsu, China from 2015 to 2019 were collected. The lag-effects up to 21 days of daily maximum temperature (Tmax) on infectious diarrhea were explored using a quasi-Poisson regression with a distributed lag non-linear model (DLNM) approach. The cases number of infectious diarrhea was significantly associated with seasonal variation of meteorological factors, and the burden of disease mainly occurred among children aged 0–2 years old. Moreover, when the reference value was set at 16.7°C, Tmax had a significant lag-effect on cases of infectious diarrhea among children under 5 years old in Jiangsu Province, which was increased remarkably in cold weather with the highest risk at 8°C. The results of DLNM analysis implicated that the lag-effect of Tmax varied among the 13 cities in Jiangsu and had significant differences in 8 cities. The highest risk of Tmax was presented at 5 lag days in Huaian with a maximum RR of 1.18 (95% CI: 1.09, 1.29). Suzhou which had the highest number of diarrhea cases (15830 cases), had a maximum RR of 1.04 (95% CI:1.03, 1.05) on lag 15 days. Tmax is a considerable indicator to predict the epidemic of infectious diarrhea among 13 cities in Jiangsu, which reminds us that in cold seasons, more preventive strategies and measures should be done to prevent infectious diarrhea.

Characteristics of Norovirus Food Poisoning Outbreaks in Korea in the 2000s

ABSTRACT

Norovirus food poisoning outbreaks in Korea (South) appeared in the 2000s and have been increasing since then. We aimed to investigate the epidemiological features of norovirus food poisoning outbreaks in Korea from 2002 to 2017, on the basis of official food poisoning statistics and publically reliable reports, and to find any associations with climate factors. Norovirus was the most common cause of food poisoning among known causative substances in Korea during the study period. More than one-third of the outbreaks occurred in group meal service facilities, including school lunch programs. A few of these facilities used groundwater contaminated with noroviruses to wash or cook food, which contributed to outbreaks. Norovirus occurrences showed strong seasonality: cold and relatively dry winter air may help norovirus to flourish. Both norovirus genotypes GI and GII that are infectious to humans were detected, with GII becoming more prevalent than GI. According to our correlation analysis in connection with climate factors, average temperatures, the highest and lowest temperatures, precipitation, the number of rain days, and humidity showed a significant negative correlation with a monthly norovirus occurrence (P < 0.05). The lowest temperature and average temperature had higher coefficients of correlation, -0.377 and -0.376, respectively. The norovirus outbreaks in Korea showed complex etiological characteristics, although more prevailed in wintertime, and are now a major public health problem. The use of groundwater in group meal service settings is a public health issue, as well as a norovirus concern; therefore, groundwater used in food service facilities and businesses should be treated for safety.

HIGHLIGHTS

Clinical characteristics and risk factors for children with norovirus gastroenteritis in Taiwan

BACKGROUND

Norovirus is a common acute gastroenteritis (AGE) pathogen across all age groups worldwide, which is difficult to differentiate from other pathogens. This study aimed to understand the clinical characteristics and risk factors of norovirus gastroenteritis among children in Taiwan.

METHODS

A prospective AGE surveillance study was conducted in children aged ≤5 years who were hospitalized in 10 major hospitals in Taiwan between 2014 and 2017. The non-AGE control group included healthy children who were matched based on age, gender, season, and geographic area.

RESULTS

Overall, 674 norovirus gastroenteritis patients were enrolled. Fever (p < 0.001), mucoid stool (p < 0.001), and bloody stool (p < 0.001) occurred less frequently among norovirus gastroenteritis patients. Norovirus gastroenteritis patients yielded lower CRP values on admission (21.78 ± 36.81 vs. 46.26 ± 58.12 mg/L, p < 0.001) than non-norovirus controls. Norovirus gastroenteritis patients were associated with higher direct contact rates with AGE patients within 1 week (30.5% vs. 0.97%, p < 0.001), lower hand wash rates before meals (21.6% vs. 15.4%, p = 0.001), lower human milk (15.8% vs. 19.8%, p = 0.045) and guava consumption rates (17.8% vs. 24.3%, p = 0.002) than non-AGE participants.

CONCLUSIONS

Body temperature, stool characteristics, and CRP value can help distinguish the norovirus from other pathogens. The major risk factor of norovirus AGE is contact with AGE patient. Higher frequency of hand wash, human milk, and guava intake may be protective against norovirus gastroenteritis.

Constructed wetland for wastewater reuse: Role and efficiency in removing enteric pathogens

Water stress has become a perennial concern in most of the developing countries due to rapid urbanization and population growth. As the growing population requires more fresh water and better ways for wastewater disposal, the demand for wastewater reclamation has increased drastically in recent years. Wastewater, either raw or treated, is being widely used for agricultural irrigation in developing countries, which cause a serious threat to human health mainly because of its pathogenic content. One of the alternative methods to treat wastewater and make it reusable for agricultural irrigation is to implement constructed wetland (CW); a sustainable and cost-effective technology that is applicable for the elimination of both pollutants and pathogens from wastewater. Despite its wide application, the role of macrophytes that form an integral part of CW and specific mechanisms involved in pathogen removal by them is still barely understood due to complexities involved and influencing factors. This has, therefore, attracted various scientific studies to reveal further functional mechanisms involved in vegetated CW to increase its proficiencies. This review paper illustrates the comparative studies of different CW and their pathogen removal efficiencies with major emphasis on macrophytes involved and factors influencing related mechanism. Further, the paper also covers detailed information on the enteric pathogens present in wastewater and the associated health risks involved in its reuse. The ultimate objective is to further clarify the role of CW in enteric pathogen removal and its efficiency for wastewater purification in perspective with safe reuse in agriculture.

Association of meteorological factors with infectious diarrhea incidence in Guangzhou, southern China: A time-series study (2006-2017)

BACKGROUND

Infectious diarrhea (ID) has exerted a severe disease burden on the world. The seasonal ID patterns suggest that meteorological factors (MFs) may influence ID incidence. The aim of this study was to evaluate the effect of MFs on ID, and to provide scientific evidence to the relevant health authorities for disease control and prevention.

METHODS

Data from ID cases and daily MFs (including mean temperature, diurnal temperature range, relative humidity, precipitation, atmospheric pressure, and wind velocity) in Guangzhou, Southern China from 2006 to 2017 were collected. Using a distributed lag non-linear model approach, we assessed the relationship between MFs and ID incidence.

RESULTS

Compared with the lowest ID risk values, low mean temperature, relative humidity, and precipitation were associated with an increased risk for ID, while higher diurnal temperature range and atmospheric pressure were also associated with increased risk. Maximum atmospheric pressure and minimum relative humidity had larger cumulative effects within 21 lag days, yielding relative risks of 133.11 (95% CI: 61.29-289.09) and 18.17 (14.42-22.89), respectively. The cumulative effect within 21 lag days of minimum temperature was higher than that from maximum temperature in all sub-populations. The cumulative effects of minimum temperature for men, teenagers, and young adults (10-29 years) were higher than those for other populations.

CONCLUSIONS

MFs should be considered when developing prevention and surveillance programs for ID. Special attention should be paid to vulnerable populations, such as teenagers and young adults.

Epidemiology of Norovirus Outbreaks Reported to the Public Health Emergency Event Surveillance System, China, 2014⁻2017

We conducted a retrospective analysis of norovirus outbreaks reported to the National Public Health Emergency Event Surveillance System (PHEESS) in China from January 1, 2014 to December 31, 2017. We reviewed all acute gastroenteritis outbreaks (n = 692) submitted to PHEESS to identify the frequency, seasonality, geographic distribution, setting, and transmission mode of outbreaks due to norovirus. A total of 616 norovirus outbreaks resulting in 30,848 cases were reported. Among these outbreaks, 571 (93%) occurred in school settings including 239 (39%) in primary schools, 136 (22%) in childcare facilities, and 121 (20%) in secondary schools. The majority of outbreaks (63%) were due to person-to-person transmission, followed by multiple modes of transmission (11%), foodborne (5%) and waterborne (3%) transmission. These findings highlight the importance of improving hand hygiene and environmental disinfection in high-risk settings. Developing a standard and quantitative outbreak reporting structure could improve the usefulness of PHEESS for monitoring norovirus outbreaks.

A time-series study of the association of rainfall, relative humidity and ambient temperature with hospitalizations for rotavirus and norovirus infection among children in Hong Kong

BACKGROUND

Rotavirus and norovirus are infectious pathogens primarily affecting children under 5 years old. The impact of rainfall on diarrheal diseases remains inconclusive. This study aimed to evaluate the association between short-term variation in rainfall, temperature and humidity, and rotavirus and norovirus hospitalizations among young children in Hong Kong.

METHODS

Generalized additive negative binomial regression models with distributed lag non-linear terms, were fit with daily counts of hospital admissions due to rotavirus and norovirus infection as the outcomes and daily total rainfall and other meteorological variables as predictors, adjusting for seasonality and trend.

RESULTS

Generally, greater rainfall was associated with fewer rotavirus, but more norovirus hospitalizations. Extreme precipitation (99.5 mm, 99th percentile) was found to be associated with 0.40 (95% confidence interval (CI) 0.20-0.79) and 1.93 (95% CI 1.21-3.09) times the risk of hospitalization due to rotavirus and norovirus infection respectively, relative to trace rainfall. Stronger associations were observed in winter for rotavirus and in summer for norovirus. The duration of association with rotavirus was notably longer than norovirus. Higher temperatures were found to be associated with fewer hospitalizations for both rotavirus and norovirus infection, while higher relative humidity was generally associated with more norovirus, but fewer rotavirus, hospitalizations.

CONCLUSIONS

Both rotavirus and norovirus hospitalizations were strongly associated with recent precipitation variation but in opposite directions. With the introduction of the rotavirus vaccine norovirus is likely to become a greater threat than rotavirus and thus greater precipitation may become more clearly associated with more childhood diarrhea.

The Distribution of Enteric Infections Utilizing Stool Microbial Polymerase Chain Reaction Testing in Clinical Practice

BACKGROUND

Gastrointestinal infection is a major cause of morbidity. We sought to characterize the pathogenic etiologies of gastrointestinal infection to identify seasonal patterns and predictors of specific infections utilizing a multiplex PCR assay in clinical practice.

METHODS

We performed a cross-sectional study of 9403 patients who underwent 13,231 stool tests with a FilmArray gastrointestinal pathogen PCR panel during an episode of diarrhea from March 2015 to May 2017. Our primary outcome was the presence of a positive panel. Logistic regression was used to test for associations between season and infections.

RESULTS

A positive result was found in 3426 tests (25.9%) in 2988 patients (31.8%), yielding 4667 pathogens consisting of 1469 viruses (31.5%), 2925 bacteria (62.7%), and 273 parasites (5.8%). Age less than 50 years was associated with a higher prevalence of pathogens compared to age ≥ 50 (p < 0.0001). The overall prevalence of a positive result for bacteria peaked in the summer (635, 29.2%), and the prevalence of viruses peaked in the winter (446, 31.8%). Compared to the winter, testing in the summer yielded a higher prevalence of bacteria (OR 1.52, 95% CI 1.33, 1.73, p < 0.0001) and lower odds of viruses (OR 0.69, 95% CI 0.58, 0.81, p < 0.0001), primarily driven by E. coli species and norovirus.

CONCLUSIONS

Season was a major determinant in detecting specific pathogens. Our substantially lower positivity rate than previous reports in the literature on multiplex PCR assays may more accurately reflect true clinical practice. Recognizing the temporal distribution of enteric pathogens may help facilitate empiric treatment decisions in certain clinical situations.

Development of genetic programming-based model for predicting oyster norovirus outbreak risks

Oyster norovirus outbreaks pose increasing risks to human health and seafood industry worldwide but exact causes of the outbreaks are rarely identified, making it highly unlikely to reduce the risks. This paper presents a genetic programming (GP) based approach to identifying the primary cause of oyster norovirus outbreaks and predicting oyster norovirus outbreaks in order to reduce the risks. In terms of the primary cause, it was found that oyster norovirus outbreaks were controlled by cumulative effects of antecedent environmental conditions characterized by low solar radiation, low water temperature, low gage height (the height of water above a gage datum), low salinity, heavy rainfall, and strong offshore wind. The six environmental variables were determined by using Random Forest (RF) and Binary Logistic Regression (BLR) methods within the framework of the GP approach. In terms of predicting norovirus outbreaks, a risk-based GP model was developed using the six environmental variables and various combinations of the variables with different time lags. The results of local and global sensitivity analyses showed that gage height, temperature, and solar radiation were by far the three most important environmental predictors for oyster norovirus outbreaks, though other variables were also important. Specifically, very low temperature and gage height significantly increased the risk of norovirus outbreaks while high solar radiation markedly reduced the risk, suggesting that low temperature and gage height were associated with the norovirus source while solar radiation was the primary sink of norovirus. The GP model was utilized to hindcast daily risks of oyster norovirus outbreaks along the Northern Gulf of Mexico coast. The daily hindcasting results indicated that the GP model was capable of hindcasting all historical oyster norovirus outbreaks from January 2002 to June 2014 in the Gulf of Mexico with only two false positive outbreaks for the 12.5-year period. The performance of the GP model was characterized with the area under the Receiver Operating Characteristic curve of 0.86, the true positive rate (sensitivity) of 78.53% and the true negative rate (specificity) of 88.82%, respectively, demonstrating the efficacy of the GP model. The findings and results offered new insights into the oyster norovirus outbreaks in terms of source, sink, cause, and predictors. The GP model provided an efficient and effective tool for predicting potential oyster norovirus outbreaks and implementing management interventions to prevent or at least reduce norovirus risks to both the human health and the seafood industry.

Genotypic and Epidemiological Trends of Acute Gastroenteritis Associated with Noroviruses in China from 2006 to 2016

There are periodical norovirus-associated acute gastroenteritis outbreaks around the world. This study aimed to analyze the molecular and epidemiological features of norovirus infections in China during 2006–2016. We extracted epidemiological data from 132 norovirus outbreaks and the norovirus genotyping for 1291 sequences in China over the past ten years. A total of 132 norovirus outbreaks (8133 cases) were reported in China, where the east and south regions were most affected [47.7% (63/132)]. The highest number of outbreaks occurred in 2015. A seasonal pattern has been observed, with a peak from November to the following March. Most of the outbreaks occurred in middle and primary schools, accounting for 28.8% (38/132), and 28.0% (37/132) of outbreaks, respectively. The dominant age group was 10 to 19 years old, responsible for 75.7% (933/1232) of cases. Generally, the dominant genotypes was GII, for 81.9% (1058/1291) of sequences. G II.4 was the predominant genotype in China from 2004 to 2014. However, the GII.17 became more prevalent starting in 2014. Norovirus-associated acute gastroenteritis increased sharply in recent years caused by the emergence of GII.17, but epidemiological features have not changed during 2006–2016. Vigilant surveillance should be strengthened to promptly detect any variation.

Environmental indicators for human norovirus outbreaks

Norovirus is the most common cause of outbreaks of non-bacterial gastroenteritis in human. While the winter seasonality of norovirus outbreaks has been widely reported, the association between norovirus outbreak epidemics and environmental factors remains not fully understood. This literature review is intended to improve understanding of environmental factors governing norovirus outbreaks and how the factors affect norovirus transmission. To that end, a large number of studies (67) from countries around the world were critically reviewed and discussed. Results of the literature review show that temperature, humidity, and rainfall are the most important environmental variables governing the norovirus epidemic cycle. It was found that low temperature between -6.6 and 20 °C, relative humidity between 10 and 66 %, and rainfall from 1 day to 3 months before an outbreak are effective ranges of the environmental factors, which favor the prevalence of norovirus. Some other environmental factors might have an association with the cycle of norovirus epidemics. However, further investigations are needed to understand effects of the other factors on norovirus incidence. The findings of this literature review improve our understanding of the relationship between norovirus outbreaks and environmental factors and provide the direction for future research on norovirus outbreaks.

Role of Food Handlers in Norovirus Outbreaks in London and South East England, 2013 to 2015

Outbreaks caused by norovirus infection are common and occur throughout the year. Outbreaks can be related to food outlets either through a contaminated food source or an infected food handler. Both asymptomatic and symptomatic food handlers are potentially implicated in outbreaks, but evidence of transmission is limited. To understand potential food handler transmission in outbreak scenarios, epidemiological and microbiological data on possible and confirmed norovirus outbreaks reported in London and South East England in a 2-year period were reviewed. One hundred eighty-six outbreaks were associated with a food outlet or registered caterer in this period. These occurred throughout the year with peaks in quarter 1 of study years. A case series of 17 outbreaks investigated by the local field epidemiological service were evaluated further, representing more than 606 cases. In five outbreaks, symptomatic food handlers were tested and found positive for norovirus. In four outbreaks, symptomatic food handlers were not tested. Asymptomatic food handlers were tested in three outbreaks but positive for norovirus in one only. Environmental sampling did not identify the causative agent conclusively in any of the outbreaks included in this analysis. Food sampling identified norovirus in one outbreak. Recommendations from this study include for outbreak investigations to encourage testing of symptomatic food handlers and for food and environmental samples to be taken as soon as possible. In addition, sampling of asymptomatic food handlers should be considered when possible. However, in light of the complexity in conclusively identifying a source of infection, general measures to improve hand hygiene are recommended, with specific education among food handlers about the potential for foodborne pathogen transmission during asymptomatic infection, as well as reinforcing the importance of self-exclusion from food handling activities when symptomatic.

Influence of School Year on Seasonality of Norovirus Outbreaks in Developed Countries

Factors affecting the seasonal distribution of norovirus outbreaks are not well understood. This study examined whether grade school settings at the start of the school year may be a factor. We searched Ovid Medline from January 2002 to June 2014 for studies that provided all reported norovirus outbreaks in a developed country by month for a minimum of three years. Historical school years were obtained from verifiable sources. The start of the norovirus seasonal outbreak peak and peak outbreak month were determined for each study and compared to the start month of school. Northern hemisphere and southern hemisphere countries had a different norovirus seasonality and different school year structures (traditional compared to year round). In the two studies that provided outbreaks by age, outbreaks among children started several months before outbreaks in the adult population. The median number of months between school start and start of the seasonal outbreak peak was two months (interquartile range [IQR] = 2.0-3.0), while the median number of months between school start and peak outbreak month was four months (IQR = 3.0-4.0). These findings suggest the possibility the school setting at the start of the school year may be a factor in the seasonality of norovirus.

Did summer weather factors affect gastrointestinal infection hospitalizations in New York State?

BACKGROUND

Gastrointestinal infections, a substantial public health problem worldwide, have been associated with single weather factors but the joint effect of multiple weather factors on gastrointestinal infections remains unclear.

METHODS

We conducted a retrospective time-series analysis to investigate effects of weather conditions on hospitalizations for gastrointestinal infections (GIH) in New York State in July and August from 1991 to 2004. Applying generalized additive model (GAM), we evaluated the associations between daily GIH count and multiple weather factors including temperature, humidity, and precipitation (0-10 lag days), adjusting for long term trend, seasonality, and calendar effects.

RESULTS

Maximum temperature, minimum temperature, and maximum universal apparent temperature (UAT) showed that each °C increase in temperature was significantly associated with an increase (0.70-0.96%) in daily GIH count, with the greatest impacts observed at lag 1. Extreme heat (EH: >90th percentile) (3.68% at lag 1) and precipitation (0.31% at lag 4) showed larger impacts on increases of GIH and a clear dose-response relationship for EH. Stratified analyses showed that the impacts of extreme heat on GIH tend to be greater among Hispanics, blacks, females, and those with bacterial infections.

CONCLUSION

We found that high maximum and minimum temperature, UAT, precipitation, and extreme heat in summer significantly increased the risks of GIH in NYS. Our findings also suggest that bacteria might be a significant cause for GIH in the summer, and minority, female and those with bacterial infection may be more vulnerable to heat's effects on GIH.

Elimination of viruses from domestic wastewater: requirements and technologies

Domestic wastewater contains various pathogens, which, if not sufficiently eliminated, may enter the receiving water bodies and cause water-transmitted diseases. Among the waterborne pathogens, viruses may occur, survive and/or decay much differently from bacteria in water. In many cases, the diseases caused by viruses are more severe. Therefore, research efforts are mainly directed at the behavior of viruses in water environments, as well as the elimination of viruses from wastewater. In this paper, an overview of the occurrence of viruses in wastewater is presented, together with their categories, methods of detection and potential to cause waterborne diseases. As wastewater treatment plants are critical nodes for the influx and termination of virus transmission, the behavior of viruses at each stage of treatment is reviewed. Particular attention is paid to the unit operations, which play crucial roles in virus removals, such as coagulation and membrane filtration, and that for virus inactivation, such as chemical disinfection and UV irradiation. Future needs for the development of new technologies for virus elimination, source control, and finding more suitable indicators of viral pathogens are also highlighted.

Acute diarrhea in adults consulting a general practitioner in France during winter: incidence, clinical characteristics, management and risk factors

Background

Data describing the epidemiology and management of viral acute diarrhea (AD) in adults are scant. The objective of this study was to identify the incidence, clinical characteristics, management and risk factors of winter viral AD in adults.

Methods

The incidence of AD in adults during two consecutive winters (from December 2010 to April 2011 and from December 2011 to April 2012) was estimated from the French Sentinelles network. During these two winters, a subset of Sentinelles general practitioners (GPs) identified and included adult patients who presented with AD and who filled out a questionnaire and returned a stool specimen for virological examination. All stool specimens were tested for astrovirus, group A rotavirus, human enteric adenovirus, and norovirus of genogroup I and genogroup II. Age- and sex-matched controls were included to permit a case–control analysis with the aim of identifying risk factors for viral AD.

Results

During the studied winters, the average incidence of AD in adults was estimated to be 3,158 per 100,000 French adults (95% CI [2,321 – 3,997]). The most reported clinical signs were abdominal pain (91.1%), watery diarrhea (88.5%), and nausea (83.3%). GPs prescribed a treatment in 95% of the patients with AD, and 80% of the working patients with AD could not go to work. Stool examinations were positive for at least one enteric virus in 65% (95% CI [57 – 73]) of patients with AD with a predominance of noroviruses (49%). Having been in contact with a person who has suffered from AD in the last 7 days, whether within or outside the household, and having a job (or being a student) were risk factors significantly associated with acquiring viral AD.

Conclusions

During the winter, AD of viral origin is a frequent disease in adults, and noroviruses are most often the cause. No preventable risk factor was identified other than contact with a person with AD. Thus, at the present time, reinforcement of education related to hand hygiene remains the only way to reduce the burden of disease.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-014-0574-4) contains supplementary material, which is available to authorized users.

Association of climatic factors with infectious diseases in the Arctic and subarctic region--a systematic review

Background

The Arctic and subarctic area are likely to be highly affected by climate change, with possible impacts on human health due to effects on food security and infectious diseases.

Objectives

To investigate the evidence for an association between climatic factors and infectious diseases, and to identify the most climate-sensitive diseases and vulnerable populations in the Arctic and subarctic region.

Methods

A systematic review was conducted. A search was made in PubMed, with the last update in May 2013. Inclusion criteria included human cases of infectious disease as outcome, climate or weather factor as exposure, and Arctic or subarctic areas as study origin. Narrative reviews, case reports, and projection studies were excluded. Abstracts and selected full texts were read and evaluated by two independent readers. A data collection sheet and an adjusted version of the SIGN methodology checklist were used to assess the quality grade of each article.

Results

In total, 1953 abstracts were initially found, of which finally 29 articles were included. Almost half of the studies were carried out in Canada (n=14), the rest from Sweden (n=6), Finland (n=4), Norway (n=2), Russia (n=2), and Alaska, US (n=1). Articles were analyzed by disease group: food- and waterborne diseases, vector-borne diseases, airborne viral- and airborne bacterial diseases. Strong evidence was found in our review for an association between climatic factors and food- and waterborne diseases. The scientific evidence for a link between climate and specific vector- and rodent-borne diseases was weak due to that only a few diseases being addressed in more than one publication, although several articles were of very high quality. Air temperature and humidity seem to be important climatic factors to investigate further for viral- and bacterial airborne diseases, but from our results no conclusion about a causal relationship could be drawn.

Conclusions

More studies of high quality are needed to investigate the adverse health impacts of weather and climatic factors in the Arctic and subarctic region. No studies from Greenland or Iceland were found, and only a few from Siberia and Alaska. Disease and syndromic surveillance should be part of climate change adaptation measures in the Arctic and subarctic regions, with monitoring of extreme weather events known to pose a risk for certain infectious diseases implemented at the community level.

A probabilistic quantitative microbial risk assessment model of norovirus disease burden from wastewater irrigation of vegetables in Shepparton, Australia

Wastewater can be an important resource for water-scarce regions of the world, but a major barrier to its use is the associated health risk. Quantitative microbial risk assessment (QMRA) is a probabilistic modeling technique used to determine the health risks from wastewater reuse, but only a handful of QMRA studies have examined the norovirus health risks from consumption of vegetables irrigated with human wastewater, even though norovirus is a, if not the most, significant microbial cause of diarrheal disease world-wide. Furthermore, the majority of these studies have focused only on risks from lettuce consumption. To meet the knowledge gap in health risks for other vegetables, a QMRA model was constructed for agricultural wastewater irrigation in the regional city of Shepparton, Australia, using fecal shedding rates to estimate norovirus concentration in raw sewage. Annual norovirus disease burden was estimated for the consumption of lettuce, broccoli, cabbage, Asian vegetables, and cucumber after irrigation with treated wastewater. Results indicate that the waste stabilization pond treatment did not have sufficient virus removal to meet the World Health Organization (WHO) threshold for acceptable level of risk for wastewater reuse, but addition of disinfection treatments provided acceptable results for consumption of cucumber and broccoli. This is the first QMRA study to incorporate virus accumulation from previous wastewater irrigation events.

Occurrence of waterborne pathogens and Escherichia coli at offshore drinking water intakes in lake Ontario

The occurrence of waterborne pathogens was investigated at three drinking water intakes located about 2 km offshore in Lake Ontario. Water sampling was conducted over 3 years for Campylobacter spp., Cryptosporidium spp., Giardia spp., cultivable enteric viruses, and water quality parameters. All pathogens were detected in the offshore source water for each water treatment plant (WTP1 to WTP3), although at relatively low frequencies and concentrations. Giardia was the most common pathogen, occurring in 36% of water samples from the influent of WTP1 (n = 46), and with a maximum concentration of 0.70 cysts/liter in this influent. Cryptosporidium occurred as frequently as 15% in the WTP2 influent (n = 35), with a maximum concentration of 0.40 oocysts/liter in the WTP1 influent. The human Bacteroidales HF183 DNA marker was most common in the WTP1 influent (19%), and this was the only WTP where the Cryptosporidium hominis genotype was detected. No water quality parameter was predictive of pathogen occurrence across all three WTP influents. Escherichia coli was often below detection when pathogens were detected, and spikes in E. coli concentrations often did not coincide with pathogen occurrence. After summer rain events, river plumes had E. coli concentrations as high as 222 CFU/100 ml in surface waters 2 km offshore, without impacting drinking water intakes below the thermocline on the lake bottom. At times, prechlorination to control mussels at offshore intake cribs compromised the use of E. coli for "raw" water quality assessment, particularly for chlorine-resistant Cryptosporidium. E. coli measured by standard methods did not reliably predict pathogen occurrence at drinking water intakes in offshore ecosystems.

Assessing multiple foodborne, waterborne and environmental exposures of healthy people to potential enteric pathogen sources: effect of age, gender, season, and recall period

Information is lacking in Canada on the frequency of exposures of healthy people to enteric pathogen sources (i.e. water, food, animal contact) at the community level. This information is critical to develop more robust risk assessments and prioritize control measures. A 12-month-long cross-sectional telephone survey of 1200 healthy individuals in a sentinel community was performed. Survey respondents were divided into three recall period groups (3, 7, 14 days). The occurrence of 46 exposures (including water, animal contact, environmental contact and high-risk foods) was assessed per recall period. Effect of age, gender, and season on exposures was modelled and frequencies of exposure were extrapolated. Thirty-five exposures had similar occurrences across recall periods. Age was significant for 23 exposures, season for 18, and gender for three. Exposures that vary by age and season (i.e. bottled water, swimming, etc.) warrant consideration when investigating and analysing cases of enteric illness.

Detection and forecasting of oyster norovirus outbreaks: recent advances and future perspectives

Norovirus is a highly infectious pathogen that is commonly found in oysters growing in fecally contaminated waters. Norovirus outbreaks can cause the closure of oyster harvesting waters and acute gastroenteritis in humans associated with consumption of contaminated raw oysters. Extensive efforts and progresses have been made in detection and forecasting of oyster norovirus outbreaks over the past decades. The main objective of this paper is to provide a literature review of methods and techniques for detecting and forecasting oyster norovirus outbreaks and thereby to identify the future directions for improving the detection and forecasting of norovirus outbreaks. It is found that (1) norovirus outbreaks display strong seasonality with the outbreak peak occurring commonly in December-March in the U.S. and April-May in the Europe; (2) norovirus outbreaks are affected by multiple environmental factors, including but not limited to precipitation, temperature, solar radiation, wind, and salinity; (3) various modeling approaches may be employed to forecast norovirus outbreaks, including Bayesian models, regression models, Artificial Neural Networks, and process-based models; and (4) diverse techniques are available for near real-time detection of norovirus outbreaks, including multiplex PCR, seminested PCR, real-time PCR, quantitative PCR, and satellite remote sensing. The findings are important to the management of oyster growing waters and to future investigations into norovirus outbreaks. It is recommended that a combined approach of sensor-assisted real time monitoring and modeling-based forecasting should be utilized for an efficient and effective detection and forecasting of norovirus outbreaks caused by consumption of contaminated oysters.

Seasonality of viral infections: mechanisms and unknowns

Seasonality is a long-recognized attribute of many viral infections of humans, but the mechanisms underlying seasonality, particularly for person-to-person communicable diseases, remain poorly understood. Better understanding of drivers of seasonality could provide insights into the relationship between the physical environment and infection risk, which is particularly important in the context of global ecological change in general, and climate change in particular. In broad terms, seasonality represents oscillation in pathogens' effective reproductive number, which, in turn, must reflect oscillatory changes in infectiousness, contact patterns, pathogen survival, or host susceptibility. Epidemiological challenges to correct identification of seasonal drivers of risk include failure to adjust for predictable correlation between disease incidence and seasonal exposures, and unmeasured confounding. The existing evidence suggests that the seasonality of some enteric and respiratory viral pathogens may be driven by enhanced wintertime survival of pathogens, and also by increased host susceptibility resulting from relative 'wintertime immune suppression'. For vector-borne diseases and zoonoses, environmental influences on vector or reservoir abundance, and vector biting rates, are probably more important. However, numerous areas of uncertainty exist, making this an exciting area for future research.

Norovirus Monitoring in Bivalve Molluscs Harvested and Commercialized in Southern Italy

Norovirus (NoV) is the main cause of human nonbacterial gastroenteritis throughout the world. NoVs are classified into five genogroups: GI, GII, GIII, GIV, and GV. NoVs from GI and GII are the most commonly reported NoVs associated with human infections, and raw or undercooked shellfish have been identified as the main potential infection vehicle. European Commission Regulation 2073/2005 defines only bacteriological parameters for use as safety criteria for shellfish because reference methods for detection of viruses are lacking. From July 2007 to April 2010, 163 shellfish samples were collected in southern Italy from harvesting areas, authorized or nonauthorized retailers, and a restaurant after an outbreak of human gastroenteritis. The shellfish were analyzed for the presence of NoVs from GI and GII using the one-step real-time reverse transcription PCR protocol. A total of 94 shellfish samples (57.7%) were positive for the presence of NoV, and GII was the most frequently identified genogroup.

Analytical solution for the modeling of the natural time-dependent reduction of waterborne viruses injected into fractured aquifers

We propose an analytical solution in order to explain the processes that determine the fate and behavior of the viruses during transport in a fractured aquifer at Salento (Italy). The calculations yield the efficiency of filtration in fractures at a site near Nardò (Southern Italy) in reducing the numbers of enteric viruses (i.e., Enteroviruses and Norovirus) in secondary municipal effluents that have been injected in the aquifer over the period 2006-2007. The model predicted, by a theoretical expression, the time-dependent rate of virus reduction, which was in good agreement with field data. The analytical solution yields the achievable "Log reduction credits" for virus reduction in wells located at the setback distances that are usually adopted in local drinking water regulations. The resulting new analytical formula for the time-dependent reduction of viruses during subsurface transport can easily be applied in health risk-based models used to forecast the spread of waterborne diseases and provides appropriate criteria (i.e., distances) needed to meet standards for the quality of drinking water derived from undisinfected groundwater.

Norovirus as a foodborne disease hazard

Norovirus (NoV) is the most common cause of infectious gastroenteritis in the world. Gastroenteritis caused by bacterial and parasitic pathogens is commonly linked to food sources, but the link between NoV and contaminated foods has been more difficult to establish. Even when epidemiological information indicates that an outbreak originated with food, the presence of NoV in the suspect product may not be confirmed. If food is found to contain a common strain of NoV that circulates widely in the community, it is not possible to use strain typing to link the contamination to patient cases. Although food is certainly implicated in NoV spread, there are additional person-to-person and fomite transmission routes that have been shown to be important. NoV has an extremely low infectious dose, is stable in the environment, and resists disinfection. Cell culture methods are not available, so viability cannot be determined. Finally, many NoV outbreaks originate with when an infected food handler contaminates ready-to-eat food, which can be interpreted as foodborne or person-to-person transmission. This review will discuss both the physical characteristics of NoVs and the available epidemiological information with particular reference to the role of foods in NoV transmission.